The use of telemedicine in child sexual abuse evaluations

OBJECTIVE: To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD: The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS: The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS: Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.     

Juror and expert knowledge of child sexual abuse.

Mental health professionals with expertise in child sexual abuse (CSA) often testify as expert witnesses in court. There is significant controversy over the admissibility of this type of evidence. To be admissible, the testimony of an expert must be beyond the common knowledge of the jury and based on information generally considered to be reliable within the professional community in which it is used. To date, no empirical data have existed to allow courts to make an informed judgement as to the extent of either juror knowledge or professional acceptance of CSA data. The present study addresses this issue. Jurors and experts completed a questionnaire designed to reveal their understanding of CSA. Results indicate that experts demonstrated strong consensus on 29 of 40 items included in the questionnaire, and that relative to experts, jurors have limited knowledge of these issues. These results suggest that many of the scientific findings concerning CSA are reliable and that the information is often beyond the common knowledge of the jury. These findings argue for the use of expert testimony in select cases of child sexual abuse.     

Forensic child sexual abuse evaluations: assessing subjectivity and bias in professional judgements

Objectives

Evaluators examining the same evidence often arrive at substantially different conclusions in forensic assessments of child sexual abuse (CSA). This study attempts to identify and quantify subjective factors that contribute to such disagreements so that interventions can be devised to improve the reliability of case decisions.

Methods

Participants included 1106 professionals in the field of child maltreatment representing a range of professional positions or job titles and years of experience. Each completed the Child Forensic Attitude Scale (CFAS), a 28-item survey assessing 3 forensic attitudes believed to influence professional judgments about CSA allegations: emphasis-on-sensitivity (i.e., a focus on minimizing false negatives or errors of undercalling abuse); emphasis-on-specificity (i.e., a focus on minimizing false positives or errors of overcalling abuse); and skepticism toward child and adolescent reports of CSA. A subset of 605 professionals also participated in 1 of 3 diverse decision exercises to assess the influence of the 3 forensic attitudes on ratings of case credibility.

Results

Exploratory factor analysis identified 4 factors or attitude subscales that corresponded closely with the original CFAS scales: 2 subscales for emphasis-on-sensitivity and 1 each for emphasis-on-specificity and skepticism. Attitude subscale scores differed significantly by sample source (in-state trainings vs. national conferences), gender, years of experience, and professional position, with Child Protective Service workers unexpectedly more concerned about overcalling abuse and more skeptical of child disclosures than other professionals—a pattern of scores associated with an increased probability of disbelieving CSA allegations. The 3 decision exercises offered validation of the attitude subscales as predictors of professional ratings of case credibility, with adjusted R²s for the three exercises ranging from .06 to .24, suggesting highly variable effect sizes.

Conclusions

Evaluator disagreements about CSA allegations can be explained, in part, by individual differences in 3 attitudes related to forensic decision-making: emphasis-on-sensitivity, emphasis-on-specificity, and skepticism toward child reports of abuse. These attitudes operate as predispositions or biases toward viewing CSA allegations as likely true or likely false. Several strategies for curbing the influence of subjective factors are highlighted including self-awareness of personal biases and team approaches to assessment.     

Child on child sexual abuse: psychological perspectives

OBJECTIVE: This study describes the emotional and behavioral responses of children who have been sexually victimized by juveniles (CC) 17 years of age and younger compared to child victims of adults (CA) 18 years of age and older. METHOD: A total sample of N = 194 children and adolescents participated in the study, with 26% (n = 51) comprising CC and 74% (n = 143) encompassing CA. The mother/caretaker was administered a demographic form, Achenbach's Child Behavior Checklist (CBCL), and the Family Assessment Measure (FAM-P). The child was given the Family Assessment Measure (FAM-C) and the Trauma Symptom Checklist for Children (TSCC). The clinician completed the Parental Reaction to Incest Disclosure Scale (PRIDS). RESULTS: No differences were found between the two groups for the type of sexual abuse, penetration, or the use of force. CC were younger and more likely to be males who were abused in a school setting, home, or a relative's home by a sibling or a non-related male. CC endorsed clinically significant sexual preoccupations and manifested borderline clinically significant symptomatology. CONCLUSIONS: Children victimized by other children manifested elevated levels of emotional and behavioral problems and were not significantly different from those who had been sexually abused by adults.     

The child sexual abuse accommodation syndrome

Child victims of sexual abuse face secondary trauma in the crisis of discovery. Their attempts to reconcile their private experiences with the realities of the outer world are assaulted by the disbelief, blame and rejection they experience from adults. The normal coping behavior of the child contradicts the entrenched beliefs and expectations typically held by adults, stigmatizing the child with charges of lying, manipulating or imagining from parents, courts and clinicians. Such abandonment by the very adults most crucial to the child's protection and recovery drives the child deeper into self-blame, self-hate, alienation and revictimization. In contrast, the advocacy of an empathic clinician within a supportive treatment network can provide vital credibility and endorsement for the child. Evaluation of the responses of normal children to sexual assault provides clear evidence that societal definitions of "normal" victim behavior are inappropriate and procrustean, serving adults as mythic insulators against the child's pain. Within this climate of prejudice, the sequential survival options available to the victim further alienate the child from any hope of outside credibility or acceptance. Ironically, the child's inevitable choice of the "wrong" options reinforces and perpetuates the prejudicial myths. The most typical reactions of children are classified in this paper as the child sexual abuse accommodation syndrome. The syndrome is composed of five categories, of which two define basic childhood vulnerability and three are sequentially contingent on sexual assault: (1) secrecy, (2) helplessness, (3) entrapment and accommodation, (4) delayed, unconvincing disclosure, and (5) retraction. The accommodation syndrome is proposed as a simple and logical model for use by clinicians to improve understanding and acceptance of the child's position in the complex and controversial dynamics of sexual victimization. Application of the syndrome tends to challenge entrenched myths and prejudice, providing credibility and advocacy for the child within the home, the courts, and throughout the treatment process. The paper also provides discussion of the child's coping strategies as analogs for subsequent behavioral and psychological problems, including implications for specific modalities of treatment.     

Nine years after child sexual abuse

OBJECTIVE: During 1988-1990, 103 children presented to Child Protection Units (CPU) at two children's hospitals in Sydney, Australia. Nine years later, the psychological adjustment of these young people (mean age=19.1 years, SD=3.4 years; range=14-25 years) was compared with that of non-abused young people of similar age and gender to assess group differences and examine potential risk factors. METHOD: At intake, data on the nature of the index sexual abuse, demographics and the family environment were collected by clinicians. A comparison group, of similar age and gender, was selected from schools in the catchment area of the CPUs. Six years after presentation for the abuse, records of the statutory child protection authority were checked to determine any further notifications for abuse and/or neglect. Nine years after intake, 49 of the abused young people and 68 of the non-abused young people and/or their parents were interviewed and assessed. RESULTS: The sexually abused young people performed more poorly than non-abused young people on psychometric tests of depression (p=.001), self-esteem (p<.001), anxiety (p<.001), behavior (Child Behavior Checklist: p=.01; Youth Self Report: p=.01; Young Adult Self Report: p<.001), and despair (p=.001). They were also more likely to have a history of bingeing (p=.002), self-inducing vomiting (p=.02), smoking cigarettes (p=.01), and using amphetamines (p=.002), ecstasy (p=.002) and cocaine (p=.004). Potential risk factors were in two groups, family and child. Family factors: family functioning, parental drug/alcohol problems, mother's sexual abuse history, mother's depression and socio-economic status. Child factors: despair and hopefulness, number of negative life events, ratings of their father's care, previous notifications for child sexual abuse and placements in out-of-home care by the statutory child protection authority. In the presence of other risk factors, child sexual abuse was a significant predictor of self-esteem, behavior and bingeing. CONCLUSIONS: Rather than focusing only on the individual's child sexual abuse, treatment may also need to address the family's functioning and the individual's feelings of despair.     

Erroneous concerns about child sexual abuse

AIM: To assess the incidence and nature of concerns about sexual abuse, with particular reference to erroneous concerns of sexual abuse made by children. METHODS: A review of case notes of all child sexual abuse reports to the Denver Department of Social Services over 12 months. Cases were put into four groups: substantiated, not sexual abuse, inconclusive and erroneous accounts by children. RESULTS: 551 cases were reviewed. Forty-three percent were substantiated, 21% were inconclusive and 34% were not considered to be abuse cases. There were 14 (2.5%) erroneous concerns emanating from children. They comprised three cases of allegations made in collusion with a parent, three cases where an innocent event was misinterpreted as sexual abuse and eight cases (1.5%) of false allegations of sexual abuse.CONCLUSION: Erroneous concern of sexual abuse from children are uncommon. The four categories of concern in this study, in contrast to the simple classification of substantiated and unsubstantiated, provide a means of encouraging open minded assessments of the typical concerns which a child protection agency receives.     

Reports of child sexual abuse in the schools

Few studies have examined the problem of child sexual abuse (CSA) as it relates to the role of the school psychologist. The purpose of this study was to examine the incidence of CSA reports to school psychologists, to examine the perceived quality of service to child victims, and to survey the usage of CSA prevention and screening programs as adjunct services in managing this problem. Of the 171 respondents, 498 child sexual abuse cases were reported. Respondents with prior CSA training rated their performance significantly higher than those without training in handling these cases. Those respondents reporting use of CSA prevention and screening programs generally rated their effectiveness as average or above. The results of this study suggested a need for training of school psychologists in the assessment of child sexual abuse. The results also implicated the use of prevention and screening programs as part of a service delivery program to all students in the public schools.     

Characteristics of child sexual abuse treatment programs

Within the professional community, a vast number of sexual abuse treatment programs have emerged to meet the needs of victims and their families. Significant variations among these programs can be observed due to differences in philosophy, system context, client focus, problem definition, and the treatment strategy adopted. Unfortunately, little comparative information is available regarding the operation of different programs and, more importantly, their relative treatment effectiveness. This article presents the findings from a nationwide survey of 553 sexual abuse treatment programs. The survey focused on program context, client, and service characteristics. Overall it was found that most programs are affiliated with a larger public or private agency, focus on treating victims, and rely on a combination of individual, family, dyad, and group therapy approaches.     

Use of anatomical dolls among professionals in sexual abuse evaluations

A total of 295 child protection workers, law enforcement officers, mental health practitioners, and physicians were surveyed to ascertain their uses of the anatomical dolls in child sexual abuse evaluations and their interpretations of young children's interactions with the dolls. The dolls enjoy fairly wide use among all four professional groups although most professionals employing the dolls have had little specific training in their use. Law enforcement officers were significantly less likely than the other professionals to view children's demonstrations of sexual acts with the dolls as convincing evidence of sexual abuse. There was no behavior (e.g., undressing the dolls, touching the dolls' genitals) which all professional groups unanimously agreed would be normal play behavior by young children ages 2-5, who had not been sexually abused. Results highlight the need for training resources and normative research.     

A comprehensive child sexual abuse treatment program

The number of families troubled by parent-child incest in the typical community is much larger than suspected by professional helpers. If left unattended, the victim(s) and the family as a whole will be critically traumatized. Parental incest in the nuclear family can be likened to terminal cancer in the individual. The community must encourage the incestuous families to seek treatment and must provide comprehensive in-depth therapy to all members of the family. The etiology and dynamics of parental incest and the treatment method developed by the Directors of the Child Sexual Abuse Treatment Program of Santa Clara County (CSATP), California, are discussed. Over the past ten years the CSATP has provided therapy to over 4,000 children and their families (about 14,000 individuals), by far the largest number so treated by any single organization. About 90% of the children have been returned to their families; and the recidivism rate in the families who have completed the treatment program remains at less than 1%.     

Urgent medical assessment after child sexual abuse

BACKGROUND: Immediate medical assessment has been recommended for children after sexual abuse to identify physical injuries, secure forensic evidence, and provide for the safety of the child. However, it is unclear whether young children seen urgently within 72 hours of reported sexual contact would have higher frequencies of interview or examination findings as compared to those seen non-urgently or whether forensic findings would be affected by child characteristics, type of reported contact, or later events. DESIGN/SETTING: We evaluated 190 consecutive cases of children under 13 years of age urgently referred during a 5-year period in 1998-2003 to a community child advocacy center and compared them to those non-urgently referred with regard to their physical examination findings, any sexually transmitted infections or forensic evidence, gender, pubertal development, type of contact, reported ejaculation, later bathing or changing clothes, time to examination, and gender, age and relationship of alleged perpetrator. RESULTS: Children seen urgently were younger and had less frequent CPS involvement, more disclosures, and more positive physical examinations, and had more contact with older perpetrators than those seen non-urgently. Overall, most children were female and had normal or non-specific physical examinations. Certain case characteristics were predictive of evidence isolation in the 9% who had positive forensic evidence identified. Semen or sperm was identified from body swabs only from non-bathed, female children older than 10 years of age or on clothing or objects. CONCLUSIONS: Female children over 10 years old who report ejaculation or genital contact without bathing have the highest likelihood of positive examinations or forensic evidence. While there are other potential benefits of early examination, physicians seeking to identify forensic evidence should consider the needs of the child and other factors when determining the timing of medical assessment after sexual abuse.     

Methodological issues in child sexual abuse research

The amount of research concerning the prevalence and consequences of child sexual abuse has increased dramatically during the past decade. Too little attention has been paid to possible methodological influences on this research. This investigation reports on the influences of response rate, ordering of questions, and definition of child sexual abuse on the results of a survey of college students' childhood and adolescent sexual experiences. Response rates affected prevalence rate estimates, and the use of varying definitions of child sexual abuse affected estimates of both prevalence and consequences. The importance of the awareness of these methodological issue in future research efforts is discussed.