Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse

Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p < 0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.     

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.     

An examination of trends in child sexual abuse investigations in Ontario over time

BackgroundChild sexual abuse (CSA) rates have been declining since the 1990s (Dunne et al., 2003; Finkelhor & Jones, 2004, 2012; Jones et al., 2001). Discrepancies in contexts and measures complicate comparing CSA rates across jurisdictions and studies, and there is limited literature about trends in CSA in Canada.ObjectiveUsing data from the Ontario Incidence Study of Reported Child Abuse and Neglect (OIS), the only source of provincially aggregated data in Ontario, Canada, that describes child welfare investigations, this paper provides information on reported and investigated CSA over the past 20 years.Participants and settingThe OIS uses a file review methodology; information is collected directly from investigating child welfare workers.MethodsA sample of child welfare agencies is selected for the study, and data are collected over a three-month period. Weights are applied to produce annual provincial estimates.ResultsThe rates of investigated CSA in Ontario decreased between 1993 and 2013, from 5.20 (95% CI [3.94, 6.47]) to 1.81 (95% CI [0.97, 2.66]) children per 1000. During this time, the rate of all child maltreatment-related investigations doubled, from 21.41 (95% CI [18.38, 24.42]) to 53.32 ([29.61, 77.03]) children per 1000.ConclusionsUnlike other forms of child maltreatment, the incidence of investigated CSA in Ontario declined since 1993. Substantiation rates for CSA investigations decreased more dramatically than the rate of all CSA investigations, which could indicate a true decline in rate or an inability to accurately identify cases of CSA.     

The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children

Data obtained from a random sample of 930 adult women in San Francisco provide the soundest basis heretofore available for estimating the prevalence of intrafamilial and extrafamilial sexual abuse of female children. This article describes the methodology of this survey, as well as some of the key findings. For example: 16% of these women reported at least one experience of intrafamilial sexual abuse before the age of 18 years; 12% reported at least one such experience before the age of 14 years; 31% reported at least one experience of extrafamilial sexual abuse before the age of 18 years; and 20% reported at least one such experience before the age of 14 years. When both categories of sexual abuse are combined, 38% reported at least one experience before the age of 18 years; and 28% reported at least one such experience before the age of 14 years. Only 2% of the cases of intrafamilial and 6% of the cases of extrafamilial child sexual abuse were ever reported to the police. A plea is made for the urgent need to recognize the magnitude of the problem of child sexual abuse, and to act to prevent it.     

The association between perceived injunctive norms toward corporal punishment,parenting support,and risk for child physical abuse

The use of corporal punishment (CP) is a strong risk factor for many poor outcomes for children including child maltreatment. The use of CP occurs within social contexts which are important to understand. Although it is known that perceived social norms regarding CP are related to its use, the specific role that a mother’s primary support person plays in influencing attitudes toward and use of CP remains unknown. The current study assessed linkages between maternal perceived social support in parenting and perceived injunctive norms of CP from her primary source of support, with maternal attitudes toward and use of CP. Survey data were collected from female primary caregivers (N = 436) of children age 2 to 7 years (mean age = 3.7) enrolled in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics in Southeastern Louisiana. Most frequently, the biological father of the child (37.9%) and the maternal grandmother of the child (24.2%) were identified as the participant’s primary source of social support in parenting. Perceived injunctive norms of this support person toward CP use were significantly and positively associated with attitudes toward, AOR = 5.97, 95% CI = [4.04, 8.82], and use of CP, AOR = 3.77, 95% CI = [2.55, 5.59]. However, perceived social support was not associated with these outcomes and also did not moderate these associations. Findings suggest that efforts to reduce maternal risk for child physical abuse and use of CP must include the mother’s primary source of social support if they are to be successful.     

Recorded offending among child sexual abuse victims: A 30-year follow-up

In this paper we employed a prospective design to examine the effect of child sexual abuse (CSA) on life-course offending by comparing victims to both their siblings and random controls in the Netherlands. Information on victimization was gathered from court files and on offending from official criminal records. We found that victims of CSA were more at risk of offending than random controls, but so were their siblings. Only female victims were more likely to offend than their own siblings. The increased risk for offending was not specifically found for sexual offenses, instead it was found for various types of offenses. The found difference between female victims and siblings held true for abuse perpetrated by someone outside the family. We therefore conclude that family and environmental factors are the most important to explain offending among male CSA victims, while these factors alone are not enough to explain the effect of CSA on offending for females.     

The impacts of institutional child sexual abuse: A rapid review of the evidence

While awareness of institutional child sexual abuse has grown in recent years, there remains limited understanding of its occurrence and outcomes as a distinct form of abuse. Drawing on research commissioned by the Australian Royal Commission into Institutional Responses to Child Sexual Abuse, this article presents a rapid review of available evidence on the impacts of institutional abuse on victim/survivors. Literature searches identified 75 sources spanning international peer reviewed work and reports to Government that document or quantify the impacts of mostly historical child sexual abuse occurring in religious, educational, sporting and residential or out-of-home care settings. Consistent with child sexual abuse in other contexts, institutional child sexual abuse is found to be associated with numerous, pervasive and connected impacts upon the psychological, physical, social, educative and economic wellbeing of victims/survivors. Further, institutional child sexual abuse is associated with vicarious trauma at the individual, family and community level, and with impacts to the spiritual wellbeing of victims/survivors of abuse that occurs in religious settings. The identified literature suggests the trauma of institutional child sexual abuse may be exacerbated by the interplay of abuse dynamics in institutional settings, which may reduce or impede circumstances supporting disclosure, belief, support and protection from future harm. Acknowledging the limitations of the present study and the available evidence, this narrative synthesis provides insights into the complex impacts of institutional child sexual abuse.     

Rationalising predictors of child sexual exploitation and sex-trading

Although there is evidence for specific risk factors leading to child sexual exploitation and prostitution, these influences overlap and have rarely been examined concurrently. The present study examined case files for 175 young persons who attended a voluntary organization in Leicester, United Kingdom, which supports people who are sexually exploited or at risk of sexual exploitation. Based on the case files, the presence or absence of known risk factors for becoming a sex worker was coded. Data were analyzed using t-test, logistic regression, and smallest space analysis. Users of the voluntary organization's services who had been sexually exploited exhibited a significantly greater number of risk factors than service users who had not been victims of sexual exploitation. The logistic regression produced a significant model fit. However, of the 14 potential predictors – many of which were associated with each other – only four variables significantly predicted actual sexual exploitation: running away, poverty, drug and/or alcohol use, and having friends or family members in prostitution. Surprisingly, running away was found to significantly decrease the odds of becoming involved in sexual exploitation. Smallest space analysis of the data revealed 5 clusters of risk factors. Two of the clusters, which reflected a desperation and need construct and immature or out-of-control lifestyles, were significantly associated with sexual exploitation. Our research suggests that some risk factors (e.g. physical and emotional abuse, early delinquency, and homelessness) for becoming involved in sexual exploitation are common but are part of the problematic milieu of the individuals affected and not directly associated with sex trading itself. Our results also indicate that it is important to engage with the families and associates of young persons at risk of becoming (or remaining) a sex worker if one wants to reduce the numbers of persons who engage in this activity.     

Child sexual abuse prevention education: A review of school policy and curriculum provision in Australia

The past four decades have seen increasing public and professional awareness of child sexual abuse. Congruent with public health approaches to prevention, efforts to eliminate child sexual abuse have inspired the emergence of prevention initiatives which can be provided to all children as part of their standard school curriculum. However, relatively little is known about the scope and nature of child sexual abuse prevention efforts in government school systems internationally. This paper assesses and compares the policies and curriculum initiatives in primary (elementary) schools across state and territory Departments of Education in Australia. Using publicly available electronic data, a deductive qualitative content analysis of policy and curriculum documents was undertaken to examine the characteristics of child sexual abuse prevention education in these school systems. It was found that the system-level provision occurs unevenly across state and territory jurisdictions. This results in the potential for substantial inequity in Australian children’s access to learning opportunities in child abuse prevention education as a part of their standard school curriculum. In this research, we have developed a strategy for generating a set of theoretically-sound empirical criteria that may be more extensively applied in comparative research about prevention initiatives internationally.     

Credibility assessment in child sexual abuse investigations: A descriptive analysis

A major challenge in cases of child sexual abuse (CSA) is determining the credibility of children's reports. Consequently cases may be misclassified as false or deemed ‘no judgment possible’. Based on a large national sample of reports of CSA made in Israel in 2014, the study examines child and event characteristics contributing to the probability that reports of abuse would be judged credible. National data files of all children aged 3–14, who were referred for investigation following suspected victimization of sexual abuse, and had disclosed sexual abuse, were analyzed. Cases were classified as either ‘credible’ or ‘no judgment possible’. The probability of reaching a ‘credible’ judgment was examined in relation to characteristics of the child (age, gender, cognitive delay, marital status of the parents,) and of the abusive event (abuse severity, frequency, perpetrator–victim relationship, perpetrator's use of grooming, and perpetrator's use of coercion), controlling for investigator's identity at the cluster level of the analysis. Of 1563 cases analyzed, 57.9% were assessed as credible. The most powerful predictors of a credible judgment were older age and absence of a cognitive delay. Reports of children to married parents, who experienced a single abusive event that involved perpetrator's use of grooming, were also more likely to be judged as credible. Rates of credible judgments found are lower than expected suggesting under-identification of truthful reports of CSA. In particular, those cases of severe and multiple abuse involving younger and cognitively delayed children are the ones with the lowest chances of being assessed as credible.     

The economic burden of child sexual abuse in the United States

The present study provides an estimate of the U.S. economic impact of child sexual abuse (CSA). Costs of CSA were measured from the societal perspective and include health care costs, productivity losses, child welfare costs, violence/crime costs, special education costs, and suicide death costs. We separately estimated quality-adjusted life year (QALY) losses. For each category, we used the best available secondary data to develop cost per case estimates. All costs were estimated in U.S. dollars and adjusted to the reference year 2015. Estimating 20 new cases of fatal and 40,387 new substantiated cases of nonfatal CSA that occurred in 2015, the lifetime economic burden of CSA is approximately $9.3 billion, the lifetime cost for victims of fatal CSA per female and male victim is on average $1,128,334 and $1,482,933, respectively, and the average lifetime cost for victims of nonfatal CSA is of $282,734 per female victim. For male victims of nonfatal CSA, there was insufficient information on productivity losses, contributing to a lower average estimated lifetime cost of $74,691 per male victim. If we included QALYs, these costs would increase by approximately $40,000 per victim. With the exception of male productivity losses, all estimates were based on robust, replicable incidence-based costing methods. The availability of accurate, up-to-date estimates should contribute to policy analysis, facilitate comparisons with other public health problems, and support future economic evaluations of CSA-specific policy and practice. In particular, we hope the availability of credible and contemporary estimates will support increased attention to primary prevention of CSA.     

Child victims of sexual abuse: Teachers' evaluation of emotion regulation and social adaptation in school

This study assessed the social adaptation of sexually abused children and tested whether children's emotion regulation competencies mediated the association between child sexual abuse (CSA) and two outcomes of the social domain (i.e. withdrawal and social difficulties). A group of 283 child victims of sexual abuse and a comparison group composed of 60 nonabused children was recruited. Teachers completed questionnaires assessing the children's emotion regulation competencies, withdrawal, and social difficulties exhibited in the school context. Results showed that sexually abused children displayed poorer emotion regulation skills and higher levels of both withdrawal and social difficulties relative to nonabused children. CSA was associated with social difficulties and withdrawn behavior through the mediation of emotion regulation competencies. Teachers and school psychologists should be assisted in identifying children at risk of social difficulties and emotional dysregulation and schools be encouraged to adopt a trauma‐informed approach.     

Child sexual abuse research knowledge among child abuse professionals and laypersons

The purposes of this study were to: (1) Assess child abuse professionals’ and nonprofessionals’ knowledge of scientific research findings that are relevant to forensic child sexual abuse (CSA) evaluations and (2) describe associations between child abuse professionals’ levels of research knowledge and their education and experience. An 18-item multiple-choice test was administered to 188 child abuse professionals and 457 nonprofessionals (undergraduate college students) in Brazil and the United States. The nonprofessionals’ average percent correct, M = 44%, was not significantly different than what would be expected for random guessing (45%). The professionals’ average percent correct, M = 55%, was higher than that of nonprofessionals and random guessing (both ps < .001). The average percent correct score for the US-sample psychologists, M = 76%, was higher than the average score of the other professionals, M = 51%, p < .001. Professionals’ educational level, as measured by the highest academic degree obtained, was positively associated with percent correct scores, Spearman's ρ = .46, p < .001. Controlling for educational attainment, professional experience, as measured by the total number of CSA evaluations performed, was weakly associated with percent correct scores, partial r = .15, p = .04. Percent correct scores were low for both nonprofessionals and professionals. Most of the participants in this study were uninformed or misinformed about scientific research findings that are important for conducting optimal forensic CSA evaluations and for making accurate judgments about the validity of sexual abuse allegations.     

Serious games for learning: games-based child sexual abuse prevention in schools

In spite of research demonstrating conceptual weakness in many child sexual abuse (CSA) prevention programmes and outdated modes of delivery, students continue to participate in a diversity of initiatives. Referring to the development of a games-based approach to CSA prevention in Australia, this paper examines empirically based attributes of effective CSA prevention programmes for schools including contemporary pedagogies for learning. The paper draws on findings to inform the conceptual development phase of Orbit, an online, free and equal-access, games-based educational approach to CSA prevention for children aged 8–10 years. First, the paper provides a review of CSA prevention in schools and games-based approaches to key learnings in prevention. Second, an overview of Orbit (the Feeling Safe sexual abuse prevention project) is provided. Finally, implications for the development of games-based prevention programmes are offered and an argument is made for the advancement of games-based prevention resources.     

Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination

BackgroundChildhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam.ObjectiveTo explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology.Participants and SettingCaregivers and adolescents who presented for a child sexual abuse medical evaluation at our county’s child advocacy center.MethodsWe completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached.ResultsThere was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system.ConclusionTelemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.     

Criminal justice outcomes of prosecution of child sexual abuse: A case flow analysis

This study examined the progress and disposition of child sexual abuse cases referred for prosecution in four urban jurisdictions. Most cases were accepted for prosecution. The vast majority of cases carried forward for prosecution resulted in guilty pleas. Only 9% of the total sample went to trial. A majority of the small number that went to trial were convicted. Over 3/4 of those convicted were incarcerated. The rate at which cases were carried forward for prosecution and convicted was comparable to that of a national sample of felony arrests overall, but child sexual abuse cases were more likely to go to trial (p < .005) and received more severe sentences (p < .005). Our results are strikingly consistent with those from previous studies of prosecution of child sexual abuse. A new understanding of prosecution of child sexual abuse is recommended that takes into account the large proportion of cases that do not go to trial.     

A meta-analysis of the prevalence of child sexual abuse disclosure in forensic settings

BackgroundIdentification, substantiation, prosecution, and treatment of child sexual abuse often rely heavily on a disclosure from the victim in the absence of corroborating evidence. For some, disclosure can be impeded by developmental or motivational barriers, thus compromising child safety and wellbeing. The literature on disclosure prevalence and mitigating influences does not yield a coherent picture. A more accurate estimate will help to inform investigation strategies to facilitate disclosure.ObjectiveThis study provides a meta-analysis of available research examining the prevalence of sexual abuse disclosure in forensic interviews with children under 18 years, and examines a range of factors that may influence the likelihood of disclosure.MethodDatabases were searched for published and unpublished studies up to May 2017. In total, 2393 abstracts were assessed for eligibility, 216 full-text articles were reviewed, and 45 samples (with 31,225 participants) provided estimates of effect sizes.ResultsThe mean prevalence of child sexual abuse disclosure in forensic settings was 64.1% (95% CI: 60.0–68.1). Between-study variability was explained by: (1) child age and gender, with higher prevalence in older children and females; (2) prior disclosure, with higher prevalence when present; and (3) study year, with higher prevalence in more recent studies.ConclusionsThis meta-analysis confirms an upward trend in child sexual abuse disclosure prevalence. However, more than a third of children do not disclose when interviewed, with those who are younger, male, and without a prior disclosure at greatest risk. Important implications for forensic interviewing protocols and future research are discussed.     

Physical and sexual abuse among school children: Prevalence and prevention

Prevalence of physical and sexual abuse, with emphasis on data provided by the 1986 National Incidence Study sponsored by the U.S. Department of Health and Human Services, is discussed within certain data collection constraints. Incidence results are reported by subcategory of abuse, child's sex, child's age, child's race/ethnicity, family income, and family size. Effects of physical and sexual abuse and characteristics of abusers are presented to establish the context in which primary, secondary, and tertiary prevention programs are developed and delivered. Research on abuse prevention programs is discussed, with attention drawn to problems associated with the lack of a research base for school-based abuse prevention programs.