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.     

Narrative fragmentation in child sexual abuse: The role of age and post-traumatic stress disorder

The present study aimed to assess the effects of age and PTSD on the narrative fragmentation in memories for child sexual abuse. Lexical complexity, cohesion and coherence were analyzed within a group of 86 allegations of children (M = 10 years; SD = 3.7; range: 4–17) who were victims of sexual abuse. Results illustrated that age played an important role in establishing narrative coherence and predicted the level of orientation, the sequence of events and the level of evaluation of the event. Instead, PTSD was related to narrative coherence and cohesion. Therefore, in children, the narrative fragmentation could be an effective diagnostic tool for understanding the effects of PTSD. Moreover in a legal setting the traumatic effects of PTSD on the narrative coherence and cohesion could be significant indices in the evaluation of child testimony.     

Prevalence of child sexual abuse reported by a cross-sectional sample of New Zealand women

OBJECTIVE: The objective is to describe the prevalence of child sexual abuse (CSA) among women in New Zealand, document ethnic specific rates, and outline the frequency of abuse experienced and the most commonly identified perpetrators. Associations between CSA and later adverse consequences were also explored. METHODS: Retrospective report from a random sample of 2,855 women aged 18-64 years old in two regions in New Zealand. Face-to-face interviews with one randomly selected woman from each household were conducted. RESULTS: The overall prevalence rates for CSA were 23.5% for women from the urban region and 28.2% from the rural region. In both urban and rural regions, Māori women more frequently reported experiences of CSA than women from European and other ethnic groups (urban: 30.5% vs. 17.0% and rural: 35.1% vs. 20.7%). The median age of onset of the abuse was 9 years, and the median estimated age of the abuser was 30 years. Half of those who experienced CSA reported that it occurred once or twice, 27% "a few times," and 23% "multiple times." Sole perpetrators were involved in 83% of cases. The majority of cases were perpetrated by a family member, most frequently male. Compared with non-victims, victims of CSA were twice as likely to experience later intimate partner violence and violence by others. CONCLUSIONS: This study reports on a large, population-based sample in an ethnically diverse population in New Zealand, providing the first ethnic-specific rates of CSA available. Findings suggest important priorities for prevention and intervention activities.     

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.     

Incidence and impact of sexual abuse in a child outpatient sample: The role of direct inquiry

From the child psychiatry outpatient department of a university medical center, 64 charts were reviewed in two phases: 29 were randomly selected from outpatient files, and 35 were examined after clinicians were asked to directly query sexual abuse. Although the reported sexual abuse rate for randomly selected charts was quite low (6.9%), reference to sexual abuse history in charts of children who were asked about molestation was 4.5 times more frequent (31.4%; 11.5% of all boys, 50% of all girls). Children with an identified sexual abuse history reported more psychological symptoms, had made more suicide attempts in the past, and were more likely than nonabused children to receive a diagnosis of major depression.     

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.     

Pregnancy and delivery for women with a history of child sexual abuse

OBJECTIVE: To study whether women with a history of child sexual abuse are at increased risk of delivering low birth weight infants. Secondary aims were to study smoking habits, obstetric complications, health care use, and health complaints during pregnancy among women with a history of child sexual abuse. METHOD: In a case control study, 82 women with birth of a low birth weight infant (< 2500 g) (cases) and 91 women with birth of a normal birth weight infant (controls) were interviewed about experiences of child sexual abuse. RESULTS: Fourteen percent of the women disclosed a history of child sexual abuse involving at least genital touch. Birth of a low birth weight infant was not associated with a history of child sexual abuse (OR 1.03, 95% CI .44-2.40). More women with a history of child sexual abuse were smokers during pregnancy (56% vs. 31%) compared with nonabused women. Abused women reported lower age at menarche and sexual debut. Nonscheduled contacts with the antenatal care clinic and discomfort during pregnancy were more frequent among abused women when controlled for low birth weight. CONCLUSIONS: Women who delivered low birth weight infants were not more likely to have experienced child sexual abuse than women who delivered nonlow birth weight infants. Abused women were unemployed and daily smokers more often than nonabused women. Some of the abused women reported more health complaints, and more use of health care services during pregnancy, but did not have more obstetric complications during pregnancy and delivery.     

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.     

Improving credibility assessment in child sexual abuse allegations: the role of the NICHD investigative interview protocol

OBJECTIVES: The study was designed to explore whether the credibility of children's statements regarding their alleged experiences of child sexual abuse could be assessed in a more valid and reliable way when investigative interviews were conducted using the NICHD protocol rather than in an unstructured manner. METHODS: Forty-two experienced Israeli youth investigators each assessed the credibility of allegations of sexual abuse made by alleged victims of sexual abuse when interviewed either with or without the protocol. Half of the alleged incidents were judged likely to have happened ("plausible") on the basis of independent evidence, while half were deemed unlikely to have happened ("implausible"). RESULTS: More non-protocol than protocol interviews were rated as "No judgment possible" rather than either credible or incredible. Allegations made in protocol interviews were more accurately rated as credible or incredible when they were either plausible or implausible, respectively, than those made in non-protocol statements. Levels of inter-rater reliability were also higher when protocol interviews were rated. The differences were significant only for plausible cases, however. CONCLUSIONS: The use of the NICHD protocol facilitated the assessment of credibility by child investigators although incredible allegations (those describing incidents that were unlikely to have happened) remained difficult to detect, even when the protocol was used.     

Childhood sexual abuse, attachment, and trauma symptoms in college females: the moderating role of attachment

OBJECTIVE: The present study tests a model linking attachment, childhood sexual abuse (CSA), and adult psychological functioning. It expands on previous work by assessing the degree to which attachment security moderates the relationship between a history of child sexual abuse and trauma-related symptoms in college females. METHOD: Self-reports of attachment, childhood sexual abuse, and adult psychological functioning were obtained from 324 female undergraduate students attending a Southeastern U.S. university. Separate analyses were conducted examining the potential moderating role for close-adult, parent-child, and peer attachment styles. RESULTS: In this sample, 37.7% of participants reported sexually abusive experiences prior to age 16. History of child sexual abuse was consistently associated with higher levels of trauma-related symptoms and lower levels of attachment security in close-adult, parent-child, and peer relations. Additionally, attachment security was consistently associated with trauma-related symptoms. Close-adult, parent-child, and peer attachment differentially moderated trauma-related symptoms. Specifically, in peer relationships, the strength of the relationships between attachment measures and trauma symptoms were greater for CSA survivors than for non-abused participants. The opposite pattern of results was found for attachment in parental and close-adult relationships. CONCLUSION: Results suggest that attachment security in peer and parent relationships protects against the negative effects of CSA, while only weak, marginally significant protective effects were observed for close-adult relationships. Only modest support was found for the conceptualization of attachment as a moderator of the relationship between CSA and trauma-related symptoms. However, the results suggest that attachment security at least partially protects against negative CSA outcomes.     

The impact of child sexual abuse and stigma on methods of coping with sexual assault among undergraduate women.

OBJECTIVE: The aim of the current study was to determine whether a prior history of child sexual abuse increased the likelihood of using disengagement methods of coping with a sexual assault that had occurred within the past year. Once this was established, a mediational model was tested in which it was hypothesized that specific traumagenic dynamics and changed world views would mediate the association between child and/or adolescent sexual abuse and increased use of disengagement coping methods in response to a recent sexual assault. METHOD: One thousand and fifty women undergraduates from a New England state university completed a survey for research credit. Respondents were asked detailed questions regarding experiences of sexual assault within the past year, histories of child and/or adolescent sexual abuse, traumagenic dynamics, and world assumptions. Analyses were based on 106 participants who had experienced a sexual assault within the past year. RESULTS: Sexually assaulted young women with a history of child sexual abuse used more disengagement methods of coping to deal with the adult sexual assault than women without this history. In addition, the relationship between prior sexual abuse and the use of disengagement coping strategies was mediated by feelings of stigma, but not by feelings of betrayal and powerlessness or beliefs in the meaningfulness and benevolence of the world. CONCLUSIONS: This is the first study to find that sexually revictimized young women may be particularly at-risk of relying on disengagement methods of coping with sexual assault. Furthermore, this association is mediated by feelings of shame or stigma. Directions for further research and clinical implications are discussed.     

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.     

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.     

Religion in child sexual abuse forensic interviews

Religion is an under-studied factor affecting children’s sexual victimization and their willingness to discuss such experiences. In this qualitative study, 39 child forensic interviewers and child advocacy center (CAC) directors in the United States discussed religious influences on children’s sexual abuse experiences, their relationships to CACs, and their disclosures in the forensic setting. Participants reported both harmonious and dissonant interactions between religiously observant children and families on one hand and child advocacy centers on the other. Themes emerged related to abuse in religious contexts and religious justifications for abuse; clergy and religious supports for disclosures as well as suppression of disclosures; and the ways CACS accommodate religious diversity and forge collaborations with clergy. Participants discussed a wide range of religions. Recommendations for practice and research are included.     

The diagnostic utility of sexual behavior problems in diagnosing sexual abuse in a forensic child abuse evaluation clinic

OBJECTIVE: This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample. METHOD: A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores. RESULTS: The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children. CONCLUSIONS: This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse.