Getting evidence into action to tackle institutional child abuse

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse is an example of a government response to survivors’ demands to address the harm they suffered. It is also a major response by a national government to improve child safety in the future. Facing up to child abuse is difficult and in other countries similar inquiries have suffered delays and derailing. This commentary uses an evidence-to-action lens to explore why clear evidence of child sexual abuse may be ignored and side-lined. It argues that where evidence challenges the powerful, is surprising and shocking, or undercuts current institutional and policy arrangements, then that evidence is likely to be ignored, undermined or refuted – all factors which are present in the case of historical institutional child sexual abuse.     

A response to the Royal Commission into institutional responses to child sexual abuse in Australia

Abstract

The final report of the Australian Royal Commission into institutional responses to child sexual abuse comprises 17 volumes, one of which addresses its findings in relation to schools. In this article, I raise two key questions in response to the devastating details of the allegations made by survivors of their abuse: how was any of this possible, and what really does go on in schools? In answer to these questions, I critique both the codes of ethics and conduct authored by the Victorian Institute of Teaching and draw attention to their conceptual inadequacy and terminal ambiguity. I then make a case for renewed research into sociological and historical aspects of schooling in Australia, emphasising a need to gain access to ‘private’, especially boarding, schools. In particular, I argue for a Foucauldian approach to understanding how education in catholic seminaries needs to be better understood in the context of child sexual abuse in Catholic schools.     

Child sexual abuse in Japan: A systematic review and future directions

IntroductionEstimating the national prevalence of child sexual abuse (CSA) and its association with health and developmental outcomes is the first step in developing prevention strategies. While such data are available from many countries, less is known about the epidemiology of CSA in Japan.MethodsFor this systematic review, we searched English databases: Embase, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), Ovid OLDMEDLINE(R), PsycINFO, and Japanese databases: Cinii, J-Stage, Children’s Rainbow Center Japan, Japan Child and Family Research Institute, Japanese Journal of Child Abuse and Neglect to identify articles published before July 2015 examining the lifetime prevalence of CSA in Japan using non-clinical samples. Data were extracted from published reports.ResultsWe initially identified 606 citations and after abstract review, retrieved 120 publications. Six studies that met the selection criteria and additional two relevant studies were reviewed. The range of contact CSA for females was 10.4%–60.7%, and the prevalence of this type of CSA for males was 4.1%. The range of penetrative CSA for females was 1.3%–8.3% and that for males was 0.5%–1.3%. A number of methodological issues were identified, including a lack of validated measures of CSA, and low response rates.ConclusionIn contrast to a lower prevalence of penetrative CSA, the prevalence of contact CSA among Japanese females may be comparable or higher in relation to international estimates. Future research on children's perceptions of and exposure to sexual abuse, crime and exploitation in Japan is discussed.     

Survivors of institutional abuse in long-term child care in Scotland

BackgroundThe Scottish Child Abuse Inquiry (SCAI) commissioned the research project to document the outcomes of institutional abuse in long-term child care in Scotland.ObjectiveTo profile the experiences of survivors abused in long-term child care in Scotland, and to develop a model which linked maltreatment, risk and protective factors, and outcomes.Participants and Setting225 survivors of historical institutional abuse in Scotland, who made witness statements to SCAI.MethodsData were extracted from witness statements using a coding frame developed through a thematic analysis of a subsample of 52 statements.ResultsSurvivors had been in care in predominantly Catholic and non-religious residential institutions in Scotland for an average of 8 years, having entered at an average age of 6.8 years. They had suffered multiple forms of maltreatment. Maltreatment rates were: physical abuse, 95.6%; emotional abuse, 85.3%; sexual abuse, 60.4%; emotional neglect, 51.1%; and physical neglect, 37.3%. Across the lifespan survivors had negative outcomes in psychosocial adjustment (96%), mental health (84%), and physical health (43%). The effect of maltreatment in care on psychosocial problems was mediated by both risk and protective factors; and on mental health was mediated by risk factors, but not protective factors. Maltreatment in care had a direct effect on physical health which was not mediated by risk or protective factors. The effects of the cumulative number of risk factors on adverse mental health and psychosocial outcomes was greater than that of maltreatment, and protective factors had a limited impact on adverse outcomes.ConclusionsEvidence-based child protection policies and practices should be implemented to prevent institutional abuse and treat child abuse survivors in Scotland.     

Child sexual abuse in Indonesia: A systematic review of literature,law and policy

BackgroundLike many middle-income countries, knowledge about child sexual abuse (CSA) is limited in Indonesia. The national government has stated a commitment to protect children from the worst forms of abuse, yet the sensitivity of CSA along with the complexity of culture and law, present substantial challenges.ObjectiveThis article reviews current knowledge about CSA in Indonesia, in the context of existing laws and policies that influence CSA prevention and intervention.MethodA systematic review of this research was conducted in the following manner: a review of scholarly literature and grey literature in English (19 papers) and in Bahasa Indonesian (11 papers), and a review of CSA-related Indonesian laws (4 documents) and policies (5 documents).ResultsThis review finds that knowledge about CSA in Indonesia is still limited. The taboos on discussing sexual matters were identified as factors that impede reporting of CSA. Poverty also leads to increasing children’s risk of sexual abuse. There was less attention to CSA occurring within family contexts and focus was more upon its occurrence outside of the family. The study identified that contradictory definitions of children within the law add to children’s vulnerability to CSA; this is especially the case for girls. Current child protection strategies in prevention and intervention lack specific focus on CSA.ConclusionFurther research is needed to enable the development of evidence-based approaches to better harmonize the development of law and policy with contemporary knowledge about CSA.     

Similarities in modi operandi of institutional and non-institutional child sexual offending: Systematic case comparisons

Little is known about the extent to whichinstitutional child sex offending differs from non-institutional offending. Strategies to secure the compliance of child victims were systematically compared to compare the modi operandi (prior to, during and following abuse), and the type of power (intimate, aggressive, coercive) applied by child sexual offenders in institutional versus non-institutional settings. A sample of 59 of the most recent child sexual abuse cases referred for prosecution in three Australian states was manually reviewed and coded. Of these, six were cases of institutional abuse, one of which involved crossover offending. Based on complainant age and gender and patterns in offending behaviors, institutional cases were matched with cases of non-institutional abuse. Complainants of both genders ranged in age from 5 to 16 years at abuse onset. Offenders were male family members or friends, priests, an employer and one female school teacher. Results demonstrated commonalities in the modi operandi and grooming methods applied in institutional and non-institutional contexts. Implications for abuse prevention are summarized.     

Differences in child sexual abuse cases involving child versus adolescent complainants

While adolescents report the highest rates of sexual abuse victimization, few studies have investigated how child sexual abuse (CSA) cases involving adolescent complainants may differ from cases involving child complainants. The current study draws on 3,430 allegations of CSA in Canada to compare abuse characteristics and judicial outcomes in cases involving adolescent complainants to cases involving child complainants. Adolescent complainants were more likely than child complainants to be abused by a stranger or a person with a community connection to the complainant, while children were more likely than adolescents to be abused by a parent or other relative. Furthermore, compared to child complainants, adolescent complainants were more frequently involved in the most intrusive offenses and their cases were more likely to involve violence. Both groups were most likely to disclose the abuse to a parent, though a greater proportion of children disclosed the abuse to a parent. There were no differences in the delay to disclosure. Accused were equally likely to plead “guilty” and to be convicted in cases involving child and adolescent complainants. However, offenders convicted of the most intrusive offenses received longer probation sentences when the complainant was a child than when the complainant was an adolescent. These findings have implications for ensuring appropriate support and services to adolescent victims of CSA.     

The barriers to a national inquiry into child sexual abuse in the United States

There is an often-overlooked but critical factor at the center of institutional child sexual abuse that must be acknowledged and addressed: adults tend to place the interest of institutions and other adults above the protection of children. As the Australian Royal Commission into Institutional Responses to Child Sexual Abuse has shown, this phenomenon is evident across institutional settings and any institutional reform aimed at improving child safety must therefore guard against this tendency if it is to be effective in protecting children. In the United States there are also other barriers to dealing with child sexual abuse in institutional contexts. State government responses to the challenges of child sexual abuse have varied. However, the federal governmsent has been silent on the problem of religious institutional sexual abuse. This commentary considers how the politics of religious liberty in the United States inhibits action by protecting institutions that cover up child sexual abuse.     

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.     

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.     

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.     

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.     

Child sexual abuse,disclosure and PTSD: A systematic and critical review

BackgroundChild sexual abuse (CSA) is a prevalent exposure with potentially serious, negative health consequences, including post-traumatic stress disorder (PTSD) and its symptomatology.ObjectiveTo conduct a systematic and critical review in order to investigate the relationship between CSA disclosure patterns and PTSD.Participants and settingStudies included clinical, college and community-based samples of adults’ and children’s experiences of CSA.MethodsWe conducted systematic searches in five databases (Medline, Embase, PyscINFO, CINAHL, ERIC, Sociological Abstracts) from database inception to October 17, 2017 using index terms and keywords for CSA, disclosure, and PTSD. We included any English-language, primary studies involving children or adults with experiences of CSA that used quantitative research designs to explore the relationship between disclosure and PTSD. We used systematic critical review methodology in order to investigate the relationship between disclosure and PTSD symptoms and disorders. We also investigated factors that explained the relationship between disclosure and PTSD, such as individual, exposure or environmental factors.ResultsTwenty-two articles reporting 20 studies were included in this review. Studies assessing the relationship between CSA and PTSD tended to account for personal (e.g., gender) and CSA exposure variables (e.g., severity of CSA) only. While authors generally used validated measures to assess for PTSD symptoms and disorders, they tended to use author-generated or unvalidated measures to assess for disclosure process variables.ConclusionThe relationship between factors that affect disclosure, and responses to disclosure, are not well theorized in quantitative literature. Study findings suggest important avenues for future research, such as the need to assess disclosure longitudinally.     

Remaking collective knowledge: An analysis of the complex and multiple effects of inquiries into historical institutional child abuse

This article provides an overview and critical analysis of inquiries into historical institutional child abuse and examines their multiple functions and complex effects. The article takes a broadly international view but focuses primarily on Australia, the UK and Ireland, jurisdictions in which there have been major national inquiries. Drawing on sociological and other social science literature, it begins by considering the forms, functions, and purposes of inquiries. An overview of emergent concerns with institutional abuse in the 1980s and 1990s is then provided, followed by an examination of the response of many governments since that time in establishing inquiries. Key findings and recommendations are considered. The final sections of the article explore the evaluation of inquiries, both during their operation and in their aftermath. Policy change and legislative reform are discussed but the focus is on aspects often underplayed or overlooked, including an inquiry’s credibility, its role in processes of knowledge production, and the part it plays in producing social and cultural shifts. In the context of growing numbers of inquiries across Western democracies, including the Australian Royal Commission into Institutional Responses to Child Sexual Abuse, it is argued that grasping the complexity of the inquiry mechanism, with its inherent tensions and its multiple effects, is crucial to evaluating inquiry outcomes.     

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.     

The unusual suspects: Female versus male accused in child sexual abuse cases

When women encounter the criminal justice system, it is typically as victims rather than as offenders. Consequently, there is limited empirical research on women who have sexually offended against children, but there is a clinically-significant group of victims who have experienced female-perpetrated child sexual abuse (CSA). In a database of 4237 CSA cases that were heard in criminal courts between 1986 and 2012, we found 70 cases that involved female accused. We compared female-accused cases against a randomly selected sample of 70 male-accused cases from the same database. We investigated associations between gender of the accused and characteristics of the victim, offense, and criminal proceeding. Several important differences between female- and male-accused cases were found: proportionally more male complainants were in female-accused cases; female-accused offenses were longer in duration; and despite offenses being similarly intrusive, female perpetrators received shorter sentences. This research indicates that there are potentially unique pathways to abuse for women and men, and unique experiences in the criminal justice system. Although female perpetrators are involved in a small proportion of CSA offenses, the cases that we describe herein are important to consider when developing appropriate support and intervention programs for offenders and victims of CSA.     

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.     

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.     

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.     

A community development approach to the prevention of institutional and societal child maltreatment

The Community/Institutional Development (CID) system addresses the needs of children placed in out-of-home care facilities. The major purpose of the system is to prevent the occurrence of institutional and societal child maltreatment. It features community/institutional collaboration in the review of institutionalized children's care, and the development of programs to prevent child maltreatment. This would represent a genuine collaboration between institutions and their communities, assessing the contributions of both to the quality of child care. At this time the CID system is a pilot project in the state of Kansas. There are a total of eight public and private child care institutions involved. The project is endorsed by the Office of the Governor, the Department of Social and Rehabilitation Services and the Kansas Chapter of the National Committee for the Prevention of Child Abuse. Preliminary impressions indicate that the CID concept is practical, feasible and cost effective. It could also be adapted to the needs of other age groups. The concept is outlined.