Perinatal interventions for mothers and fathers who are survivors of childhood sexual abuse

Childhood sexual abuse (CSA) is a worldwide problem with severe long-term consequences. A history of CSA can impact the childbearing experience of mothers and fathers; affecting their mental health, parenting skills and compromising infant development. Nonetheless, the perinatal period offers huge opportunity for intervention and hope. This literature review collates evidence for perinatal psychosocial interventions targeting both mothers and fathers who are survivors of CSA. Publications dating from 1970 to June 2016 were searched using Medline, Maternity and Infant Health, PsychINFO, PsychArticles, PubMed and the International Bibliography of the Social Sciences (IBSS). There were no perinatal interventions that considered the needs of survivor fathers. Sixteen publications on 9 psychosocial perinatal interventions for CSA survivors were identified. However, no sub-analyses specific to CSA survivors were reported. Trauma-specific perinatal interventions drew from a range of theoretical models and varied widely in format. Generally interventions were associated with improvements in maternal mental health, parenting competence, infant attachment security and positive public health outcomes. They were safe and feasible to implement, acceptable to parents and therapist, and therapists were able to implement protocols with adequate fidelity. Yet current data is hampered by small sample size, inconsistent reporting of CSA rates and outcome measures, scarcity of observational data and longer-term follow-up. Intervention modifications are proposed for CSA survivors in view of their unique childbearing experiences.     

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.     

Parenting behaviors and perceived parenting competence of child sexual abuse survivors.

OBJECTIVE: This paper reports data testing two alternative hypotheses: (1) the relationship between child sexual abuse and subsequent parenting attitudes and behaviors is a function of the third variable, growing up experiences other than CSA; and (2) maternal depression mediates the relationship between CSA and the same parenting variables. METHOD: The current study was a retrospective survey of 516 very low-income, urban mothers. Parenting was assessed with three measures: The Parenting Competence Scale and the verbal and severe violence subscales of the Conflict Tactics Scale. RESULTS: Findings for two of the dependent variables, perceived parenting competence and severe violence, supported the third variable hypothesis. The mediational hypothesis was not supported for any of the parenting indicators. CONCLUSIONS: Findings regarding the third variable hypothesis are discrepant from those of the one earlier study that tested this hypothesis, suggesting that before conclusions can be drawn regarding the effect of CSA on parenting further research is in order.     

Reaction to videocolposcopy in the assessment of child sexual abuse.

OBJECTIVE: The purpose of this study was to clinically assess children's reactions to videocolposcopy with real-time observation of magnified anogenital images (VCO), and to evaluate whether these reactions are affected by patient or other characteristics such as response to preparation, disclosure of child sexual abuse (CSA), or examination findings. METHOD: Consecutive cases of children ages less than 18 years referred to a children's hospital clinic for nonemergent evaluation of suspected CSA during 1997 through 1999 were studied. We noted the child's response with clinical observation before and after videocolposcopy, and used the Genital Examination Distress Scale (GEDS) after evaluation. We compared these responses to patient gender, age, ethnicity, pubertal status, disclosure of child sexual abuse (CSA), and physical examination findings using univariate and regression analyses. RESULTS: Two hundred twenty-seven children (mean age 7.2 years, range 0-17) underwent videocolposcopy, of whom 55.1% disclosed sexual abuse and 17.2% had a positive examination. More than 80% were female, prepubertal, and non-Hispanic White. Most (85%) watched their examination on the monitor and were either cooperative or enthusiastic before and after videocolposcopy. Fewer very young children (ages 0-3 years) or female adolescents (13-17 years) watched the monitor. Summed GEDS scores were strongly correlated with observed responses after the procedure (p = .01), and children with CSA disclosure were three times more likely to watch the monitor and five times more likely than those without disclosure to have improved comfort. Other patient characteristics were not significantly associated with patient reaction to VCO. CONCLUSIONS: Most children are interested in watching their anogenital examination using magnified real-time images obtained during videocolposcopy and tolerate the procedure well. The GEDS is highly correlated with subjective clinical observation. While some children may particularly benefit from participating in their examination by using VCO, long-term effects of the evaluation and any relationship of a child's reaction to videocolposcopy with their history of sexual victimization remain to be established.     

Expert medical assessment in determining probability of alleged child sexual abuse

The purpose of this paper is to describe the role of the physician as part of the investigative team in child sexual abuse both in corroborating previously obtained disclosures and in determining the level of probability of sexual abuse where there has been no disclosure. At retrospective chart audit, history of physical and behavioral symptoms and physical and laboratory findings suggestive of child sexual abuse were correlated with allegations where known in order to classify 63 patients as to probability of sexual abuse. In this study 14.3% of cases were "unfounded" based on available evidence while 65% were "probable" or "determined." The remainder were "uncertain." Of 16 patients with physical signs, in 11 cases physical findings corroborated suspicion of child sexual abuse. The need for a systematic approach to the "directed medical interview" and examination, preferably videotaped, is discussed.     

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.     

Gender differences in social reactions to abuse disclosures, post-abuse coping, and PTSD of child sexual abuse survivors

OBJECTIVE:This research examines the understudied issue of gender differences in disclosure, social reactions, post-abuse coping, and PTSD of adult survivors of child sexual abuse (CSA). METHOD:Data were collected on a cross-sectional convenience sample of 733 college students completing a confidential survey about their demographic characteristics, sexual abuse experiences, disclosure characteristics, post-abuse coping, and social reactions from others. RESULTS:Female students reported greater prevalence and severity of CSA, more distress and self-blame immediately post-assault, and greater reliance on coping strategies of withdrawal and trying to forget than male students. Women were more likely to have disclosed their abuse to others, to have received positive reactions, and to report greater PTSD symptom severity, but were no more likely to receive negative reactions upon disclosure than men. Women delaying disclosure had greater PTSD symptom severity, whereas men's symptoms did not vary by timing of disclosure. Additional regression analyses examined predictors of PTSD symptom severity and negative and positive social reactions to abuse disclosures. CONCLUSIONS:Several gender differences were observed in this sample of college students in terms of sexual abuse experiences, psychological symptoms, coping, PTSD, and some aspects of disclosure and social reactions from others.     

Adult mental health outcomes of child sexual abuse survivors born at extremely low birth weight

The high prevalence of child sexual abuse (CSA) is concerning, particularly as survivors are at increased risk for multiple adverse outcomes, including poor mental health across the lifespan. Children born at an extremely low birth weight (ELBW; <1000 g) and who experience CSA may be a group that is especially vulnerable to psychopathology later in life. However, no research has considered the mental health risks associated with being born at ELBW and experiencing CSA. In this study, we investigated the mental health of 179 ELBW survivors and 145 matched normal birth weight (NBW; >2500 g) participants at ages 22–26 and 29–36. At age 22–26, CSA was associated with increased odds of clinically significant internalizing (OR = 7.32, 95% CI: 2.31–23.23) and externalizing (OR = 4.65, 95% CI: 1.11–19.51) problems among ELBW participants exposed to CSA compared to those who did not, though confidence intervals were wide. At age 29–36, CSA was linked to increased odds of any current (OR = 3.43, 95% CI: 1.08–10.87) and lifetime (OR = 7.09, 95% CI: 2.00–25.03) non-substance use psychiatric disorders, however, this did not hold after adjustment for covariates. Statistically significant differences in mental health outcomes were not observed in NBW participants exposed to CSA compared to NBW participants who were not exposed. Survivors of significant perinatal adversity who are also exposed to CSA may be at higher risk for psychopathology through the fourth decade of life.     

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.     

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.     

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.     

Suicide attempts in sexual abuse victims and their mothers

Suicide attempts occurred in 11 of 201 (5.4%) families in which sexual abuse was substantiated during a 2$\text{1}\text{2}$-year study period. Thirteen attempts occurred in the eleven families—five in mothers and eight in daughter-victims. No perpetrators in this social agency sample attempted suicide. Three mothers made attempts within the 1st week after the sexual abuse report; these three had borderline personalities, prior suicide attempts, personal histories of incest, and, surprisingly, all returned rapidly to adequate maternal functioning. The two mothers who made attempts later had primary depressions with underlying dependent personalities and never returned to successful mothering of their victimized daughters, both of whom themselves attempted suicide later in the family's treatment course. All eight daughters who attempted suicide were 14 to 16 years old and had been involved in incest with father figures. None of their families remained intact after the disclosure of incest, and their mothers actively blamed and disbelieved these victims. Seven of the eight had behavior problems which may have masked 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.     

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.     

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%.