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.     

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.     

Multidimensional assessment of resilience in mothers who are child sexual abuse survivors

OBJECTIVE: There has been relatively little attention given to positive adaptation following childhood sexual abuse (CSA), and typically such resilience has been explored primarily in the intrapersonal domain. This study explored questions about later resilience following CSA within a multidimensional framework by assessing resilience across intrapersonal, interpersonal, and intrafamilial domains. METHOD: This community sample consisted of 79 mothers with a history of CSA who had a child living at home with them. Participants completed four outcome measures (Center for Epidemiologic Studies--Depression Scale, Parenting Stress Index [PSI] Health Scale, PSI Parenting Competence Scale, and a measure of marital satisfaction). Risk and protective factors examined in relation to outcome included mother's age, socioeconomic status, severity of the CSA experience, coping strategy (avoidance, seeking social support, and problem solving), child characteristics, and spousal/partner support. RESULTS: Results indicated that when multiple adaptational domains were assessed, mothers showed discrepancies in how adequately they functioned across domains. While severity of the CSA experience was only weakly associated with outcome, use of avoidant coping emerged as a significant risk factor and was strongly and consistently associated with negative outcome across domains. Spousal/partner support was a strong protective factor and buffered the relationship between depressive symptoms and parenting competence. Difficult child characteristics were significantly associated with mothers' perceptions of physical health and parenting competence. CONCLUSIONS: The findings suggest the importance of comprehensive multimethod assessments of resilience and extend the knowledge of factors associated with positive outcome. The results highlight the need for further research exploring current contextual risk and protective factors associated with resilience in each domain.     

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.     

School programs to prevent intrafamilial child sexual abuse

The incidence of child sexual abuse would argue for the schools assuming a larger role in the development of preventive and educational programs. Because of the public school system's consistent and longitudinal contact with children and families it is perhaps the most promising institution for the delivery of preventive efforts. This article presents specific suggestions for school-based programs directed toward the prevention of intrafamilial child sexual abuse. Further, it is argued that for maximum effectiveness, the support of local parent-teacher organizations be elicited; that educational programs be presented separately for parents and children; and that a variety of programs in concert with the development level of participants be presented on topics related to child sexual abuse. Topics regarded as important for prevention efforts are factual information on sexual abuse, appropriate and inappropriate touch, the respective role responsibilities and rights of parents and children, and a sex education approach that stresses the values of nonexploitation and discrimination in the choice of whether to engage in sexual behavior and the choice of partners.     

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.     

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.     

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.     

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.     

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%.     

Counseling in the area of child sexual abuse within the family

This paper considers the recent recognition in Ireland of the problem of child sexual abuse. In 1983, the Government Department of Health, for the first time, allocated a separate category for it in its statistics. Treatment to date has been one of localised and ad hoc arrangements.Counseling approaches follow broadly the divisions that exist in the theoretical models that seek to explain the aetiology of abuse. These can be characterised as (1) those programs that derive from the family systems model and that emphasise dysfunctional family dynamics and (2) programs established for the counseling of a wide range of sex offenders, including intrafamily abusers, and which emphasise traits or aspects of individual perpetrator functioning. Both approaches, however, share fundamental prerequisites. These prerequisites are considered.Three issues are of particular relevance during counseling. The first relates to the child victim at the time of the discovery or disclosure of the abuse, and prior to entry into a family counseling program. The second looks at counseling programs that emphasise the family dimension. The third deals with counseling approaches for perpetrators of abuse. Each of these three topics will be discussed.     

Issues in the definition of child sexual abuse in prevalence research

Despite efforts to promote uniform criteria for defining child sexual abuse, there are still variations in the definitions adopted by individual researchers. This paper focuses on four representative studies, describes differences in the definitions used and examines how such differences may contribute to discrepancies in the estimated prevalence of abuse. Similarities and dissimilarities are identified in several areas: the upper age limit for child sexual abuse, the criteria used to define a given sexual experience as abusive, the inclusion or exclusion of experiences involving age peers, and the use of different criteria for incidents occurring during adolescence. Prevalence rates from one study, which used a slightly less restrictive definition of abuse, were recalculated based on the definitions of other researchers. This resulted in a 14% decrease in the number of individuals identified as abused. While this is a substantial change, it accounts for only a portion of the discrepancy in prevalence rates, suggesting that other factors, such as methodological differences, need to be examined with regard to their impact on prevalence rates. Historical and legal issues pertaining to the definition of child sexual abuse are also discussed.     

The ability of elementary school children to learn child sexual abuse prevention concepts.

This research was designed to address several of the methodological problems in the current body of knowledge on the efficacy of child abuse prevention programs for elementary school-aged children. A new measure, the Children's Knowledge of Abuse Questionnaire (C.K.A.Q.) was developed, and its psychometric properties assessed. In total, 400 children were tested in four groups. Half of the sample participated in a child abuse prevention program Touching, and the other half were in a waiting list control group. Half of each group were pretested, and the other half were not, in order to determine whether the pretesting sensitized the students. All children were tested again 5 months afterward to investigate the long-term retention of prevention concepts. Results showed that children who participated in the prevention program scored significantly higher on the C.K.A.Q. than children in the control condition. Age was a critical factor, with significant improvements as age increased between the kindergarten, Grade 1, Grade 3 and Grade 6 students. All participants maintained their level of knowledge after 5 months had passed. The relevance and practical implications which stem from this research are discussed.     

Abuse in the investigation and treatment of intrafamilial child sexual abuse

This paper examines the effects of current practice in the investigation and treatment of documented incest abusers on the offenders and families involved. Fifteen offenders attending the Utah Parents United group completed a questionnaire on the sequence of events in the investigation and prosecution of their cases and the concomitant results of the investigation on their job status, living and financial situations, family and social relationships, and media reporting of the abuse. Results indicate that there is great variability in the investigation and prosecution of incest cases and the public announcement of abuse convictions. The consequences of the abuse investigation are devastating for offender and his family in terms of job loss; need for public assistance; family disbandonment through removal of the offender, victim, or both from the family, marital separation, and foster care for nonabused siblings; changes of residence, and the public announcement of the abuse in the media. Results also show that offenders receive little, if any, social support from family or friends. Changes in the current approach to the investigation and prosecution of incest offenders are proposed and include the following: (1) banning the publication of convictions for child abuse; (2) streamlining the legal process so that it is consistent from case to case; and (3) developing diversion programs as alternatives to prison for offenders. Suggested are self-help, court-ordered therapeutic programs, such as Parents United, that are designed for the treatment of families involved in child sexual abuse and incest. The desired outcomes of such a diversion program are low offender recidivism, avoidance of the offender's family being placed on welfare, less reliance on foster care placement for the offender's children, involvement of the offender's family in moving toward reunion when feasible, and the use of existing half-way houses in lieu of incarceration when necessary.     

A review of the short-term effects of child sexual abuse

This is the first of a two-part report that critically evaluates empirical studies on the short- and long-term effects of child sexual abuse. With the exception of sexualized behavior, the majority of short-term effects noted in the literature are symptoms that characterize child clinical samples in general. Among adolescents, commonly reported sequelae include sexual dissatisfaction, promiscuity, homosexuality, and an increased risk for revictimization. Depression and suicidal ideation or behavior also appear to be more common among victims of sexual abuse compared to normal and psychiatric nonabused controls. Frequency and duration of abuse, abuse involving penetration, force, or violence, and a close relationship to the perpetrator appear to be the most harmful in terms of long-lasting effects on the child. The high prevalence of marital breakdown and psychopathology among parents of children who are sexually abused makes it difficult to determine the specific impact of sexual abuse over and above the effects of a disturbed home environment. Given the broad range of outcome among sexual abuse victims, as well as the methodological weaknesses present in many of the studies reviewed, it is not possible at this time to postulate the existence of a "post-sexual-abuse-syndrome" with a specific course or outcome.