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.     

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.     

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.     

Juror and expert knowledge of child sexual abuse.

Mental health professionals with expertise in child sexual abuse (CSA) often testify as expert witnesses in court. There is significant controversy over the admissibility of this type of evidence. To be admissible, the testimony of an expert must be beyond the common knowledge of the jury and based on information generally considered to be reliable within the professional community in which it is used. To date, no empirical data have existed to allow courts to make an informed judgement as to the extent of either juror knowledge or professional acceptance of CSA data. The present study addresses this issue. Jurors and experts completed a questionnaire designed to reveal their understanding of CSA. Results indicate that experts demonstrated strong consensus on 29 of 40 items included in the questionnaire, and that relative to experts, jurors have limited knowledge of these issues. These results suggest that many of the scientific findings concerning CSA are reliable and that the information is often beyond the common knowledge of the jury. These findings argue for the use of expert testimony in select cases of child sexual abuse.     

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.     

A review of the long-term effects of child sexual abuse.

The existing literature on the long-term sequelae of child sexual abuse is reviewed. The evidence suggests that sexual abuse is an important problem with serious long-term sequelae; but the specific effects of sexual abuse, independent of force, threat of force, or such family variables as parental psychopathology, are still to be clarified. Adult women with a history of childhood sexual abuse show greater evidence of sexual disturbance or dysfunction, homosexual experiences in adolescence or adulthood, depression, and are more likely than nonabused women to be revictimized. Anxiety, fear, and suicidal ideas and behavior have also been associated with a history of childhood sexual abuse but force and threat of force may be a necessary concomitant. As yet, there is insufficient evidence to confirm a relation between a history of childhood sexual abuse and a postsexual abuse syndrome and multiple or borderline personality disorder. Male victims of child sexual abuse show disturbed adult sexual functioning. The relation between age of onset of abuse and outcome is still equivocal. Greater long-term harm is associated with abuse involving a father or stepfather and abuse involving penetration. Longer duration is associated with greater impact, and the use of force or threat of force is associated with greater harm.     

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.     

Attitudes of health professionals to child sexual abuse and incest

While there has been increasing interest in the topic of child sexual abuse, few studies have focused on attitudes or the determinants of such attitudes held by professionals. To what extent concern is based on stereotyping or factual knowledge is not clear. The present study uses a combination of experimental and survey methodologies to address these issues. Sample case histories were issued to subjects who were then asked to complete a questionnaire on topics relating to the case and to incest in general. Results showed that the type of sexual activity involved influenced responses: type of relationship between adult and child, less so. Estimates of incest were low, but incest was considered, especially by female respondents, to be harmful to the victim.     

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.