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Methods of screening and assessing for child sexual abuse

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Title: Methods of screening and assessing for child sexual abuse


1
Methods of screening and assessing for child
sexual abuse
  • L. Dennison Reed, Psy.D.

2

Two Roles for Psychologists in Assessing for
Child Sexual Abuse
  1. Screening for CSA
  2. Comprehensive Assessment for CSA

3
screening for csa vs. Comprehensive
assessment for csa
  • A Screening for CSA simply seeks to answer the
    reporting threshold question Is there a
    reasonable cause to suspect that the child was
    sexually abused?
  • A Comprehensive Assessment for CSA typically
    seeks to answer the question Was the child
    sexually abused? and, if so, seeks to uncover
    details surrounding the abuse. Data gathering
    generally goes well beyond what is required when
    Screening for CSA

4
impetus for screening for csa
  • A childs parent (usually the mother) has
    concerns about possible CSA (usually
    intrafamilial CSA) and requests a screening for
    CSA
  • During a therapy session, a child may make a
    concerning statement to his/her therapist or may
    engage in developmentally abnormal sexual
    behavior
  • During a psychological evaluation unrelated to
    CSA a child may make a concerning statement or
    may engage in developmentally abnormal sexual
    behavior

5
Circumstances that may lead a parent/caregiver
to request a screening for csa
  • The child makes a concerning statement to the
    parent or in the parents presence which raises
    questions in the parents mind about possible
    sexual abuse of the child
  • The parent observes the child engaging in some
    sort of concerning behavior that raises questions
    in the parents mind about possible sexual abuse
  • The parent believes that the child has been
    exposed to someone who is capable of sexually
    abusing the child (e.g., the childs father)

6
A Protocol for Screening for CSA
  • and
  • Case Examples

7
methods of Screening for csa
  • The methods used for CSA screening depend, in
    part, on the concerned partys basis for
    suspicion
  • Depending upon the basis for suspicion, it may or
    may not be necessary for the evaluator to
    interview the child

8
Overview of Typical Steps in Screening for CSA
  • Initial meeting with concerned caregiver alone.
    Determine whether reporting threshold has been
    met based upon parents report of childs
    purported statements and behavior. If threshold
    has been met, file abuse report.
  • If case is ambiguous, meet with child alone for
    one or more forensic interview sessions
  • Make a reporting decision, provide feedback to
    parent (if appropriate) and make an abuse report
    if threshold has been met

9
regardless of the caregivers basis for
suspicion, Routinely inquire about abnormal
sexual behavior
  • It is prudent to determine whether the child has
    engaged in any abnormal sexual behavior even if
    this is not the basis for suspicion (Routinely
    administer the CSBI)
  • When screening for CSA, abnormal sexual behavior
    alone generally meets the reporting thresholdin
    which case it may not be necessary for the
    evaluator to conduct a forensic interview of the
    child

10
Those Who should usually be interviewed when
Screening for Child Sexual Abuse
  • The concerned partyusually the childs
    parent/caregiver
  • The child who is the suspected victim although
    this may not be necessary if
  • The parent reports that the child made a clear
    abuse disclosure
  • The parent reports that the child has engaged in
    sexual behavior that is clearly abnormal
  • Sometimes, others to whom the child has made
    concerning statements or who have observed the
    child engaging in abnormal sexual behavior (e.g.,
    other relatives, day care providers, teachers,
    babysitters)

11
Initial meeting with the concerned caregiver
  • Whenever possible, advise the caregiver of your
    reporting obligations before scheduling the
    initial session
  • The first session is usually limited to meeting
    with the parent alone (no reason to bring the
    child)
  • Obtain informed consent in writing
  • Allow at least 1.5 hours for the initial session

12
Initial meeting with the concerned caregiver
  • If the child is 2-12 years old, have the parent
    complete the CSBI at the outset. Any items
    endorsed by the parent should be reviewed in
    depth
  • Have the parent reconstruct in as much detail as
    possible their basis for concern/suspicion, e.g.,
    the childs concerning statements and how they
    were elicited the childs behavior

13
Assessment of childrens sexual behavior with the
csbiduring screening and comprehensive
assessment for csa
14
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15
Inquire in detail about each endorsed item
  • Confirm that the item was correctly marked have
    parent describe any ambiguous items, e.g., child
    masturbates with hand
  • Have parent elaborate about each endorsed item
  • Who observed the behavior?
  • When and where does it occur?
  • How does the parent react?
  • How does the child react to the parents
    reaction?

16
Three Types of Scores on the CSBI
  • Total score
  • Sex Abuse Specific Items (SASI), e.g., puts
    mouth on anothers sex parts
  • Developmentally-related Sexual Behavior (DRSB),
    e.g., 3-year-old touches sex parts in public
    places

17
CSBI Measures that are most suggestive of CSA
  • Clinically elevated CSBI Total score ( T65)
    is suggestive of sexual abuse.
  • Especially if Sexual Abuse Specific Items
    (SASI) score is also clinically elevated ( T65)
    e.g., puts mouth on another childs sex parts

18
Probable explanations for clinical elevations on
CSBI Total score SASI score
  • Sexual abuse
  • Vicarious exposure to sexuality (e.g., observing
    caregivers or others engaging in sexual behavior)
  • Conduct disorder, Oppositional-defiant disorder
    or general aggressiveness
  • Family nudity
  • Physical Abuse and/or Neglect
  • Deliberate exaggeration of childs sexual
    behaviors on CSBI by the childs caregiver (Total
    raw score gt 45 is likely to be invalid)

19
Inquire about alternative explanations for
childs sexualized behaviors
  • Family nudity (relates primarily to
    self-stimulating behavior and sexual curiosity)
  • Vicarious exposure to the particular sexual
    behavior endorsed
  • Physical Abuse and/or Neglect
  • Conduct disorder, Oppositional-defiant disorder
    or general aggressiveness
  • Also, rule on deliberate exaggeration of childs
    sexual behaviors on CSBI by the childs caregiver
    (Total raw score gt 45 is likely to be invalid)

20
Significance of Developmentally Related Sexual
Behaviors (DRSB) on CSBI
  • DRSB scores are often elevated along with other
    sexual behavior problems, but often relate to
    factors other than sexual abuse, e.g., vicarious
    exposure to family nudity and sexuality
  • When the majority of the CSBI Total score
    elevation is based on DRSB items (rather than
    SASI), these are oftenbut not alwaysyounger
    (non-sexually abused) children in the midst of
    some life transition, e.g., parental divorce

21
The utility of the Trauma symptoms checklist for
children (TSCC) in screening and comprehensive
assessment for csa
  • For kids ages 8-16 consider having them complete
    the TSCC as it may fosteror at least predict
    disclosure
  • It may be helpful to have the child complete the
    TSCC after some rapport building and before
    abuse-related questioning he TSCC

22
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23
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24
Sexual CONcERNS-Distress Subscale (Sc-d) on TSCC
  • Includes items relating to sexual conflicts,
    fears, and other unwanted sexual responses
  • Getting upset when people talk about sex
  • Not trusting people because they might want sex
  • Thinking about sex when I dont want to.

25
Sexual Concerns-Distress (SC-D) Subscale on
TSCCis associated with CSA
  • Includes items relating to sexual conflicts,
    fears, and other unwanted sexual responses
  • Getting upset when people talk about sex
  • Not trusting people because they might want sex
  • Thinking about sex when I dont want to.

26
Significance of Elevations on both the CSBI
Total score and the TSCC Sexual
Concerns-Distress Subscale
  • Although no tests by themselves prove that a
    child was sexually abused, significant elevations
    on both of these scales are particularly
    noteworthy
  • Friedrich (2002) found that high scores on both
    of these scales among children for whom there was
    at most a suspicion of sexual abuse are often
    illuminating of prior sexual maltreatment.
    Follow-up interviews with children in an
    inpatient setting who had elevations on both of
    these scales and had not previously disclosed
    sexual abuse led to disclosures of sexual abuse
    in roughly half of these children

27
Sexually Abused Children Who Are In Denial
Sometimes Obtain Unusually Low Sexual Distress
Subscale Scores
28
--Screening--Case Examples
29
The case of DD
  • 9 year-old girl referred for evaluation because
    of an upsurge in night terrors, difficulty
    sleeping alone, problems separating from mother,
    withdrawal from/avoidance of father, and recent
    onset masturbation. DD also began insisting on
    wearing baggy T-shirts and jeans. Although DD
    was several years away from menarche, her mother
    found tampon containers in DDs clothes and bed
    sheets and DD admitted she had put them in
    herself, but she denied she had been molested or
    that anyone told her how to use tampons. DDs
    behavioral problems began about 3 months ago.
  • DDs mother completed the CSBI. DD underwent an
    initial rapport building session and completed
    the TSCC

30
  • DD obtained CSBI Total score of 68 and SASI score
    of 54 based on
  • Stands too close to people
  • Talks about wanting to be the opposite sex
  • Masturbates with hand
  • Touches sex parts when at home
  • Puts objects in vagina
  • Gets upset when adults are kissing
  • Is very interested in opposite sex

31
DDs TSCC results
  • Clinically significant problems on three
    subscales
  • Sexual Concerns-Distress
  • Post-traumatic stress
  • Anxiety
  • PTSD subscale
  • Anxiety subscale

32
Findings re. DD
  • During the 2nd interview of DD, she reported she
    had been fondled on 4 occasions while at summer
    camp by a 15-year-old boy who also attended the
    camp. DD stated, He ordered me to meet him at
    midnight by the canoes or he would kill me. She
    further stated that he rubbed her chest and
    down there indicating her vagina. She had told
    no one about the abuse and explained that as soon
    as she returned from camp (three months ago), she
    switched to wearing only baggy T-shirts and jeans
    so boys dont like me.

33
The case of EE
  • 10-year-old boy referred for screening by after
    two unrelated boys in EEs neighborhood
    complained that EE had anally penetrated them
    with an object.
  • EE was living with his mother and two siblings at
    the time of the screening. EEs mother did not
    believe EE had been molested however, her oldest
    child had been molested by a maternal uncle when
    the mother was in treatment for substance abuse
    more than one year earlier. The uncle had been
    sentenced to outpatient therapy after pleading
    guilty to molesting one of his nieces.

34
  • EEs CSBI Total SASI T-scores gt110 (Total raw
    score 30 not exaggerating) DRSB T-score 45
  • Touches sex parts at home and in public places
    masturbates with object (blanket, pillow, plastic
    toy) French kisses pretends dolls are having
    sex talks about sex acts touches mothers
    breasts touches other childrens sex parts
    tries to have intercourse with other children
    touches animals sex parts

35
Findings re. EE
  • A pediatric exam found evidence of anal scarring
    that could be consistent with anal penetration
    however, EE had a history of encopresis, which
    could explain the scarring
  • EE admitted that his maternal uncle had molested
    EE for more than two years, and the most recent
    incident had occurred 3 months earlier (while the
    uncle was in outpatient therapy for molesting
    EEs sister). EEs molestation included
    fondling, sodomy and fellatio
  • EEs uncle was subsequently convicted for
    molesting EE

36
The Case of AA
  • 7-year-old boy referred by his family physician
    who thought AA may have been sexually abused by
    his mothers former boyfriend
  • AAs mother reported that her ex-boyfriend had
    been physically abusive to AA, which is what
    prompted their separation. She also said AA had
    witnessed her having intercourse with her
    ex-boyfriend, probably more than once. The
    ex-boyfriend also frequently touched her in a
    sexual fashion in AAs presence, e.g., lifting up
    her blouse or skirt and putting his hand inside
    her pants. She and her son had lived in 16
    different homes since the AAs birth.

37
  • AAs CSBI (by mother) Total T-score 73 SASI
    T-score 71
  • Touches or tries to touch (mothers) breasts
    touches (mothers) sex parts, e.g., he grabbed
    her crotch when she was wearing a swimming suit
    talks about sexual acts wants to watch TV or
    movies that show nudity is very interested in
    the opposite sex (i.e. , his mother)

38
Information provided by AAs grandmother and
teacher
  • AAs grandmother, who baby-sits AA 60 hrs. a
    week, completed the CSBI. This resulted in
    scores in the normal range on Total score and
    SASI. She denied that AA had ever touched her
    breasts or grabbed her sexually (as he had done
    to his mother), or that he self-stimulated
  • AAs (female) teachers description of AAs
    behavior was quite similar to the grandmothers
    description. She denied having seen AA engage in
    any sexual behavior in the classroom.

39
Findings re. AA
  • AA denied that his mothers ex-boyfriend or
    anyone else had molested him but he acknowledged
    seeing mothers ex-boyfriend engage in sexual
    behavior with his mother
  • Although AA obtained SASI and Total scores in the
    clinical range on the CSBI completed by his
    mother, his sexual behavior was restricted to
    acting out with his mother and there was no
    indication that he engaged in self-stimulating
    behavior, or sexual activity with himself, or
    with any adults or with his peers
  • it was concluded that his sexual behavior was
    most likely primarily the result of his exposure
    to sexuality between mother and her ex-boyfriend
    rather than being attributable to contact sexual
    abuse

40
Sexual Distress Subscale on TSCC
  • Includes items relating to sexual conflicts,
    fears, and other unwanted sexual responses
  • Getting upset when people talk about sex
  • Not trusting people because they might want sex
  • Thinking about sex when I dont want to.

41
Screening with TSCC Sexual Distress
Subscale--Case Examples--
42
  • R.D.-12 y/o Asian female reporting extensive PA
    from age 7 by mother SA from age 9 by older
    brother
  • Valid profile Clinical elevations on SC, SC-P
    and SC-D ANX, DEP, PTS and DIS-F
  • Common profile for chronic abuse extensive
    treatment probably necessary

43
  • SH-10 y/o White F. forcibly raped on way home
    from school. Genital trauma consistent with
    forced sex. No other trauma history
  • Valid profile Clinically elevated SC-D only.
  • Common profile for acute (not chronic) sexual
    victimization. Future elevations on PTS and/or
    DEP are possible

44
  • A.F. 9 y/o White M in treatment for school probs.
    Denies SA, but step-brother admitted anally
    raping A.F. for years. Also, medical evidence of
    chronic anal penetration
  • Invalid profile (UND 76T) no clinical scale
    elevations. Common among abused children denying
    abuse

45
the Child interview modelused by MHP, CAC/CPT
LE
  • Consists of forensic interview(s) of the
    suspected victim
  • In most cases, the childs abuse-related
    statements and the manner in which they were
    elicited are the most important, and often the
    only evidence of CSA
  • Research has found that most children who are
    suspected victims of CSA disclose abuse when
    interviewed at forensic interview centers, e.g.,
    Childrens Advocacy Centers, Child Protection
    Teams. Most of these children had made prior
    disclosures
  • Abuse disclosure is more likely when (1) the
    child has made a prior disclosure (2) the child
    is older, e.g., gt6 y/o (3) the abuser is a not a
    relative and (4) the childs caregiver(s) are
    open to the possibility that the child was
    sexually abused

46
How many times should a child be interviewed
about CSA?
  • This depends on what happens during the
    interview(s)
  • Multiple interviews coupled with leading,
    suggestive and misleading questions can result in
    some young children (especially those 3-5
    years-old) falsely affirming sexual abuse
  • Multiple interviews in which children are
    questioned in a non-leading manner are much less
    likely to falsely affirm abuse and sexually
    abused children may be more willing to disclose
    abuse and be more able to recall greater detail
    about their abuse when interviewed on multiple
    occasions

47
Factors relating to the child and the scope of
the evaluation also determine the number of
interviews
  • The childs age, functioning, attention span,
    rapport with the interviewer, willingness to
    discuss abuse (e.g., whether there was a prior
    disclosure), and the childs safety are important
    factors
  • If the scope of the evaluation is narrow (e.g.,
    screening for CSA) one or two child interviews
    may suffice for some children. If the scope is
    broader (e.g., comprehensive psychological
    evaluation of the child), more interviews will be
    needed

48
Extended evaluations
  • Extended evaluations are recommended when the
    results of the first interview(s) are
    inconclusive
  • The National Childrens Advocacy Center (NCAC)
    found that about 25 of cases could not be
    resolved during a single interview however,
    after about 6 abuse-focused interviews, 75 of
    these cases were resolved (i.e., in about 50,
    abuse was substantiated about 25 were
    determined not to involve abuse and 25 were
    still inconclusive)

49
Documentation of abuse-related interviews of
children
  • There should be a good record of the entire
    interview but, most importantly, the
    abuse-related portion
  • The record should include not only the verbatim
    abuse-related statements and information provided
    by the child, but also the verbatim questions and
    other methods used by the interviewer to elicit
    the information
  • The childs non-verbal gestures should also be
    included, e.g., avoidant behaviors, gaze
    aversion, affect

50
Documentation via note-taking
  • Note-taking has serious disadvantages
  • Research has shown that interviewers
    contemporaneous verbatim notes failed to
    include more than half of their questions and
    comments and about one-fourth of the details
    provided by children. Interviewers also tended to
    attribute childrens responses to more open-ended
    questions than the interviewers actually
    asked(Lamb, et al, 2000). This could lead to
    erroneous conclusions about whether abuse
    occurred.
  • It is unrealistic to expect interviewers to be
    able to note, verbatim, all the critical
    information while simultaneously questioning a
    child about abuse or to recall, after the fact,
    the abuse-related conversation verbatim

51
Documentation via audiotaping
  • Advantages
  • Far superior to note-taking
  • Provides a complete record of all verbalizations
  • Good audiotape (digital) recorders are relatively
    inexpensive compared to video cameras
  • Disadvantages
  • Non-verbal gestures are not recorded
  • Poor interview techniques and childs
    inconsistent statements are exposed and can
    become the focus
  • Poor-quality recorders poor recording methods
    can result in inaudible recordings
  • A minority of children may be inhibited by the
    tape-recorder
  • Note It is prudent to take some notes even when
    audiotaping interviews

52
Documentation via videotaping
  • Advantages
  • Most complete record of verbalizations and
    non-verbal gestures
  • Videotapes of children disclosing abuse may be
    very persuasive in convincing others that abuse
    occurred (e.g., non-offending parent, juries) and
    effective in eliciting confessions/pleas from the
    abuser
  • Disadvantages
  • Not readily available for spontaneous disclosures
  • Poor interview techniques and childrens
    inconsistent statements are exposed and can
    become the focus
  • Videotaping can inhibit some children

53
Spontaneous csa disclosures by children in
therapy should also be properly documented
  • Sometimes children who are in therapy for
    situations or problems unrelated to CSA
    spontaneously disclose abuse to their therapist
  • Sexual abuse disclosures to therapists should
    also be properly documented and such disclosures
    warrant an abuse report

54
Permission to tape and informed consent to tape
  • Whether your task is to screen for CSA or to
    provide services unrelated to CSA (e.g., therapy,
    psychological evaluation), it is desirable at the
    outset of the professional relationship to obtain
    the parents consent (in writing) for you to tape
    sessions with the child at your sole discretion
  • It is unethical to audiotape or videotape a child
    without their knowledge, so be sure to inform the
    child about the taping in a developmentally
    appropriate fashion

55
Limitations of the child interview model
  • Many forensic interview centers (and some
    psychologists) perform only one child interview,
    which is sometimes insufficient
  • Some sexually abused children will require more
    than one interview before disclosing
  • Other children will not disclose their abuse or
    will deny abuse despite the number of
    interviewsespecially if (1) they have not made
    a prior disclosure (2) they are younger,
    especially ages 3-6 (3) the abuse was
    perpetrated by a relative and, (4) the childs
    caregivers reject the possibility that the child
    was sexually abused

56
The joint investigation modelused by law
enforcement and cps
  • This model is not utilized by mental health
    professionals but it is the model that is usually
    employed when an abuse report is made
  • Collaborative investigation by Child Protective
    Services (e.g., DCF) and Law Enforcement
  • Most states have statutes requiring joint
    investigation by CPS and LE in child abuse cases
  • Data gathering usually includes interviews of
    the child, the non-suspected parent(s), the
    suspect other potential witnesses a forensic
    medical exam of the child (rape kit) and
    sometimes collection of physical evidence at the
    crime scene

57
Advantages and limitations of the joint
investigation model
  • Advantages
  • Reliance on multiple sources of data (not just
    the child interview) enhances the prospects for
    arriving at the truth
  • Can be very effective when there is good
    interagency cooperation and a swift response to
    maximize the element of surprise)
  • Limitations
  • Turf wars and lack of information sharing
    between agencies can result in ineffective
    investigation, repetitive interviews, etc.
  • Many LE agencies fail to pursue CSA cases
    aggressivelyespecially intrafamilial cases

58
The Parent-child interaction model
  • Observation of interaction between parents and
    child
  • Typically used only in cases of suspected incest
    perpetrated by a parent
  • Usually used in combination with other models,
    e.g., child interview, comprehensive assessment

59
Limitations of the parent-child interaction model
  • There are no empirically validated criteria for
    distinguishing between parent-child interactions
    that are indicative of incest and those that are
    not
  • There is considerable variability in how
    incestually abused children and their abusing
    parents relate to each other. Many children who
    have been sexually abused by a parent show
    affection towards that parent and dysfunctional
    parent-child interactions can have many different
    causes

60
Parent-child contact is contraindicated for
certain vulnerable children
  • Parent-child contacteven when it is
    supervisedcan exacerbate emotional problems in
    some vulnerable children, e.g., those suffering
    from PTSD resulting from traumatic incest
    perpetrated by that parent
  • In such cases, interaction between the parent who
    is the accused/suspected abuser and the child
    should be avoided

61
Highly questionable parent-child strategies
  • Some mental health professionals (e.g., Gardner)
    recommend
  • Interviewing the child about the suspected abuse
    in the presence of the accused parent
  • Having the accused parent confront the child
    regarding the sexual abuse allegations

62
Professional guidelines provide conflicting advice
  • APSAC Practice Guidelines (1997) state
  • No one suspected of committing abuse should be
    present or in the vicinity during an
    investigative interview of the suspected child
    victim. This precaution should preclude the
    suspected offender from accompanying the child to
    and from the interview site (p.4)
  • American Academy of Child Adolescent
    Psychiatry-AACAP (1997) guidelines state
  • If a false allegation is suspected consider
    interviewing child and alleged perpetrator
    together, especially if the allegation arose in
    context of a custody or visitation dispute. Keep
    in mind the effect of such an interview on the
    child. The AACAP guidelines also note that this
    practice is controversial (p. 22)

63
Be prepared to defend your procedures on
scientific grounds
  • Since empirically-derived criteria for
    distinguishing between parent-child interactions
    that suggest incest and those that do not are
    lacking, the practice of making such
    determinations on this basis does not appear to
    be defensible on scientific grounds
  • Interviewing a child about abuse in the presence
    of his/her suspected abuser, and insisting that
    the accused parent confront the child about the
    abuse are not empirically supported
    strategiesand are arguably unethical practices

64
The comprehensive assessment modelused
primarily by MHP
  • Mental Health Professionals most often use this
    model when appointed by family court judges to
    evaluate for suspected incestual abuse and other
    matters in the context of a child custody
    evaluation (e.g., parental substance abuse,
    domestic violence, custody recommendations)
  • Data gathering may include interviews and
    psychological testing of the parents and child
    home visits and obtaining information from
    collateral informants, e.g., other MHPs,
    schools/teachers, medical doctors, protective
    services (abuse reports), legal documents,
    criminal history, polygraph results

65
Advantages and limitations of the comprehensive
assessment model
  • Advantages
  • Because it is broad in scope, it is more likely
    to yield valid results and more likely to uncover
    evidence of abuse than are less comprehensive
    models
  • Disadvantages
  • Costly and time-consuming

66
regardless of whether one is performing a
comprehensive assessment for csa or is merely
screening for csaChild interviewing skills are
critical
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