Considerations When Performing Psychological Evaluations of Sexually Abused Children

1. Considerations When Performing Psychological Evaluations of Sexually Abused Children L. Dennison Reed, Psy.D. Nova Southeastern University

2. Caveat • This sort of evaluation is to be done only after sexual abuse has been confirmed via a competent assessment

3. Reference • Psychological Assessment of Sexually Abused Children and Their Families (2002). William Friedrich.

4. Purposes of Comprehensive Psychological Evaluation of Sexually Abused Children • Assess the child’s current psychological functioning and treatment needs • Generic and abuse-specific assessment • Evaluations that do not address abuse-specific symptoms are insufficient • Assess the role of “risk factors” and “protective factors” known to moderate the impact of CSA and recovery from CSA—especially family variables

5. An Assessment of a Sexually Abused Child That Does Not Include an Assessment of that Child’s Parents and an Assessment of the Parent-Child Relationship is Severely Limited • Parents can serve as “risk factors” or “protective factors”

6. Healthy Parent-Child Attachments and Parental Support Are The Most Potent “Protective” Factors for Sexually Abused Children • Secure Attachment (preceding, during and after the abuse) • Parent believes the child • Does not blame the child • Is able to speak openly with the child about the abuse • Ensures that the child obtains necessary external support, i.e., therapy, school remediation

7. Family-related “Risk Factors” • Unresolved CSA (or other trauma) in parent(s) • Discontinuity of parenting (disruptions/losses) • Parental alcoholism/psychiatric disorders • Marital Discord, i.e., conflict, separation, divorce • Rejection, physical abuse, emotional abuse, neglect of child • Domestic violence • Educational problems in parent (s) • Employment problems in parents/poverty • Criminal history in either parent • Parents’ inability/failure to use effective child management skills

8. Assessment of ‘parental victimization history’ is a necessary adjunct to the evaluation of the child • A key moderator of the impact of CSA is the parent-child relationship (attachment style) • Insecure attachment predominates in maltreated children. • An enormous risk factor for insecure attachment is a history of unresolved victimization in the parent, i.e., sexual, physical, emotional abuse and neglect • Unresolved history of victimization in the mother is directly related to disorganized attachment in preschoolers; greater vulnerability to anxiety and phobia in childhood; and dissociation when older

9. Screening for Unresolved Trauma in the Parent Trauma Symptom Inventory Intrusive Experiences Defensive Avoidance Sexual Concerns Impaired Self-Reference Tension-Reduction Behaviors Parents struggling with their own abuse often find it especially difficult to be available to help their abused child

10. Who Can We Rely on For An Accurate Description of Children’s Symptoms and Psychological Functioning ? • The sexually abused child? • The child’s parent? • The child’s teachers? • Others?

11. The Parent’s Report and the Child’s Report of Symptoms Are Often Quite Different • The little research that has used multiple reporters with sexually abused children illustrates that the parent and child report show minimal overlap Shapiro, Leifer, Martone & Kassem, 1990

12. Are Sexually Abused Children and Their Parents Accurate Observers and Reporters of Symptoms? • Oftentimes, they are not

13. OVER-REPORTING AND UNDERREPORTING OF CHILDREN’S SYMPTOMS BY SEXUALLY ABUSED CHILDREN AND BY THEIR PARENTS

14. Underreporting Biases In The Self-Reports of Sexually Abused Children*The Attachment Factor* • Sexually abused children who lack secure attachments and who did not grow up in a ‘feelings-friendly’ environment are less able and willing to describe their internal feelings than children who grew up feeling securely attached to their parents and were encouraged to talk about their feelings. Such children tend to underreport their symptoms • British data on sexually abused children in foster care, who would be expected to have an impaired sense of self-worth, showed that ‘none’ of these children were in the problematic range on measures of self-esteem (Farmer & Pollock, 1998)

15. Underreporting Biases In The Self-Reports of Sexually Abused Children*Defense Mechanisms in Traumatized Kids* • Severely abused children often avoid thinking about their distress and often rely on denial and/or rationalization as a primary defense • When children with PTSD are interviewed or complete behavioral checklists, their avoidant symptoms contribute to their denial of subjective distress. The steer clear of any reminders of the trauma

16. Underreporting Biases In Parents of Sexually Abused Children*Parents Who Are Poor Observers* • Parents of sexually abused children are often poor observers of their child. This is particularly true in those cases where: • Incest has occurred on a protracted basis. Incest sometimes persists in part because of parental inattention • The parents have their own psychological problems (i.e., unresolved trauma) • The parents received inadequate parenting themselves • This can result in parents’ underreporting of their children’s behavior problems.

17. Underreporting Biases In Parents of Sexually Abused Children *Defense Mechanisms in Parents* • Shame and Guilt can suppress parents’ reports of behavioral problems in their children. For example, if the abuse is incestuous, the parent may protect themselves or their family from an overload of shame and guilt by minimizing the impact of the abuse

18. Underreporting Biases In Parents of Sexually Abused Children*Deliberate Deception by Parents* • Some parents will deliberately underreport symptoms in their child in order to try to convince others that their child was not abused

19. Over-reporting Biases In Parents of Sexually Abused Children*Depressed & Hypervigilant Parents* • Research shows that parents who are depressed report more symptoms in their child than their children’s teachers do • Parents who have been traumatized by learning of their child’s abuse can become hypervigilant to what they consider to be ‘signs’ that their child is suffering from the abuse

20. Teachers Are Often Excellent Informants About Their Students! • Teachers have a good sense of normative behavior for the children they teach, i.e., normal vs. abnormal behavior for children of a particular age • Teachers oftentimes spend more time with children than the children’s own parents do • Teachers are less likely to be biased when describing “someone else’s” child

21. Don’t forget the Teachers! • BASC2 and CBCL teacher’s report forms can be invaluable in assessing the child and in assessing the response biases of the child and the parent

22. Utilize Multiple Informants Whenever Possible • The child, parents, teachers, extended family, child’s therapist, etc. • This provides a more holistic and more balanced view of the child’s functioning, and also can provide insights about the biases of the various reporters

23. Utilize Multiple Measures Whenever Possible • Some studies of sexually abused children rely on the results of only one measure or test • Different assessment procedures reveal different percentages of asymptomatic children • This is why it is important to use multiple assessment procedures

24. The Kendall-Tackett Meta-Analysis Found That Approximately 30% of Sexually Abused Children Are “Asymptomatic”? • But where did that information come from?

25. Two Major Weaknesses With Kendall-Tackett, et al’s Findings re. Proportion of Asymptomatic Sexually Abused Children(per Friedrich) • Most of the studies included in the Kendall-Tackett meta-analysis used only: • A SINGLE INFORMANT (usually the parent) • A SINGLE MEASURE • Studies using multiple informants and multiple measures have found significantly fewer asymptomatic children

26. Studies using multiple measures and multiple informants generally find lower rates of “symptom-free” sexually abused children • 19% asymptomatic (Wright, 1998) • 12% asymptomatic (Friedrich, 2002)

27. ATTACHMENT- RELATED ASSESSMENT • A growing body of research indicates the centrality of the parent-child relationship in the adjustment of sexually abused children • The quality of the parent-child relationship, more than any other variable, defines the child’s ability to change and rebound from victimization (Friedrich, 2004)

28. Maltreated Children Are Significantly More Likely to be Insecurely Attached than Non-Maltreated Children

29. Sources of Information for Assessing the Parent-Child Relationship • Observation of the Parent-Child or Family Interacting • This is the BEST method for assessing the parent-child relationship and type of attachment • Parent • Interviews, checklists and testing • Child • Interviews, checklists and testing

30. Limitations with Observation of Parent-Child Interaction • The context for the interaction is atypical, i.e., the parent knows they are being observed; the interaction often takes place in the evaluator’s office • One cannot determine whether sexual abuse occurred on the basis of how parents interact with their children during observation

31. Treatment forAttachment-Related Problems • Parent-Child Interaction Therapy (in vivo coaching) • Empirically validated • Effective with preschoolers to early teens • Provides role-modeling and immediate feedback re. identifying positives in the child and the parent, attunement to the child, nurturing, disciplinary strategies • Cognitive therapy approach for non-offending mothers (Deblinger & Helfin, 1996)

32. Limitations of Didactic Parenting Classes, e.g., “Parent Effectiveness Training” • The key factor predicting the effectiveness of parent training is ‘maternal responsiveness,’ which is related to the parent-child attachment—not to the behavioral interventions that were being taught • Therefore, focusing on improving the parent-child attachment style (as with Parent-Child Interaction Therapy) is generally far more useful than parenting ‘classes’

33. Treatment Recommendations for PTSD • Safety first! Ensure that the child is living in a safe environment and that their trauma is not being re-stimulated • Dysregulation problems are easier to correct than attachment-related problems • Trauma Focused Cognitive behavior therapy (TF-CBT) works well with both adults and children suffering from PTSD • EMDR can also be quite effective-especially with acute trauma in adolescents

34. Free Online Training in TF-CBT! • The Medical University of South Carolina, in cooperation with leaders in the field of TF-CBT have developed “TF-CBT Web” • Handouts, demonstration videos and other materials are available on this web site. • CEUs are available upon completion of the course • http://tfcbt.musc.edu/

35. Have caregiver complete CSBI and follow-up with caregiver on endorsed items EVALUATION OF SEXUAL BEHAVIOR PROBLEMS

36. Assess for “Sexual Concerns” & “Sexual Distress” as well as Sexual Behavior Problems • Trauma Symptom Checklist for Children (TSCC)— ‘Sexual Distress’; ‘Sexual Preoccupation’; ‘Sexual Concerns’ scales • completed by children ages 8-16 • Trauma Symptom Checklist for Young Children (TSCYC)—’Sexual Concerns’ scale • completed by caregiver of kids 3-12

37. Assess for Safety • Ensure that the child’s environment is safe and that it is not re-stimulating the traumatic response

38. Do all sexually abused children need extensive psychotherapy?

39. “Natural therapy” does occur in many (supportive) families and, in some cases, it is sufficient • There are no data that say that every abused child needs extensive therapy • Every child who has been sexually abused should receive developmentally sensitive corrective and supportive feedback from concerned adults. • This can come from the parents (preferably with guidance from informed mental health professionals)

40. Necessary Components of ‘Professional’ Therapy for Sexually Abused Children • Parent-child therapy to address relational issues • Abuse-specific intervention for children and their caregivers to teach them how to deal with traumatic CSA sequelae (i.e., PTSD, sexualized behavior), and to resolve the victim’s self perception vis-à-vis the CSA • Prevention of further abuse

41. Duration of Therapy for Sexually Abused Children • In most cases the term of abuse-focused therapeutic treatment for the sexually abused child will be short to moderate, i.e., 12-24 sessions. However, this depends on the presenting problems and client-related factors. Saunders, B.E., Berliner, L., & Hanson, R.F. (Eds.). (2004). Child Physical and Sexual Abuse: Guidelines for Treatment. (Revised Report: April 26, 2004). Charleston, S.C.: National Crime Victim Research and Treatment Center Download at: http://www.musc.edu/cvc/guidelinesfinal.pdf

42. Multiple Abuse-related Issues Take Longer to Treat • An agency-based study of boys who presented with multiple abuse-related issues and had already received brief, structured interventions but were still symptomatic found that the majority of these boys required an additional 6 to 8 months of therapy simply to be initially successful. (Friedrich, 2002)

43. The Quality of the Parent-Child Attachment Affects the Length of Treatment • The lack of a secure parent-child attachment can greatly extend the length of treatment for sexually abused children

44. Parents with a Poor Prognosis Parents with severely reduced intelligence Parents with malignant Axis II diagnoses, i.e., Antisocial, Narcissistic personality disorders Dissociatively disordered parents Parents who persist in abusive relationships Parents who cannot follow through with simple self-monitoring requests from one session to the next

45. Top-rated Therapies for Specific Symptoms Associated with Sexual Abuse • Attachment-related problems • Parent-Child Interaction Therapy (PCIC) • PTSD symptoms • Trauma-focused cognitive-behavior therapy (TF-CBT) • Eye movement Desensitization and Reprocessing (EMDR) for adolescents • Sexual Behavior Problems • TF-CBT group treatment for parent and child