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 • Screening for CSA • 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 child’s 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 parent’s presence which raises questions in the parent’s 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 parent’s 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 child’s 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 party’s “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 parent’s report of child’s 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 caregiver’s 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 threshold—in 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 party—usually the child’s 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 child’s concerning statements and how they were elicited; the child’s behavior

13. Assessment of children’s sexual behavior with the csbiduring screening and comprehensive assessment for csa

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 parent’s reaction?

16. Three Types of Scores on the CSBI • “Total” score • “Sex Abuse Specific Items” (SASI), e.g., puts mouth on another’s 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 child’s 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 child’s sexual behaviors on CSBI by the child’s caregiver (Total ‘raw’ score > 45 is likely to be invalid)

19. Inquire about alternative explanations for child’s 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 child’s sexual behaviors on CSBI by the child’s caregiver (Total ‘raw’ score > 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 often—but not always—younger (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 foster—or 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

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 don’t 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 don’t 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 DD’s 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. DD’s behavioral problems began about 3 months ago. • DD’s 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. DD’s 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 don’t like me.”

33. The case of EE • 10-year-old boy referred for screening by after two unrelated boys in EE’s 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. EE’s 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. EE’s CSBI Total & SASI T-scores >110 (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 mother’s breasts; touches other children’s sex parts; tries to have intercourse with other children; touches animal’s 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 EE’s sister). EE’s molestation included fondling, sodomy and fellatio • EE’s 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 mother’s former boyfriend • AA’s 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 AA’s 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 AA’s birth.

37. AA’s CSBI (by mother) Total T-score 73; SASI T-score 71 • Touches or tries to touch (mother’s) breasts; touches (mother’s) 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 AA’s grandmother and teacher • AA’s 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 • AA’s (female) teacher’s description of AA’s behavior was quite similar to the grandmother’s description. She denied having seen AA engage in any sexual behavior in the classroom.

39. Findings re. AA • AA denied that his mother’s ex-boyfriend or anyone else had molested him; but he acknowledged seeing mother’s 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 don’t 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 child’s abuse-related statements and the manner in which they were elicited are the most important, and often the onlyevidence of CSA • Research has found that most children who are suspected victims of CSA disclose abuse when interviewed at forensic interview centers, e.g., Children’s 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., >6 y/o; (3) the abuser is a not a relative; and (4) the child’s 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 child’s: age, functioning, attention span, rapport with the interviewer, willingness to discuss abuse (e.g., whether there was a prior disclosure), and the child’s 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 Children’s 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 verbatimabuse-related statements and information provided by the child, but also the verbatimquestions and other methods used by the interviewer to elicit the information • The child’s 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 children’s 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’