The Seven Pillars of Quality Care in a Statewide Pediatric Sexual Assault Nurse Examiner Program

This article describes a systematic approach used by a statewide pediatric sexual assault nurse examiner program to ensure the quality of forensic medical examinations it provides in child sexual abuse investigations. Seven strategies for enhancing quality are described: (a) hiring experienced professionals, (b) effective training, (c) comprehensive protocols, (d) ample support for pediatric sexual assault nurses, (e) management oversight, (f) a clinical coordinator to provide ongoing training and technical assistance, and (g) a quality assurance process in which expert child abuse pediatricians review each statewide pediatric sexual assault nurse examination. To show the evolution of quality care over time, the program's experience from 2004 to 2010 is reviewed, and quality assurance data are analyzed.     

The Relationship between Knowledge and Child and Caregiver Distress during the Medical Examination for Child Sexual Abuse

When child sexual abuse is suspected, a child sexual abuse–related medical examination is recommended to ensure the child's well-being. While the extant research has sought to identify factors influencing child distress during this examination, only recently have studies began examining variables that may be directly associated with the child or with the medical setting. Knowledge of the child sexual abuse–related medical examination is one medical-related variable that has been implicated in child and caregiver distress during the examination. The current study contributes to the existing literature by investigating associations among examination knowledge in relation to caregiver and child anxiety at the time of a child sexual abuse–related medical examination, taking into account ethnicity, past child abuse, injury to child as result of abuse, and caregiver response to disclosure. Sixty-eight children and their nonoffending caregiver were assessed. Results indicated that understanding of the examination and caregiver response to disclosure were significantly associated with caregiver and child anxiety.     

Cleveland 20 years on: what have we learned about intervening in child sexual abuse?

This is the first of two linked papers. It examines the main changes in approach to child sexual abuse that have occurred since the events in Cleveland 20 years ago. Comparison between estimated prevalence rates and registrations for sexual abuse suggests that we are aware of only the tip of the iceberg. It is argued that in many cases uncertainty may have to be accepted, and that protection may be better achieved through a protective parent than through the child protection system. Clinical examples of cases presenting to a specialist child and adolescent mental health service are given. It is argued that, although society is now more willing to recognise the existence of child sexual abuse and professionals are better at dealing with families, outcomes for this group of children are not much improved. Copyright © 2008 John Wiley & Sons, Ltd.     

Child Sexual Abuse and Women's Sexual Health: The Contribution of CSA Severity and Exposure to Multiple Forms of Childhood Victimization

Research studies have provided increasing evidence for the potential adverse impact of child sexual abuse on women's sexual health. The present study examined the association between child sexual abuse and sexual health while controlling for various forms of childhood victimization. Self-report questionnaires were administered to 889 young women from the province of Quebec. Results suggest that child sexual abuse survivors were more likely to report having experienced other forms of childhood victimization than were women without child sexual abuse. Women with a history of both child sexual abuse and multiple forms of victimization were at greater risk of experiencing more adverse outcomes, including risky sexual behaviors, sexual problems, and negative sexual self-concept. Regression analyses revealed that child sexual abuse was significantly related to indicators of sexual health outcomes even when controlling for the effect of single forms of victimization. Clinically, interventions optimizing sexual health may be particularly helpful for a subgroup of child sexual abuse survivors.     

Judgments regarding parental alienation when parental hostility or child sexual abuse is alleged

Abstract

Allegations of Parental Alienation (PA), the systematic disparaging of one parent by the other parent aimed at alienating their child’s affections, as a basis for child custody decisions are highly controversial. Claims of parental hostility or allegations of child sexual abuse in custody cases may trigger concerns about PA. Family court professionals (N?=?280) rated young children’s accuracy of report (e.g., suggestibility, honesty) in general and also read three custody scenarios varying as to whether or not they included allegations of parental hostility or child sexual abuse, or no such allegations. For each scenario, the alleged alienating parent’s gender was experimentally varied between subjects. Participants rated the likelihood that each case involved PA. For the scenario that included allegations of child sexual abuse, professionals who viewed young children as more inaccurate reporters or who read about the mother (rather than a father) as the alleged alienator were more likely to rate the scenario as involving PA. For the scenario that described parental hostility but no child sexual abuse allegations, professionals who were older or female were more likely to judge the scenario as involving parental alienation when a mother (rather than a father) was the alleged alienator, whereas there were no significant predictors of responses to the no-allegation scenarios. Findings are discussed in relation to the difficult task of evaluating custody cases for PA when parental hostility or child sexual abuse is alleged.     

UK Paramedics Confidence in Identifying Child Sexual Abuse: A Mixed-Methods Investigation

United Kingdom (UK) paramedics are in a prime position to identify children and young people who are victims or at risk of sexual abuse. Paramedics have access, by phone, or in person, to unprepared homes and communities which other health professionals such as social workers may not. Little research exists however, investigating UK paramedic confidence in identifying child sexual abuse. This mixed-method explanatory sequential investigation used the self-reported confidence levels of 276 UK paramedics to inform the design of seven semi-structured focus groups with 25 UK paramedics from a large ambulance service with operating models similar to all UK services. Multiple factors contribute to a lack of confidence in identifying child sexual abuse, child sexual exploitation, and female genital mutilation, including a perceived lack of exposure to sexual abuse, the perceived hidden nature of sexual abuse, and the lack of physical symptoms and examination. An overarching lack of knowledge is the most significant contributor to a lack of confidence which in turn perpetuates misinformation surrounding prevalence, location, and the signs and symptoms of sexual abuse. These findings suggest a lack of sufficient training and a need for further research evaluating the content of current training and its method of delivery.     

Prevention of Child Sexual Abuse: Analysis and Discussion of the Field

Prevention of child sexual abuse is complicated, challenging, and highly necessary as sexual abuse of children and youth represents an extensive problem across the world. This article reviews the existing preventive interventions targeting children, parents, and professionals. An alternative way of organizing the child sexual abuse prevention research literature is offered and applied with emphasis on three areas: (a) child sexual abuse prevention interventions, (b) meta-analyses of child sexual abuse prevention interventions, and (c) general theoretical models about prevention and the child. Based on an analysis of these areas, it was found that there was a lack of connection between theoretical models and concrete preventive interventions. An overview of current challenges and future possibilities in this area is provided.     

Diagnosing physical abuse using Bayes' Theorem: a preliminary study

Objectives. To perform a preliminary study to compare the patterns of bruises in a physically abused group of children and a control group; to investigate whether these could be modelled statistically to enable probabilities of typical bruise patterns to be calculated; to apply Bayes' Theorem to find the probability that a child with a given bruise pattern has been the subject of physical abuse. Design. An observational study. Setting. Cardiff and Vale of Glamorgan. Subjects. Children who have suffered child physical abuse, 0–14 years. The diagnosis was confirmed at a case conference in all cases. A control group of 289 children who presented to the Accident and Emergency Department at the Cardiff Royal Infirmary after an accidental injury. Main outcome measures. The distribution bruise pattern in three regions of the body. The posterior probability of abuse for a given bruise pattern. Results. The bruise distribution in physically abused and control children was well described by a negative binomial distribution. There was a different distribution for the three different regions of the body in physically abused children. The bruising frequency and distribution for the physically abused group was very different from that of the controls. We were able to use parameters derived from these distributions to calculate posterior probabilities of physical abuse given a particular pattern of bruises using Bayes' Theorem. Conclusions. This preliminary study demonstrates that we can use Bayes' Theorem to combine prior probabilities of physical abuse with observed patterns of bruising in given children to obtain posterior probabilities of abuse. This principle has considerable potential for better diagnosis of the physically abused child. © 1998 John Wiley & Sons, Ltd.     

Perceptions of Child Sexual Abuse in a Hypothetical Cybersexploitation Case: The Importance of Perpetrator Honesty,Outcome Type,and Respondent Gender

This study investigated perceptions of child sexual abuse in a hypothetical cybersexploitation case. Men were predicted to be more negative toward the victim than were women. Victims were predicted to be more negatively judged when they consented to sex than when they did not and when they were lied to than when they were not. Two hundred and seventy-six respondents read a sexual abuse depiction in which the perpetrator's disclosure about his age (being honest from the outset, lying, or refusing to disclose when questioned) and the final outcome of the meeting (consensual verses nonconsensual sexual intercourse) were varied between subjects. Respondents then completed a 17-item attribution scale. ANOVAs revealed broad support for the predictions. Results have implications for education about cybercrime.     

Health Professionals' Responses to Disclosure of Child Sexual Abuse History: Female Child Sexual Abuse Survivors' Experiences

This study reports on a postal questionnaire, conducted in 2004, with female survivors of historic child sexual abuse. The questionnaire explored their experiences of health professionals' responsiveness to disclosure of child sexual abuse history. Of 61 participants, aged between 22 and 65, 69% had disclosed to health professionals. Those who had not disclosed reported that they would have liked to but were not asked about child sexual abuse. Thirty-five percent of participants suggested routine questioning about child sexual abuse. Most participants related a fear of common medical examination procedures to their experience of child sexual abuse, and 64% said this stopped them from attending regular health checks. The current study suggests the development of guidelines for dealing with possible child sexual abuse survivors would be useful for health professionals.     

Differences in Perceptions of Child Sexual Abuse Based on Perpetrator Age and Respondent Gender

Child sexual abuse changes the lives of countless children. Child sexual abuse victims experience short and long term negative outcomes that affect their daily functioning. In this study, undergraduate students' perceptions of CSA were obtained using vignettes with an adult or child perpetrator and a general questionnaire. Results indicated participants receiving the child-on-child vignette were less likely to rate the vignette as abuse, saw the abuse as less severe, and assigned less blame to the perpetrator than participants reading the adult-on-child vignette. On a general questionnaire, male participants saw child-on-child abuse as less severe and more encouraged by society than did female participants. The information can be utilized by professionals in treatment planning and preventing revictimization at disclosure.     

Evaluating Allegations of Child Sexual Abuse Within Complex Child Custody Cases

SUMMARY

This article provides a framework for identifying and assembling the interdependent elements of a child custody evaluation with allegations of child sexual abuse. The identification of several myths regarding child sexual abuse (CSA) introduces the subject matter of this article. A forensic evaluation model (Heilbrun, 2001) is then used to organize the custody evaluator's tasks into the following sequential classifications: (a) preparation; (b) data collection; (c) data interpretation; and (d) communication of results. Through this model, the entwined tasks of evaluating the child's needs and the parents' capacities to meet the child's needs, while simultaneously examining the question of child sexual abuse, are addressed.     

Cross‐examination,sexual abuse and child witness identity

This paper presents extracts from cross‐examinations with child witnesses who are alleged victims of child sexual abuse. The manner in which cross‐examination may present a challenge to the child's identity as child, victim and witness is discussed. Specifically, the child may be portrayed as ‘unchildlike’, for example in their experience of sexual relationships or in their sexual knowledge. They may be portrayed as less than innocent, through references to previous contacts with social services or to other behaviours such as delinquency. Child witnesses may be depicted as instigators rather than victims, seducing the adult or seeking revenge through sexual allegations. Finally, children are easily accused of being poor witnesses, as being confused, untruthful and having fallible memories. The paper considers the dynamics and potential impact of such cross‐examination practice within Finkelhor's framework of four traumagenics of sexual abuse: traumatic sexualization, betrayal, powerlessness and stigmatization. The potential for poorly conducted cross‐examinations to create further problems for child witnesses, particularly in the area of identity, is highlighted, and it is suggested traumagenic factors in such cross‐examinations may resemble those of abuse. The paper discusses practice implications for cross‐examination, judicial intervention and witness support following implementation of the Youth Justice and Criminal Evidence Act 1999 in England and Wales. Copyright © 2002 John Wiley & Sons, Ltd.     

Sexual Abuse Images in Cyberspace: Expanding the Ecology of the Child

Cyberspace has added a new dimension to the ecology of children made the subjects of sexual abuse images distributed online. These images cannot be permanently removed and can continue to circulate in cyberspace forever. A review of the current literature suggests that helping professionals are not consistently aware of or do not probe possibilities of online sexual victimization in the investigation, assessment, and treatment of child sexual abuse. Nor is this issue adequately addressed in their education and training. There are gaps in the literature regarding how to identify and provide treatment for these children. New assessment and treatment targets are needed to enhance existing practice approaches. A contemporary ecological model that incorporates an explicit consideration of the cybersystem is provided as a starting point for practitioners to be aware of the possibility that images of child sexual abuse were recorded and distributed online.     

Laughing Through This Pain: Medical Clowning During Examination of Sexually Abused Children: An Innovative Approach

This study examined the role of medical clowns during medical examinations of children who were sexually abused. Three case studies are described, illustrating diverse interactions among the victimized child, the medical clown, and the medical forensical examiner during medical forensic examinations held at the Tene Center for Sexually Abused Children, Poria-Pade Medical Center, Israel. The results indicated that medical clowns play a unique role both in lowering anxiety and fear among children before and during the unpleasant forensic examination as well as in mitigating potential retraumatization of the sexual abuse event resulting from the medical examination. The medical clown was found to assist in creating a pleasant and calm atmosphere, thus improving the child's cooperation during the examination.     

Does Having Children Moderate the Effect of Child Sexual Abuse on Depression?

Nearly 1 in 5 girls and 1 in 20 boys under the age of 18 will be the victim of child sexual abuse. As adults, these individuals are more likely to report myriad mental illnesses including depression. Testing the hypothesis that having children would moderate the depressive effects of child sexual abuse, the authors used public-use data of the National Longitudinal Study of Adolescent Health Wave IV (n = 5,114; mean age = 29.00 years; SD = 1.78). Results indicate that having children significantly moderates the relationship between child sexual abuse and depression for females. Though the risk of depression is increased for all females with a child sexual abuse history, this increase is less dramatic for mothers. Two potential explanations of this effect are presented: biological and psychosocial. The possible implications for mental health professionals working with mothers with a child sexual abuse history include highlighting the role of their children as possible support.     

What Poole and Wolfe (2009) Actually Said: A Comment on Everson and Faller (2012)

Everson and Faller's (2012) article on the significance of sexualized behavior in child sexual abuse assessments critiques a chapter by Poole and Wolfe (2009), but their objections assumed conclusions and practice implications that were not contained in that chapter. In this comment, I reiterate the value of educating adults about normative sexual and nonsexual behavior that could be misconstrued as symptoms of sexual abuse in some children, review key points from the chapter, and point out that Everson and Faller's critique supports the chapter's take-home messages (i.e., the importance of gathering information from multiple sources and the need to test alternative hypotheses for concerning behavior, consider the overall context of individual cases, and obtain independent verification of evidence).     

Utilizing Online Training for Child Sexual Abuse Prevention: Benefits and Limitations

The prevalence of child sexual abuse demands innovative approaches to prevent further victimization. The online environment provides new opportunities to expand existing child sexual abuse prevention trainings that target adult gatekeepers and allow for large scale interventions that are fiscally viable. This article discusses the benefits and limitations of conducting online organizational trainings from the perspective of participants, including what participants found effective, what challenges were most commonly encountered, and trainee perspectives of the program's overall impact. The final section provides recommendations and lessons learned for practitioners and researchers who hope to utilize and assess online prevention trainings in the future.     

Parents’ Experiences of Reporting Child Sexual Abuse in Urban Tanzania

This article reports parental experiences of legally reporting child sexual abuse in Tanzania. Based on in-depth interviews, four types of sexual abuse incidents are portrayed. Each evokes different reactions from parents and the community. An incident characterized as the innocent child was associated with a determination to seek justice. The forced-sex youth elicited feelings of parental betrayal of their child. The consenting curious youth resulted in uncertainty of how to proceed, while the transactional-sex youth evoked a sense of parental powerlessness to control the child because of low economic status. Differentiating between types of sexual abuse incidents may increase awareness of the complexities of child sexual abuse reporting. Education on laws regulating sexual offenses and a functional national child protection system are needed to address child sexual abuse complexities and safeguard the rights of children in Tanzania.