*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Volume 02, Issue 08
April 21, 2013
Prevalence; Barriers in reporting; Normative and non-normative behaviors; Prevention;Current treatments Stephon Proctor, PhD
From the 5th Annual Pediatric Psychology/Psychiatry Update, presented by Geisinger Health System
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Psychology Program Info Accreditation InfoCultural & Linguistic Competency Resources
Sexual Abuse of Children
From the 5th Annual Pediatric Psychology/Psychiatry Update, presented by Geisinger Health System
Stephon Proctor, PhD, Postdoctoral Pediatric Psychology Fellow, Geisinger Medical Center, Danville, PA
The goal of this program is to improve the recognition and reporting of child sexual abuse. After hearing and assimilating this program, the clinician will be better able to:
1. Recognize which types of physical and nonphysical activities and occurrences constitute sexual abuse.
2. Distinguish normative sexual behaviors from non-normative sexual behaviors.
3. Protect and maintain therapeutic alliances throughout the process of suspecting and reporting child sexual abuse.
4. Educate children and parents about the most effective means of preventing and intervening in sexual abuse.
5. Coordinate and cooperate with Child and Youth Services in cases of suspected abuse.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Proctor and the planning committee reported nothing to disclose.
Legal definition of child sexual abuse (Pennsylvania): any sexually explicit conduct with individual <18 yr of age
Variable factors in abuse: violent vs nonviolent (majority occurs nonviolently, and therefore may be difficult to detect); isolated vs ongoing (for, eg, months to years); involving physical contact vs nonphysical; can occur between 2 individuals <18 yr of age
Forms of abuse without physical contact: having children expose themselves; viewing children in exposed or sexual context; introducing children to any form of pornographic material; inducing children into sexual behavior (without contact between perpetrators and victims)
Forms of abuse involving physical contact: touching child; having child touch perpetrator; frotteurism (ie, rubbing); penetration (including that with inanimate objects)
Statistics on individuals involved in substantiated sexual abuse (2011): parents, parental paramours, and step-parents found responsible for 68% of substantiated abuse
Profiling perpetrators of abuse: in speaker’s experience, perpetrators rarely fit stereotypic images of pedophiles, and come from extremely diverse backgrounds (in terms of, eg, race, ethnicity, socioeconomic status, religion, age); this precludes protecting children by instructing them to avoid certain types of individuals
Primary emotional outcomes of sexual abuse in children: burden of secrecy (often prevents children from reporting abuse; secrecy can be reinforced by direct or indirect threats, and may be upheld for months or years); hopelessness (related to power dynamic between perpetrator and victim [particularly when perpetrators have authoritative role]); helplessness (with regard to, eg, having their plight ignored or dismissed); fear; confusion; sense of responsibility for one’s own abuse (due to emotional manipulation by perpetrators, or natural coping mechanisms)
Issues associated with child sexual abuse (multilevel meta-analysis): personality disorders; psychologic disorders; behavioral problems; high-risk behaviors (eg, self-injury); sexual issues; revictimization (in victims who never receive treatment)
Secondary outcomes of child sexual abuse: many individuals dismiss disclosures of abuse to avoid ramifications for accused individuals and associated institutions or organizations (eg, school, church, community); this leads to prioritizing effects of disclosure above effects of actual abuse, and thus leaves victims feeling insignificant
National statistics on abuse (period prevalence for 2010): of ≈60 million children included in data, 4.4% received referrals for some type of abuse; 0.7% of claims substantiated, and of these, 0.1% involved sexual abuse (representing 60,000 children); this relatively low number reflects hidden nature of sexual abuse (ie, other forms of abuse often do not require disclosure from children, since obvious injuries can alert adults)
Retrospective meta-analysis of studies on child sexual abuse over past 20 yr: surveyed adults about sexual abuse perpetrated on them before age of 18 yr; ≈10% of men and ≈25% of women reported abuse
Aggregated data from National Child Abuse and Neglect Data System: rates of child sexual abuse declined from 1982 to 2012; data available to researchers and institutions; between 1990 and 2009, rates of substantiated abuse decreased by 61% (5% during 2009 alone)
Explanations for declining rates of abuse: increased awareness; better education on prevention and intervention; improved identification, documentation, and data collection (to support informed decisions about intervention); cultural shifts increasingly highlighting abuse
Revising long-term goals: advocates have largely succeeded in increasing awareness of abuse; in speaker’s opinion, future efforts must focus on taking action against abuse (by, eg, disseminating information on effective treatments for abuse, and increasing access to those treatments)
Importance of mandated reporters of abuse: ≈50% of substantiated reports of abuse originate with referrals from mandated reporters; increased reporting leads to increased likelihood of substantiated claims; despite legal obligations, many mandated reporters still feel conflicted about reporting abuse
Study of suspected abuse encountered by physicians: all reports of suspected abuse collected by physicians submitted to panel of experts specializing in child sexual abuse, and experts assessed whether reports indicated genuine abuse; in cases in which expert panel found no credible evidence of abuse, 96% of physicians had chosen not to make reports; however, among cases in which experts saw evidence of genuine abuse, physicians had failed to report 32%
Overcoming Barriers to Reporting
Concerns about patient-physician relationships: often cause physicians to hesitate to report abuse; particular challenge for mental health practitioners, since therapeutic alliances play critical role in treatments provided; due to their fear of losing patients, clinicians may choose to handle claims informally
Fear of opening “Pandora’s box”: physicians often hesitate to make reports due to unknown and often severe consequences (eg, involvement of child welfare services and law enforcement, removal of parent from home, potentially disastrous loss of income for affected families)
Perceptions of Child and Youth Services (CYS): often negative (due to, eg, delayed response times, poor past experiences, inaction, distracting amounts of bureaucracy subtracting from efforts toward prevention and intervention)
Reasons commonly cited for failure to report abuse: professionals in relevant fields (eg, nurses, teachers, psychologists, physicians) often complain about inadequate training in recognizing signs and symptoms; confusion over personal legal role and procedures for reporting (attributed to lack of formal training and training programs [eg, only 20% of psychologists receive training on child sexual abuse in graduate school]; some states require psychologists to receive this training through, eg, continuing education, although many states do not); overconfidence in ability to identify signs of abuse and follow procedures (despite underperformance in relevant assessments)
Data on patient-physician alliances after reporting abuse: survey showed that 75% of patients continued to receive medical care from their physicians during 6-mo period after physician reported sexual abuse; in studies of psychologists who made reports, therapeutic relationships and progress remained unchanged or improved in 72% to 76% of cases
Mitigating potential damage to patient-physician alliance: explain limits of confidentiality at early stage in treatment, and ensure patients clearly comprehend these limitations; in one study of psychologists, 40% informed families of their duty to report only after reporting had been initiated (6% made reports without any discussion)
Communicating duty to report: repeatedly emphasize reasons for making report; avoid dismissing reporting as simple obligation, and instead highlight why reporting serves to protect child
Reevaluating CYS: duties focus on protecting children and providing referrals for services; systems for handling child abuse frequently overburdened (due to high-volume caseloads and concentration of severe issues); speaker asks clinicians to remain understanding of limiting consequences of serious challenges faced by CYS; even in cases in which abuse remains unsubstantiated or denied, families may still receive child, parent, or family intervention services; speaker always seeks follow-up with CYS in order to obtain ongoing information on families; although physicians can automatically receive follow-up information from CYS, all other mandated reporters must obtain releases (consider asking families to sign these during initial discussion of report)
Background on signs of abuse: speaker warns against trying to identify abuse on basis of any specific pattern or constellation of symptoms and behaviors; although inexplicable changes in behavior can indicate abuse, physicians must be wary of illusory correlations
Common consequences of child sexual abuse: changes in eating, sleeping, or toileting; somatic complaints (eg, pain, headaches); sexual behaviors (more reliable indicator, but clinicians must carefully assess for normative vs non-normative behaviors)
Normative sexual behaviors in children: often cause concern in parents; encourage parents to ignore these behaviors and/or reinforce alternative behaviors
Study of sexual behavior in children: surveyed parents of 1000 children on exhibited sexual behaviors; with male and female children 2 to 5 yr of age, parents reported witnessing 40% to 60% of applicable behaviors (eg, normal exploratory behavior focused on their bodies, curiosity about others); children 6 to 9 yr of age showed less sexual behaviors overall, although new behaviors manifested (consistent with increased knowledge about sex); in children 10 to 12 yr of age, public behaviors decrease dramatically, but private behaviors and knowledge about sex (or knowledge seeking) increase; in total, sexual behaviors decrease with older age
Factors to consider when assessing sexual behavior: culture (in international studies, children from more permissive cultures have greater propensity for self-exposure); education level of parents (studies show that parents with higher levels of education show more permissiveness toward their children’s behaviors); each family has its own unique culture, and some families may be more open to, eg, nudity; even in samples of children with no history of abuse, less common sexual behaviors can manifest; sexual behaviors can be associated with nonsexual factors (families affected by, eg, high levels of conflict, psychopathology, stress, other forms of abuse); in most cases in which parents report troubling sexual behaviors, their children have not actually encountered abuse (overall prevalence low)
Non-normative sexual behaviors: strongly correlated with child sexual abuse, but not pathognomonic; sexually acting out, particularly with more coercive or adult-like behaviors (eg, attempting to engage another in sexual intercourse or oral sex; forcing other children into sexual acts); in studies comparing sexually abused and nonabused children, victims of abuse 14-fold more likely to act out intercourse
Prevention and Treatment of Sexual Abuse
Education: most critical component; initiate at earliest age possible, and continue with adolescents and parents
Educating young children: speaker recommends introducing “bathing suit rule” (ie, body parts covered by bathing suit should not be touched by others); newer movements have emphasized teaching children to name specific body parts (in order to overcome evidentiary barriers faced when prosecuting sex crimes and to improve body awareness); education for children must include safe and unsafe touching, respecting sensitive bodily areas in themselves and others, good vs bad secrets (ie, those that evoke fear, anxiety, confusion, or worry), how to disclose inappropriate activity (eg, identify 2 people who can be told, one inside home and one outside)
Educating school-age and adolescent children: review basic lessons and body awareness; include more developmental lessons on sexual activity and sexual education; encourage communication with parents (in order to promote basic level of comfort talking about sexual abuse, even in families highly suppressive of any communication about sex); parents may use media coverage of sex abuse scandals as opportunity to discuss safety and provide education; discuss risky behaviors and sexual assault
Education for parents: encourage parents to learn about individuals with whom their child associates and how they spend their time (helps to circumvent forms of grooming and secretive behaviors associated with abuse); distinguishing normative from non-normative sexual behaviors; recognizing sudden changes in moods or behaviors; encourage parents to discuss sex with their children (detailed talks not required; focus on establishing basic comfort level necessary for discussions of abuse)
Threshold for suspicion of abuse: professionals need only to suspect abuse based on reasonable cause (ie, absolute proof not required); if uncertain, always inform family of uncertainty when discussing allegations; in cases warranting concern but remaining questionable (or involving “gray areas”), try consulting with colleagues; speaker strongly recommends private dialogue with nonoffending parent or caregiver (without child present) when considering reporting
Discussing possible abuse with caregivers: avoid provoking aggressive questioning of children by caregivers (this may cause children to shut down or recant allegations); focus on your shared interest in protecting child; share your suspicions and their basis; reiterate facts (eg, clinician acting on suspicion only; no allegations yet made); explain legal obligation, but avoid framing your obligations as formalities; explain role of CYS, and allow parent opportunity to remain present during process; express desire to continue therapeutic relationship; instill hope of finding solution
Things to avoid when communicating with parents: shaming or blaming; assuming caregiver has knowledge of abuse; informing suspected perpetrator; panicking
Discussing abuse with children: treat allegations seriously; use highly empathetic and validating tone; affirm child made correct decision by disclosing, and that abuse not his or her fault; document as much as possible (including quotes); avoid emotional reactions and application of pressure (since follow-up interviews focus on extracting evidence); keep questions open-ended; avoid making promises (about, eg, punishment of perpetrators, where child may stay)
Trauma-focused cognitive behavioral therapy: developed for victims of child sexual abuse; backed by strongest research (relative to comparable interventions); focuses on educating child and parent about anxiety, providing exposure therapy (ie, forming narrative about abuse, and using narrative to help children rethink abuse), and coping with intrusive thoughts and memories
Dr. Proctor spoke at the 5th Annual Pediatric Psychology/Psychiatry Update, held October 24, 2012, in Danville, PA, and presented by Geisinger Health System. To learn more about conferences presented by Geisinger Health System, please visit geisinger.org/professionals/education/CME/index.html. The Audio-Digest Foundation thanks Dr. Proctor and Geisinger Health System for their cooperation in the production of this program.
Allen B et al: Clinician knowledge and utilization of empirically-supported treatments for maltreated children. Child Maltreat 17:11, 2012; Allen B, Johnson JC: Utilization and implementation of trauma-focused cognitive-behavioral therapy for the treatment of maltreated children. Child Maltreat 17:80, 2012; Beach SR et al: Impact of child sex abuse on adult psychopathology: A genetically and epigenetically informed investigation. J Fam Psychol 27:3, 2013; Evitt R et al: Medical assessment for child sexual abuse: a post-code lottery? J Pediatr Child Health 48:389, 2012; Finkel MA: Children’s Disclosures of Child Sexual Abuse. Pediatr Ann 41:e1, 2012; González Ortega E, et al: Professionals’ criteria for detecting and reporting child sexual abuse. Span J Psychol 15:1325, 2012; Kim TK et al: Psychosocial factors influencing competency of children’s statements on sexual trauma. Child Abuse Negl 35:173, 2011; Mannarino AP et al: Trauma-focused cognitive-behavioral therapy for children: sustained impact of treatment 6 and 12 months later. Child Maltreat 17:231, 2012; Mikton C, Butchart A: Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ 87:353, 2009; Norman RE et al: The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med 9:e1001349, 2012; Paranal R et al: Utilizing online training for child sexual abuse prevention: benefits and limitations. J Child Sex Abus 21:507, 2012.
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