The explosion of cases involving allegations of child* sexual abuse exceeds the resources available to deal with the problem. Many clinicians lack specific training in this area, and the legal profession is often confronted with an array of self-identified experts who have emerged to fill the void. Unfortunately, these evaluators often use inadequate diagnostic techniques and fail to evaluate the child within the context of the family. If conclusions are drawn on the basis of inadequate and insufficient information, children may be harmed, parent-child relationships seriously damaged, and these cases contaminated to the point that courts and other professionals have great difficulty sorting out what did or did not occur.
The purpose of the clinical evaluation of child sexual abuse is to determine whether 1) abuse has occurred; 2) if the child needs protection; and 3) if the child needs treatment for medical or emotional problems. The following guidelines have been developed to assist clinicians performing these evaluations:
*Unless indicated otherwise,"child" refers to infants, children and adolescents.
- The choice of clinician to evaluate the child for sexual abuse.
Persons doing evaluation must be professionals with special skills and experience in child and adolescent sexual abuse, and evaluations ideally should be performed under the direction of an experienced child and adolescent psychiatrist or psychologist. Clinicians performing these evaluations should possess sound knowledge of child development, family dynamics related to sexual abuse, effects of sexual abuse on the child, and the assessment of children, adolescents and families. Further, they should be trained in the diagnostic evaluation of both children and adults. They should be comfortable with testifying in court and prepared and willing to do so.
It is important to establish that specialized training has been obtained either during the professional's formal training program or at a later time.
The evaluator and the child's or adolescent's therapist should be two different individuals. This clarifies roles and preserves confidentiality in treatment.
- The number of times the child is interviewed.
The child should be seen for the minimum number of times necessary and by the fewest number of people as is necessary. We urge that agencies share information to avoid duplication of efforts and unnecessary stress for the child. The development of teams which integrate local police and reporting agencies is an ideal approach toward encouraging corporation among agencies. Multiple interviews may be viewed by the child as a demand for more information and may encourage confabulation.
- The location of the interview.
The interview should take place in a relaxed environment, preferably not in an emergency ward or in a place with the trapping's of authority such as a police department or a principal's office. The child should be allowed privacy without interrupting phone calls or people coming in and out of the room.
- Obtaining the history.
Gathering a history on the child or adolescent from parents or caregivers is an important part of the evaluation and should include: developmental history, cognitive assessment, history of prior abuse or other traumas, relevant medical history, behavioral changes, history of the parent's abuse as a child, and the family's attitudes towards sex and modesty. Prior psychiatric disorders in the child or parent are also relevant.
- Interviewing both parents in intrafamalial abuse.
It is essential to obtain a history from the perspective of each parent. The clinician needs to be able to consider all sides of the story, and any other stresses besides sexual abuse, that could account for the child's symptoms. Sufficient time should be spent with each parent alone. This should include a psychiatric assessment of each parent, especially if there is concern that the allegation may be false, or when a parent was abused as a child. When the accused family member is not a parent, that person should be interviewed as well.
- Use of guardian ad litem.
If custody is an issue, a guardian ad litem for the child should be appointed to represent the child's best interests, preventing parents from subjecting the child to multiple evaluations in the hope of finding an expert who will support one or another's contentions.
- Considering false allegations.
The possibility of false allegations needs to be considered, particularly if allegations are coming from the parent rather than the child, if parents are engaged in a dispute over custody or visitation, and/or if the child is a preschooler. Under such circumstances, the clinician should meet alone with the child to establish trust and ensure that the child will feel some degree of control over the interview with the alleged offender. If the child is too upset by the proposed visit, and there is risk of traumatizing, the clinician may decide that the visit with the alleged offender should not occur. Resistance from a parent alone is not a reason to avoid this part of the evaluation.
False allegations may arise in other situations as well, such as the misinterpretation of a child's statement or behavior by relatives or caretakers. Adolescents may also occasionally make false allegations out of vindictiveness or to cover their own sexuality. Children who have experienced prior sexual abuse may sometimes misinterpret actions of adults or accuse the wrong person of abuse.
- Modifications in the clinical evaluation.
The magnitude of the charges involved in alleged sexual abuse, and their ramifications in terms of legal sequelae and impact on the family, require diagnostic evaluations with certain modifications. These evaluations differ from the usual psychiatric evaluation, because the examiner is being asked to determine whether certain events occurred, and determine at least one individual's credibility. It is essential that the clinician maintain emotional neutrality, approach the case with an open mind, adapt a non-judgmental stance and seek out the unique particulars of each case. Great care must be taken to avoid leading questions and coercive techniques; the child must be allowed to tell his story in his own words. The clinician needs to focus on detailed descriptions of discrete events more than once as accounts may change or new information may emerge. Finally, these evaluations differ from usual clinical evaluations in that more effort needs to be invested in obtaining corroborating information from other sources. This may include medical or school reports, prior psychiatric evaluations, and talking with significant others.
- Assessing the child's credibility.
Factors enhancing the child's credibility include detailed description's in the child's own language and from the child's point of view; spontaneity; and appropriate degree of anxiety; inclusion of idiosyncratic or sensorimotor detail; consistency of allegations over time (minor details and descriptive terms may change but the child's account of events should remain basically the same); behavioral changes consistent with the abuse; absence of motivation or undue influence for fabrication; and corroborating evidence. The evaluator needs to be aware of the child's cognitive and emotional development and how this may affect the interpretation and the recall of events.
- Anatomically correct dolls.
In these assessments, it is not necessary to use anatomically correct dolls. They may be useful for eliciting the child's terminology for anatomical parts, and for allowing the child who cannot tell or draw what happened, to demonstrate what happened. Care should be taken not to use these dolls to instruct, coach, or lead the child. Further, they should not be used as a short cut to a more comprehensive evaluation of the child and the child's family. The examiner should anticipate being asked in court that such aids alone do not provide reliable answers. (California has barred the admissibility of evidence obtained through use of anatomically correct dolls until such a time that the procedure has been accepted as reliable in the scientific community in which it was developed.)
- The use of children's drawings.
Children's drawings are helpful in assessing child sexual abuse. These include spontaneous drawings, or asking the child to draw a male and female, kinetic family drawings, self-portraits, what happened and where it happened, or even a picture of the alleged offender. The usefulness of drawings lies in the affect and information they elicit and certain findings which may be suggestive of sexual abuse as depiction of genitalia or avoidance of sexual features altogether. However, as with any other tool, they should be interpreted by an experienced clinician and in the context of the overall clinical picture.
Videotaping, when possible, can serve several useful purposes including 1) preserving the child's initial statements; 2) avoiding duplication of efforts by sharing the video with others involved in the investigation; 3) encouraging the defendant to plead guilty, thereby sparing the child from testifying in court; 4) presenting the video to the grand jury in lieu of the child; and 5) as a teaching tool to help the interviewer and others improve techniques.
In making a videotape, the following concerns, disadvantages or risks should be taken into consideration: Videos can be used to harass or intimidate the child on cross-examination, or reviews may regard the testimony as more credible because it was given on video. Videos might be shown out of context or fall into the hands of those who have no professional obligations of confidentiality or concern for the child's best interest. Clinicians should familiarize themselves with laws in their state relative to admissibility of videotaped testimony.
The child should always be informed as to the purpose of the videotape and about who is present if a one-way mirror is being used. Parental consent and the child's assent should be obtained to videotape.
- Psychological testing.
Testing alone does not diagnose sexual abuse either in the victim or offender. It is helpful as a part of the evaluation of the alleged offender, and in cases of possible false allegations, it may be helpful to have testing of both parents. In all fairness, if testing is done on one parent, it should be done on the other as well. Testing of the victim may be indicated if there are questions about intelligence or thought processes.
Child sexual abuse must be reported in accordance with ethical and legal requirements in each state. Clinicians should be aware of these requirements. The parent(s) and child should be informed as clinically indicated, and to the extent that the child protective services investigation begins, it often becomes difficult to obtain a history from the accused parent, who may become defensive.
- The medical evaluation.
Every child who may have been sexually abused should have a physical examination. The medical exam gathers medicolegal evidence and treats any problems related to the abuse. It can be informative and can reassure the child and adolescent. Preferably, the examination should be performed by a pediatrician or family physician known to the child or by a pediatric gynecologist. The physician should know the ramifications of an examination carried out in this context. Such evaluations require special training which many physicians in the community have not yet obtained. Thus it is important to determine the qualifications of the physicians planning to do the physical exam. When possible, the child should be allowed to choose the sex of the examining physician. It is recommended that a trusted, supportive adult remain with the child during the evaluation.
Whenever there is the possibility of obtaining forensic evidence, the exam should take place promptly. If the child has been raped, or there is possibility of acute trauma or infection, or the abuse occurred within 72 hours of the disclosure, the child should be examined as soon as possible in order to obtain forensic evidence. Preferably, the child should be seen in a physician's office rather than an emergency ward. The genital exam may be conducted in the context of an overall physical so as to de-emphasize it, and the child should be informed of what the physician is doing and be told afterwards what the findings are. It should be remembered that a negative genital exam does not rule out sexual abuse. The child's emotional state and degree of relaxation may affect the findings on both vaginal and rectal exams. If the child refuses to corporate with the physical exam for reasons of trauma, consideration should be given to deferring the exam until such a time when, with benefit of counseling, the child is deemed able to cooperate.
If a child is already being evaluated by a mental health professional, the physician doing the physical exam should be sensitive to the child and minimize questions about the abuse so as to avoid contaminating the child's data and duplication of interviews.
- Formulating recommendations.
The clinician needs to decide, based on history, an evaluation of child and parents, a review of corroborating evidence of child and parents, and a review of corroborating evidence, whether or not any sexual abuse occurred. A carefully written report should document the basis for these determinations. The next question concerns the immediate disposition of the child and whether it is safe to allow the child to return home. This decision is usually made by protective services, but the clinician's opinion is helpful. The decision will take into consideration whether or not the family believes and can protect the child, what the child's wishes are (depending on the age of the child), and, if living in the home, whether the offender is willing to take responsibility for his or her actions and seek help. Prior psychiatric problems which may have predisposed the abuse need to be sorted out from reactions to the abuse and its aftermath. Diagnostic impressions should be made and decisions need to be made as to what sort of treatment is recommended and for whom. This may include a range or combination of treatment modalities including individual, family, group and couples therapy, as well as behavioral and pharmacological approaches to the offender.
In some cases the evaluator may not be able to determine whether sexual abuse occurred. There are a number of reasons why this may be the case, including contamination by too many evaluations, particularly biased or leading ones. In addition, the child may be too young to verbalize what occurred, the abuse may have happened too long ago, or the child may have been subjected to the undue influence of competing parents and no longer knows what to believe. In such cases, the clinician must attempt to offer the child reasonable protection while also preserving parent-child ties.
The effects of child sexual abuse are diagnosable in the same sense that other medical conditions are diagnosable--on basis of history, physical examination and the judicious use of various tests. Rarely is one finding alone diagnostic of sexual abuse; rather, findings must be interpreted within the total context of a thorough evaluation. However, if the case proceeds, one may be expected to explain opinions in terms of reasonable degree of medical certainty.