Child sexual abuse
and exploitation is an important, and relatively recently acknowledged, part of
the child abuse and neglect problem.
Beginning in the 1970’s, a significant number of researchers turned
their attention to this aspect of child abuse; what followed was an exponential
growth in our knowledge about child sexual abuse and the creation of a substantial
body of literature on the topic. It
should be noted that, while there has been a knowledge explosion in this area,
there remains a significant number of unanswered questions about child sexual
abuse and exploitation, in all of three major areas of research on the
topic: risk assessment, intervention
and prevention. In response to this
large body of research, as well as to a high level of interest among its
members in identifying available resources, the International Society for
Prevention of Child Abuse and Neglect (ISPCAN), through the generous support of
UNICEF, undertook a project to summarize the literature on child sexual abuse
and exploitation. The intent is to
provide a starting point for professionals and interested others when the need
to refer to the literature on child sexual abuse and exploitation arises.
The three papers
presented here summarize the major evolution in thought and practice in the
field of child sexual abuse and exploitation.
The papers focus on changes and advancements in three areas: a) the understanding of professionals on the
causes and impacts of sexual abuse (i.e., risk factors), b) intervention
efforts for both victims and offenders and c) prevention efforts.
Each paper explores
our current knowledge about best practice and provides suggestions for future
research in order to continue expanding our knowledge base. These papers were written by noted experts
working in the field of child sexual abuse and exploitation: the risk factors paper was written by Irene
Intebi, M.D. from the Program de Asistencia del Matrato Infantil, Gobierno de
la Ciudad de Buenos Aires, Argentina, the intervention paper was written by
Lucy Berliner, MSW from Harborview Medical Center, University of Washington,
and the prevention paper was written by Deborah Daro, Ph.D., Chapin Hall Center
for Children, University of Chicago.
In
addition to this summary, the ISPCAN project on child sexual abuse and
exploitation contains two additional components: a) a general bibliography of citations provided to ISPCAN via its
network of members, councillors, faculty and partners as worthy of inclusion in
this project and b) an annotated bibliography containing brief summaries of the
child sexual abuse and exploitation literature most frequently referred to by a
group of experts on this issue. Both of
these bibliographies are available by visiting the ISPCAN website (www.ispcan.org.)
Paper One
Child sexual abuse:
Risk factors
Irene Intebi,
M.D.
Programa de
Asistencia del Maltrato Infantil
Gobierno de la
Ciudad de Buenos Aires (Argentina)
Introduction
Researchers and clinicians agree that the exact incidence and prevalence
of child sexual abuse in general population are not known precisely, due to the
fact that most of the cases are not reported when they occur and that surveys
show considerable variability as a result of differences in research
methodology (Berliner & Elliott, 1996).
The population surveyed, survey method, type and number of screening
questions, and definitions of sexual abuse all influence the reported figures
of abuse (Finkelhor, 1994).
At the same time, risk factors associated with child sexual abuse are a
result of factor analysis of the data obtained through surveys in general
population and from clinical samples.
Risk is the likelihood of an event occurring.
And risk assessment is a prediction on the
future. It is not something that can be observed,
but rather something that can only be inferred from the presence/absence
of risk factors. It should be regarded as a continuum, rather than a
yes/no dichotomy (de Paúl Ochotorena &
Arruabarrena Madariaga, 1996).
Not everyone at risk will have the event or problem occur. The risk
referred to in the risk assessment instruments is the likelihood of an adverse
outcome. The use of the term “Risk Assessment” implies that these instruments
may have a utility in determining whether children are likely to become victims
of abuse. Relatively speaking, risk
indicates probabilities of low frequency occurrences such as the likelihood of
abuse. Risk assessment for abuse in general populations may identify as “at
risk” large numbers of children who have not been victims of maltreatment (Runyan,
D.K., 1998).
In studies of risk factors, investigators attempt to identify
characteristics of the family (or child or perpetrator) that increase the
likelihood of sexual abuse occurring. In studies of risk the risk factors serve
as the exposure variables. Such
studies have two purposes: to identify high-risk groups so that prevention
programs can be targeted appropriately, and to understand how sexual abuse
occurs (and the factors that contribute to its occurrence). Although research on risk factors has been
fairly common in studies of other types of maltreatment (i.e., physical abuse
or neglect), such research concerning sexual abuse has been limited (Leventhal,
1998).
Current strategies
Risk assessment for child sexual abuse mainly pursues two goals: a) an effort to identify high-risk groups through
epidemiological research on risk factors; and b) an effort to identify both strengths and weaknesses that each child and
each alleged offender bring to a case, in order to assess case vulnerability
and collaborate in decision-making (Hewitt, 1999). Thus, factors related to the child, to the family, and to the
perpetrator should be considered.
Quinsey et al. (1995)
(authors who deal primarily with appraising the risk of new violent or sex
offenses among men who are known to have committed at least one sex offense in
the past), describe two types of
offender and situational variables
related to recidivism: variables that cannot be changed through active
intervention, such as offense history, age, and demographic characteristics,
called static predictors, and
variables that are changeable, such as pro-criminal attitudes or quality of
supervision, termed dynamic predictors.
Static predictors can be used to determine the degree of risk that an offender
presents. Dynamic predictors are the focus of treatment and supervision because
they involve issues about which something can be done and can, at least in
principle, modify an offender’s level of risk.
It would be interesting to consider the same types of
variables when assessing both the risk of children in general population and
the re-victimization risk of sexually abused children.
Risk factors related to the child:
the general population
Girls are at higher risk for sexual abuse than boys. Both girls and boys
are at increased risk if they have lived without one of their natural parents,
have a mother who is unavailable, or perceive their family life as unhappy
(Finkelhor & Baron, 1986; Finkelhor et al., 1990 cited by Berliner, 1996)
Studies have indicated that males who have been sexually abused are at
an increased risk of sexually abusing, that girls living with step-fathers are
at an increased risk compared to girls living with biological fathers
(Russell,1986), and that children with handicaps or developmental delays are at
an increased risk compared to normal children (Sobsey, 1992; Tharinger, Horton,
& Millea, 1990; National Center on Child Abuse and Neglect [NCCAN], 1993 ,
cited by Berliner, 1996).
Risk factors related to the child:
sexually abused children
Hewitt (1999) affirms that each child and each alleged
offender bring to a case both strengths and weaknesses and she suggests a list
of factors therapists need to consider when assessing case vulnerability. She
emphasizes that these lists have been
drawn from clinical experience, that they are not the product of factor
analysis coming from research, and that they may be modified pending the
outcome of research.
Hewitt
considers low-risk children those that: are clear about their own boundaries and
capable of stating them; have sufficient ability to verbalize; are capable of
recognizing problems and talking about them; are assertive and confident in
voicing their own views and concerns despite some adult opposition. Usually they are older than preschoolers.
On the other hand, high-risk children are younger
children or older who are passive, dependent, withdrawn, anxious, fearful,
powerless, unable to articulate concerns, unable to recognize problem behavior,
much less report it.
Risk factors related to families:
the general population
Berliner and Elliott (1996) state that empirical studies have found that
families of both incest and nonincest sexual abuse victims are reported as less
cohesive, more disorganized, and generally more dysfunctional than families of
nonabused individuals (Elliott, 1994; Harter, Alexander, & Neimeyer, 1988;
Hoagwood & Stewart, 1989; Madonna, Van Scoyk, & Jones, 1991). The
authors add that the areas most often identified as problematic in incest cases
are problems with communication, a lack of emotional closeness and flexibility,
and social isolation (Dadds, Smith, Weber, & Robinson, 1991).
According to Leventhal (1998), few studies have examined family factors
in more detail. He mentions one of the few longitudinal studies of risk factors
for sexual abuse, in which Fergusson, Lynskey, and Horwood (1996) prospectively
studied, from birth to the age of 16, a cohort of 1,265 children born in
Christchurch, New Zealand in 1977. When the children were 18, retrospective
reports of sexual abuse before age of 16 were obtained and risk factors, which
had been prospectively assessed, were examined.
Of the 1,019 subjects interviewed at age 18, 10.4% indicated that they
had been sexually abused (17.3% of females and 3.4% of males). The five major
risk factors identified were female gender of the victim, marital conflict,
poor parental attachment, paternal overprotection, and parental alcoholism or
problems with alcohol. These variables together accounted for about 10% of the
variance when predicting the occurrence of sexual abuse. Although risk factors
were clearly identified, the authors concluded that the level of prediction was
not strong.
Other studies of family factors have identified other risk factors, such
as mothers that have not finished high school, that
are sexually repressive/punitive, fathers that show no physical affection
(Finkelhor, 1979, cited by Kuehnle, 1996), parental drug abuse, a poor
parent-child relationship, and a parent with emotional instability (Leventhal,
1998).
Finkelhor (1994), on the other hand, has summarized the risk factors
into two major categories: (1) those factors that decrease the quantity and the
quality of parental care of children; and (2) those that produce vulnerable,
emotionally needy children. Other authors support the fact that child sexual
abuse also occurs in many families where other types of abuse are present, such
as spouse battering and/or physical and emotional abuse of children. (Paveza,
1987, Kuehnle, 1996).
Risk factors related to the families of sexually abused children
The list of low-risk family related factors important to assessing case
vulnerability, according to Hewitt (1999) are: parents who are fully cooperative; respectful; able to put
the child’s needs first; aware of the child’s reactions and emotional needs;
capable of empathy; accepting of the responsibility for their own behavior; not
controlling and dictatorial of the child; able to wait for the child to lead;
and aware of and respectful toward the touch rules that have been agreed to.
While factors related to high-risk parents are:
parents who minimize or deny their own involvement in the child’s allegation;
project anger onto others; accept no responsibility for their own behavior; are
domineering, insensitive, impulsive, explosive, angry, or demeaning; display no
empathy; have an inability to give up narcissistic focus; have a history of
antisocial behavior; have an uncontrolled chemical dependency status;
consistently display poor boundaries relative to feelings or touch with the
child; have sexualized interactions with the child although no sexual abuse is
seen specifically; argue and are unable
to control anger; often create difficult situations with the therapeutic manager
in the child’s presence.
Risk factors related to alleged perpetrator
Quinsey et al. (1995)
report that among child molesters, those whose victims are males have the
highest recidivism rates; those whose victims are unrelated females, lower
rates; and heterosexual incest offenders, the lowest rates; and that the
likelihood of subsequent sexual recidivism is related to the number of prior
offenses as past criminality is associated with higher probability of
re-offending. (Christiansen et al, 1965; Correctional Services of Canada,
1991). They state that variables
related to criminal history (including sexual offense history), victim choice
(including age, gender, and relationship of the victim), as well as offender
variables such as age and marital status, have been shown to be related to recidivism.
The authors also discuss the fact that follow-up data
of conviction reports underestimate the amount of re-offending that actually
occurred because small numbers of sexual assaulters commit large numbers of
offenses for which they are seldom charged.
Future strategies
De Paul Ochotorena and Arruabarrena Madariaga (1996) suggest that risk
assessment instruments should help professionals to focus on factors that are
relevant to the situation they need to assess.
Good risk assessment instruments would be those that include:
·
Assessment of all risk areas or risk
factors
·
Identification of high-risk factors
·
Identification of risk factors that
may interact dangerously
·
Assessment of duration, severity, and possibility of controlling
risk factors.
·
Assessment of positive aspects and
strengths of the family.
Leventhal (1998) suggests that future studies on risk factors can
strengthen the understanding of how sexual abuse occurs: what characteristics
prevent the sexual abuse from occurring in individuals and families that
present risk factors; and what factors contribute to sexually abused boys not
becoming perpetrators of sexual abuse or what factors contribute to boys who
have not been sexually abused becoming perpetrators.
Regarding sex offenders, Quinsey et al. (1995) report
that the most important need at present is the identification and evaluation of
dynamic predictors, such as situational predictors (including such things as
gaining or losing employment); changes in attitude or mood (which may or may not
be related to identifiable situational phenomena); treatment-induced changes
(such as skill acquisition). It is highly likely that the most relevant dynamic
predictors will involve criminogenic needs (the antecedents of sexual
offending) or variables related to the opportunity to commit further offenses,
such as compliance with supervision. The ultimate result of research on dynamic
factors is the ability to specify how much a particular course of action would
reduce a particular sex offender’s likelihood of recidivism. The authors regret that few sex offender
follow-up studies have attempted to identify variables that predict recidivism,
and even fewer have attempted to identify dynamic predictors.
And a final recommendation: researchers and professionals
working on the child sexual abuse field in different parts of the world should
be encouraged in order to develop good risk assessment instruments that
contemplate the local characteristics and scope of the problem.
Berliner, L. & Elliott, D.M.
(1996). Sexual abuse of children. In: Briere, J.; Berliner, L.; Bulkley, J.S.;
Jenny, C; and Reid, T. (Eds.): The APSAC
Handbook on Child Maltreatment (pp. 51-71).Thousand Oaks, CA: Sage.
Dadds, M.; Smith, M.; Weber, Y.;
& Robinson, A. (1991). An exploration of family and individual profiles
following father daughter incest. Child
Abuse & Neglect, 5, 575-586.
de Paúl
Ochotorena, J., & Arruabarrena Madariaga, M.I.. (1996). Manual de protección infantil.
Barcelona: Masson, S.A.
Elliott, D.M. (1994). Impaired object relations in professional women
molested as children, Psychotherapy, 31, 79-86
Fergusson, D.M.; Lynskey, M.T.; & Horwood, J. (1996). Childhood
sexual abuse and psychiatric disorders in young adulthood: I. Prevalence of
sexual abuse and factors associated with sexual abuse. Journal of the American Academy of Child Psychiatry, 34, 1355-
1364.
Finkelhor, D. (1979). Sexually victimized children. New York: Free Press.
Finkelhor, D. (1994). Current
information on the scope and nature of child sexual abuse. The Future of Children, 4, 31-53.
Finkelhor, D., & Baron, L. (1986). Risk factors for child sexual
abuse. Journal of Interpersonal Violence,
1, 43-71.
Finkelhor, D., Hotaling, G., Lewis, I.A., & Smith, C. (1990). Sexual
abuse in a national survey of adult men and women: Prevalence, characteristics
and risk factors. Child Abuse &
Neglect, 14, 19-28.
Harter, S.; Alexander, P.C.; & Neimeyer, R.A. (1988). Long-term
effects of incestuous child abuse in college women: Social adjustment, social
cognition, and family characteristics. Journal
of Consulting and Clinical Psychology, 56, 5-8.
Hewitt, S.K. (1999). Assessing allegations of sexual abuse in preschool children.
Understanding small voices. Thousand Oaks, CA: Sage Publications.
Hoagwood, K., & Stewart, J.M. (1989). Sexually abused children
perceptions of family functioning. Child
and Adolescent Social Work, 6, 139-149.
Kuehnle, K. (1996). Assessing allegations of child sexual abuse. Sarasota: Professional
resource Press.
Leventhal, J.M. (1998). Epidemiology of sexual abuse of children: Old
problems, new directions. Child Abuse
& Neglect, 22, 481-491.
Madonna, P.G.; Van Scoyk, S.; & Jones, D.P.H. (1991). Family
interactions within incest and nonincest families. American Journal of Psychiatry, 148, 46-49.
National Center on Child Abuse and Neglect (NCCAN). (1993). A report on the maltreatment of children
with disabilities. Washington, DC: Department of Health and Human Services.
Paveza, G.J. (July, 1987). Risk factors in father-daughter child sexual
abuse: Findings from a case-control study. Paper presented at the Third
National Family Violence Research Conference, Durham, NH.
Quinsey, V.L.; Lalumière, M.L.; Rice, M.E.; and
Harris, G.T. (1995). Predicting sexual offenses. In J. Campbell (editor): Assessing
dangerousness: Violence by sexual offenders, batterers, and child abusers (pp.114-
137). Thousand Oaks, CA: Sage.
Runyan, D.K. (1998). Prevalence, risk, sensitivity, and specificity: a
commentary on the epidemiology of child sexual abuse and the development of a
research agenda. Child Abuse &
Neglect, 22, 493-498.
Russell, D.E.H., (1986). The secret trauma: Incest in the lives of girls and women. New
York: Basic Books, Inc.
Sobsey, D. (1992). What we know about abuse and
disabilities. National Resource Center on
Child Sexual Abuse News 1,
4, 10.
Tharinger, D., Horton, C.B.,
& Millea, S. (1990). Sexual abuse and exploitation of children and adults
with mental retardation and other handicaps. Child Abuse & Neglect, 14, 371-383.
Lucy
Berliner, MSW
Harborview
Medical Center
University
of Washington
Intervention in sexual abuse cases has several important
purposes: (1) assess risk to children and establish a safe family environment;
(2) identify sexual offenders, hold them accountable and/or protect the
community; and (3) treat the psychological consequences of abuse experiences
and promote healthy development that will reduce risk for long term negative
outcomes. Child protection, criminal justice, and therapeutic interventions may
be necessary depending on the individual case circumstances.
Current Strategies for Intervention
Child Safety. Most sexually abused children
are victimized by someone they are related to or someone they know. Protection
against future victimization by someone who is not in a caretaker role can be
accomplished when parents do not allow contact with the offender or always
supervise contact. When the abuser is a member of the immediate family, a
parent/parent figure or a sibling, government child protection authorities
usually become involved in countries with such systems. First, an investigation
is conducted and a determination is made about whether sexual abuse occurred.
If abuse is substantiated, it has become common practice in many Western
societies to separate children and offenders at least temporarily. It is
preferred practice to remove the offender instead of the child when the
non-offending parent is supportive of the child.
Studies have shown that children are more distressed when
they are interviewed more times as part of initial investigations. However, no
deleterious effects have been found for placement out of the home or for
removal of offenders. Accurate information does not exist on how many families
in incest cases choose to stay together following sexual abuse or to be
reunified following separation between the offender and the child victim.
Anecdotal data suggest that in most cases, especially when offenders are not biological
parents or siblings, the families do not seek reunification. There are clinical
models for family reunification therapy, but no information is available on how
often these interventions are successful in restoring families or on the rates
of reabuse following reunification.
Offender Accountability/Community Protection. In the
United States, about 60% of cases confirmed during investigation are referred
for prosecution. The rates are higher for cases investigated and referred by
police than cases referred from child protection authorities. On average, more
than half of those cases result in prosecution. Cases involving older children,
more serious abuse, extra familial offenders, more and better evidence,
children with fewer problems, and the presence of maternal support for the
child are more likely to be prosecuted. A large majority cases where charges
are filed result in conviction mostly be plea. In only about 15% of cases do
children testify in court. Of convicted offenders about half are incarcerated.
Studies do not show that involvement in the criminal justice
system is harmful to children. Although children do express apprehensions about
testifying, there is no evidence that children who testify suffer more than
temporary distress. Children who testify more than once or experience long and
harsh cross-examination are more likely to be negatively affected.
Interventions designed to reduce stress about testifying have been shown to be
effective. Recidivism rates for sex offenders vary widely depending on risk
factors. Identified risk factors include deviant sexual interests, psychopathy,
having any male victim, having unrelated victims, the number of prior
charges/offenses, and younger age of the offender. This means that some
offenders are at relatively low risk, for example, those who have only offended
against a female child in the family, whereas other offenders are at extremely
high risk. While the evidence for treatment effectiveness remains unclear, it
appears that modern treatment approaches can reduce risk at least for certain
offenders. While offenders are incarcerated there is no risk to children.
Therapeutic Interventions. There is a large body of
clinical literature and a growing empirical literature on treatment for
sexually abused children. One complication for planning treatment with sexually
abused children is that the effects of sexual abuse vary widely. This is
primarily because sexual abuse encompasses a broad range of experiences. The
most typical sexual abuse experience consists of one or several events
committed by a known but not related offender, but sexual abuse can involve
violent attacks by strangers, ongoing abuse by parents, persuasion to
participate in an exploitive relationship and commercial exploitation through pornography
or child prostitution. More serious outcomes are associated with violent
experiences, when there is the perception of life threat, longer or more
frequent abuse, when there is sexual penetration, and when the offender is
closer or more important to the victim. Children who have a prior history of
trauma or pre-existing psychiatric conditions are at higher risk for problems.
Up to half of sexually abused children will develop Post-Traumatic Stress
Disorder. Sexual abuse in childhood is also associated with increased risk for
a variety of mental health conditions, relationship problems, and
revictimization in adulthood. In addition, sexual abuse often co-occurs with
other forms of abuse and adverse childhood experiences that effect their
adjustment
This variation in impact means that an assessment should be
conducted before undertaking a course of treatment. In addition to determining
the specific impact of abuse on a child, it is important to determine the
parental response. While most parents believe and support their children, some
do not, especially in incest cases, and this compromises the children’s
psychological situation. The level of parental distress about the sexual abuse
also has an effect on children’s distress. Enhancing parental capacity and
reducing their distress may be important treatment targets. A developmental
perspective that addresses children’s functioning in key areas such as
relationships with family and peers, school performance, and socialization
should always inform an assessment. Promoting a normal course of development
may serve as the key protective factor against long-term harm.
In cases where children have no or few symptoms and a
supportive environment, formal treatment may not be necessary and a brief
psychoeducational an intervention may be sufficient. In other cases children
will have significant abuse effects that will benefit by abuse-focused therapy.
Typical consequences are posttraumatic stress, depression, and anxiety. Some
abuse related problems may need to be triaged to a higher priority and require
additional specialized intervention. For example, about one third of children
will develop sexual behavior problems that should be addressed immediately to
prevent harm to other children. In yet other cases, children will have abuse
effects and other problems that may be unrelated to the abuse but require
immediate attention such as substance abuse, suicidality, or antisocial
behavior.
The treatment approach for the traumatic impact of abuse
that has been found to be effective in rigorous treatment outcome studies is
trauma-specific cognitive behavioral therapy. This intervention relies on
well-established psychological principles that are adjusted for application to
sexually abused children. It is based on the premise that children may develop
conditioned negative emotional associations to their memories or reminders of
the abuse experience and that they may adopt cognitive distortions about the
event(s). These reactions can cause distress (e.g., intrusive memories,
flashbacks, nightmares), can lead to maladaptive avoidance (e.g., irrational
restriction of activities, dissociation), or can eventually alter beliefs about
self and others (e.g., fear of all men, low self esteem). The approach includes
learning to identify and express negative abuse related emotions, anxiety
management strategies, cognitive coping, gradual exposure, correction of
cognitive distortions, and abuse-prevention skills.
Parents are also given treatment to assist them in
understanding and responding to their children’s reactions as well as handling
their own distress in ways that allow them to be more available to their
children. The components of parental treatment are similar to those for the
children. In addition, parents are taught effective behavior management
strategies to responds to children’s behavioral reactions.
Delivery of trauma specific treatment is often complicated
by the fact that families are in crisis or have other significant problems that
interfere with a focus on the child’s abuse reactions. Clinicians may need to
triage treatment priorities or engage other services to address the more
pressing problems that families may face (e.g., homelessness, legal problems,
substance abuse, domestic violence).
Sexual abuse is not a phenomenon restricted to certain
societies; every country where general population studies have been conducted
has found that sexual abuse of children is widespread. Many sexual abuse
victims, even in societies with highly developed child protection and mental
health services, do not tell anyone at the time and even if they do, the abuse
is rarely reported to authorities. Actions cannot be taken to protect children
or the community or get help for children if the abuse is not known to caring
adults or the authorities. On the other hand, encouraging children to come
forward or teaching professionals to screen for sexual abuse is only worthwhile
if the benefits of reporting outweigh the costs of remaining silent. This means
that societies and communities must be prepared to respond with protective
interventions and assistance to the child victims and their families. The most
important factor in creating a receptive climate for reporting is a societal
context that condemns sexual abuse of children and does not take a punitive
response toward the children.
Although model approaches (e.g., coordinated community
responses carried out by trained professionals) have been developed and
effective treatments (e.g., trauma-specific CBT) are available, they have yet
to be implemented in many communities. Continued efforts are needed to bring
knowledge and practice into greater concordance. Strategies that can be helpful
include passing laws, community organization, advocacy, and training.
Given the fact that many countries or communities do not
have fully developed child protection systems, an effective criminal justice
response or formal mental health services and in consideration of ethnic and
cultural differences in preferred responses, it is important that alternative
means of accomplishing the central goals of child protection and assistance are
identified. The essential ingredients would appear to be some mechanism for
protecting the victims and other children in the community from identified offenders,
a means of conveying social condemnation of sexual abuse of children, and
formal or informal ways of giving children support and the opportunity to
resolve psychological symptoms.
There are many formal and informal systems and organizations
that have a part to play in creating a protective and supportive community
response at the national or local level. Among the key participants are
national and local governments, tribal councils or other vehicles for enforcing
rules of social conduct, religious groups, legal and health care professionals,
non-governmental organizations, and extended family groups. Although allocation
of resources is an important factor in insuring that response systems and
services are widely available, it is possible to protect and help many sexually
abused children through creative mobilization of existing systems of care.
Berliner, L. & Conte, J. (1995) The effects of
disclosure and intervention on sexually abused children. Child Abuse and
Neglect, 19, 371-384.
Berliner, L.& Elliott, D. (2001) Sexual abuse of
children. In J. Meyers, L. Berliner< J. Briere, C.T. Hendrix, C. Jenny,
& T. Reid (eds.) APSAC Handbook on Child Maltreatment (pp 55-78). Thousand
Oaks, CA: Sage.
Cohen, J., Mannarino, A., Berliner. & Deblinger, E.
(2000) Trauma-focused therapy for children and adolescent: an empirical update.
Journal of Interpersonal Violence, 15, 1202-1223.
Deblinger, E. & Helflin, A. (1996) Treating sexually
abused children and their non-offending parents. Thousand Oaks, CA: Sage.
Fergusson, D., Horwood, L., & Lynsky, M. (1996) Child
sexual abuse and psychiatric disorder in young adulthood. Journal of Child and
Adolescent Psychiatry, 34, 1365-1374
Finkelhor, D (1994) Current information of the scope and
nature of child sexual abuse. Future of Children, 4, 31-53
Friedrich, W., Dittner, C., Action, R., Berliner, L.,
Butler, J., Damon, L., Davies, W., Gray, A., & Wright, J. (2001) Child
Sexual Behavior Inventory: Normative, psychiatric, and sexual abuse
comparisons. Child Maltreatment, 6, 37-49.
Hanson, R. K., & Bussiere, M. T. (1998). Predicting
relapse: a meta-analysis of sexual offender recidivism studies. Journal of Consulting and Clinical
Psychology, 66(2), 348-62.
Henry, J. (1997) System intervention trauma to child abuse
victims following disclosure. Journal of Interpersonal Violence, 12, 499-512.
Marshall, W., Anderson, D., & Fernandez, Y. (1999).
Cognitive behavioral treatment of sex offenders. West Sussex, England: Wiley.
Mullen, P., Martin, J., Anderson, J. & Romans, S. (1994)
The effect of child sexual abuse on social, interpersonal and sexual function
in adult life. British Journal of psychiatry, 165, 35-47
Sas, L. (1991) reducing the system induced trauma for child
sexual abuse victims through court preparation, assessment and follow-up. (No.
4555-1-125). Toronto: National Welfare Grants Division, Health and Welfare,
Canada.
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(2000) Treatment of sexually abused children and adolescents, American
Psychologist, 55, 1040-1049.
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Jones, D. (1996) Professional intervention in child sexual abuse. Studies in
Child Protection. London, UK: HMSO
Paper Three
Preventing Child Sexual Abuse: Promising Strategies and Next Steps
Deborah Daro Ph.D.
Chapin Hall Center for Children, University of
Chicago
Introduction
Most child abuse prevention programming and research has
focused on the development and assessment of strategies aimed at reducing the
prevalence of physical abuse and neglect. To a large extent, this pattern
reflects the field's major emphasis for the past 30 years. Until recently,
professionals and the general public perceived maltreatment to involve
problematic or damaging parenting practices. Excessive physical discipline,
failure to provide children with basic necessities and care, and mismatches
between a parent’s expectations and a child’s abilities has long been
recognized as precursors to maltreatment. Whether these failures stemmed from
limitations within the parent or within the surrounding social system, the most
prevalent and best researched methods to prevent child abuse have been efforts
to enhance parental capacity.
Beginning in the late 1970s, however, this singular focus
was altered with the long overdue recognition of child sexual abuse. Reports of
child sexual abuse in the United States, for example, increased from 6,000 in
1976 to an estimated 490,000 in 1992, with the bulk of this increase occurring
between 1976 and 1984 (McCurdy & Daro, 1994). Prevalence studies on this
problem estimate that as many as 20% of all females and 7% of all males will
experience at least one episode of sexual abuse during their childhood (Peters,
Wyatt, & Finkelhor, 1986). Furthermore, sexual abuse victims are a far more
heterogeneous population than are physical abuse or neglect victims. Risk
factors with respect to perpetrator characteristics, victim characteristics,
and socio demographic variables are far from universal (Melton, 1992).
Consequently, prevention advocates have had limited information to use in
formulating effective prevention strategies targeted to potential perpetrators
or communities.
Driven by a sense of urgency to respond to the sexual abuse
problem, prevention advocates have focused their energies on strengthening
potential victims, one of Finkelhor's (1984) four preconditions for sexual
abuse. These efforts, generally identified under the rubric of child assault
prevention education, provide direct instruction to the child on the
distinction between good, bad and questionable touching and the concept of body
ownership or the rights of children to control who touches their bodies and
where they are touched. Children are
encouraged to tell if someone touches him or her even if that person has told
the child not to reveal the incident.
Programs also offer children a range of resources they can utilize if
they have been abused. In addition,
most curricula include some type of orientation or instruction for both the parents
and school personnel. These sessions
generally review the materials to be presented to the children, discuss the
local child abuse reporting system, outline what to do if you suspect a child
has been mistreated, and examine the services available to victims and their
families (Berrick, 1988). While other sexual abuse prevention strategies do
exist, no strategy is as available or as carefully researched as educational
efforts that seek to strengthen a child's ability to resist assault.
Widespread concern has emerged over the utility and
appropriateness of providing universal education to children regarding the risk
of child sexual abuse (Reppucci & Haugaard, 1989; Gilbert, 1988; Melton,
1992). Despite the theoretical
limitations of these programs, evaluations in this area have become more
rigorous over time and have influenced the content and focus of child sexual
abuse prevention programs. At least six major review articles on child sexual
assault and victimization programs have concluded that, on balance, most
evaluations find significant, if not always substantial, gains in a child's
knowledge of sexual abuse and how to respond. (Carroll, Miltenberger &
O'Neill, 1992; Daro, 1991; Daro, 1994; Finkelhor & Strapko, 1992; Hazzard,
1990; Reppucci & Haugaard, 1989; Wurtele & Miller-Perrin, 1992). Further, a meta-analysis that reviewed the
findings from 30 such evaluations concluded that these programs produce a small
but statistically significant gain in knowledge (Berrick & Barth, 1992). While some of these gains have been noted
following repeated presentation of the concepts over a ten to 15 week period
(Downer, 1984; Woods & Dean, 1986; Young, Liddell, Pecot, Siegenthaler
&Yamagishi, 1987; and Fryer, Kraizer & Miyoski, 1987), the majority of
these gains have been realized after less than five brief presentations
(Plummer, 1984; Conte, Rosen, Saperstein & Shermack, 1985; Kolko, Moser,
Litz & Hughes, 1987; Harvey, Forehand, Brown & Holmes, 1988; Nibert,
Cooper, Fitch & Ford, 1988; Borkin & Frank, 1986; Swan, Press &
Briggs, 1985; and Garbarino, 1987).
As with all prevention efforts, these gains are unevenly
distributed across concepts and participants.
On balance, children have greater difficulty in accepting the idea that
abuse can occur at the hands of someone they know than at the hands of
strangers (Finkelhor & Strapko, 1992).
Among younger participants, the more complex concepts such as secrets
and dealing with ambiguous feelings often remain misunderstood (Gilbert,
Duerr-Berrick, LeProhn & Nyman, 1990).
While most children learn something from these efforts, a significant
percentage of children fail to show progress in every area presented. For example, Conte noted that even the best
performers in his study grasped only 50% of the concepts taught (Conte et al,
1985). Retention of the gains noted
immediately following these instructions also vary. At least one evaluator discovered that while children have been
found to retain increased awareness and knowledge of safety rules several
months after receiving the instruction, they retain less information with
respect to such key concepts as who can be a molester, the difference between
physical abuse and sexual abuse, and the fact that sexual abuse, if it occurs,
is not the victim's fault (Plummer, 1984).
In addition to having a potential for primary prevention,
child assault prevention instructions create environments in which children can
more easily disclose prior or ongoing maltreatment. In other words, independent
of the impact these programs may have on future behavior, they do offer an
opportunity for present victims to reach out for help, thereby preventing
continued abuse (Leventhal, 1987). Even
those who have little faith that any useful prevention strategy can be
developed with respect to sexual abuse, admit that child assault prevention
programs hold strong promise in obtaining earlier disclosures (Melton, 1992).
The few studies which have measured the extent to
which these interventions result in increased disclosures have been
promising.
Kolko, Moser & Hughes (1989) reported that in
five of six schools in which prevention programs were offered, school guidance
counselors received 20 confirmed reports of inappropriate sexual or physical
touching in the six months following the intervention. In contrast, no reports were noted in the
one control school in their study.
Similarly, Hazzard, Webb & Kleemeier (1988) found that eight
children reported ongoing sexual abuse and 20 others reported past occurrences
within six week of receiving a three-session program.
The generally positive findings from the evaluations
conducted to date suggest that some form of child-focused education is an
important component in our efforts to reduce the likelihood a child will submit
to ongoing sexual abuse or engage in violent behavior. The current pool of
evaluative data suggests positive outcomes can be maximized if programs include
the following features:
·
Providing children with behavioral rehearsal of prevention
strategies and offering feedback on their performance to facilitate children's
depiction of their involvement in abusive as well as unpleasant interactions
·
Developing curricula with a more balanced developmental
perspective and tailoring training materials to a child's cognitive characteristics
and learning ability
·
For young children, presenting the material in a stimulating
and varied manner to maintain their attention and reinforce the information
learned
·
Teaching generic concepts such as assertive behavior,
decision-making skills, and communication skills that children can use in
everyday situations, not just to fend off abuse
·
Repeatedly stressing the need for children to tell every
time someone continues to touch them in a way that makes them uneasy
·
Developing longer programs that are better integrated into
regular school curricula and practices
·
Creating more formal and extensive parent and teacher
training components, particularly when targeting young children
·
Developing extended after-school programs and more in-depth
discussion opportunities for certain high-risk groups (e.g., former victims,
teen parents)
Future Directions
Restructuring child sexual abuse prevention programs
in the manner outlined above is a critical first step in enhancing our capacity
to educate children, parents and communities bout the problem of sexual
abuse. Repeated commentaries on this
subject however have called for more creative thinking. These commentaries have structured this
expanded efforts within the context of Finkelhor’s conceptual model of sexual
abuse and have emphasized the need for a social service response rather than
stricter prosecution (Daro, 1994; Finkelhor, 1990; McCall, 1993; and Wurtele
& Miller-Perrin, 1992). Among the additional approaches frequently cited as
essential elements of a comprehensive strategy to prevent child sexual abuse
are:
·
Public education efforts to improve the public’s
understanding of the underlying causes and forms of child sexual abuse.
·
Directed education to those who are offending children in an
effort to encourage perpetrators to seek out services and to alter their
behaviors.
·
Parenting education programs that strengthen a parent’s
protective instincts and provide parents information on how to discuss the
issue with their children and how to secure help if their children are being
victimized. Specific guidelines that help parents distinguish among
appropriate, potentially troublesome and inappropriate sexual interests or
behaviors also can offer parents a means of monitoring their child's behaviors.
·
Life skills training for young adolescents that help them
establish positive relationships and avoid abusive behaviors with their peers.
These attributes include communication skills; problem-solving and planning
skills; assertiveness skills; negotiated conflict resolution; friendship
skills; peer resistance skills; low-risk choice-making skills; stress reduction
skills; self-improvement skills; consumer awareness skills; self-awareness
skills; critical thinking skills; and basic academic skills.
·
Support groups for children experiencing specific trauma
that may leave them feeling isolated and, therefore, more vulnerable to
advances by perpetrators
·
Support groups for vulnerable adults going through difficult
transitions that limit their ability or interest in protecting their children.
Common sense suggests that this type of comprehensive
approach is a move in the right direction. Research findings supporting this
approach are less clear and less available.
Research is needed to determine the extent to which individual behaviors
can be altered by various early intervention efforts and the extent to which
these changes result in less vulnerability for at-risk children and less
proclivity toward sexual abuse among adults.
Research must also address whether specific interventions cause
individuals any lasting discomfort or impinge upon healthy parent-child
relationships.
While the cost associated with providing all of these
services are not trivial, prevention, as opposed to treatment, is a more
cost-effective strategy in the long run for most social problems. Integrating these efforts into existing
social service and educational systems may reduce the total costs of
prevention. Such an approach not only
reduces program costs but also offers multiple opportunities to reach at-risk
children and potential perpetrators.
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