Child Abuse Assessment and Reporting

All 50 states enacted laws mandating that suspected child abuse be reported. This took place between 1963 and 1967. (Flaherty, Sege, & Hurley, 2008) Great strides have taken place in identifying and protecting children from neglect and abuse since then, but neglect and abuse still affects many children and their families. The rate of deaths resulting from abuse suggests that abuse is a fairly stable phenomenon, despite the changing nature of other statistics that are compiled on the subjects of abuse and neglect. Each year, approximately 1,500 children die because of maltreatment. (ibid) The clinician must view child abuse and neglect from both a legal and clinical perspective. This is because, in addition to clinical responsibilities, there are legal requirements such as mandated reporting. As a result, this course must identify both legal and clinical definitions of abuse and neglect.

The emotionally charged and legally fraught nature of this issue can be challenging to therapists when they first work with it. Making a report can provoke much uncertainty and anxiety in a therapist. Therapists are gratified to find that many families are not alienated from the therapist who makes a report, because they are helped to recognize that help is needed, and that there are systems in place to help them achieve valuable goals. Therapists already have skills necessary to realize this outcome in many cases. These skills include rapport-building, being outcome focused, articulating ego-syntonic values, and framing for enhancing positive motivations. However, involvement with child protective services can also go awry, as will be discussed.

Definitions, Scope and Effects of Abuse and Neglect
Clinical Definitions

Clinicians can view abuse and neglect in terms of medical consequences such as injuries and malnutrition, and psychological or developmental consequences such as symptoms of post traumatic stress disorder, behavioral problems, and delayed development. Appendix C: Abuse and Neglect: Definitions, Examples, and Signs provides a detailed listing of such factors.

Many situations of abuse and neglect are clinically complicated because they can involve multi-problem families in which there is a number of axis I and even axis II issues, serious financial and health issues, and multiple legal problems that include the abuse or neglect issue. In addition, there may be multi-generational problems associated with poverty, cognitive problems, and mental illness.

Families fall along a spectrum from fairly intact to multi-problem families. In more dysfunctional families, the abuse or neglect is part of a web of problems. Such families have numerous impairments and issues that pose a great challenge to treatment.

Abuse and neglect may occur in a cultural context in which it is normalized. This can range from a family steeped in severe disciplinary practices to members of a community that is adverse to medical treatment for religious reasons. In such circumstances, confrontation of the abuse or neglect by authorities or clinicians may be seen as morally wrong and part of a societal conspiracy to destroy higher values.

Along the spectrum of non-abusive to abusive discipline, there are controversies on where to draw the line between private family matters and a legal or clinical problem. As research sheds light on the outcome of various disciplinary patterns, society may be on firmer ground as to where to draw this line. Such research is complicated by the need to determine the true direction of causality. For example, children exposed to violence in childhood show increased levels of violence in adulthood, but some measure of this is genetic inheritance rather than modeling or traumatization. Some researchers have come to the conclusion that, overall, genetics provides the greatest explanatory power. If true, this has clinical and social policy implications. However, it is a statistical conclusion that may or may not be relevant to any given family.

Legal Definitions

Laws pertaining to sexual abuse exist as child protection statutes and criminal statutes. Criminal statutes are typically very detailed and create criminal penalties for specified sexual, physically abusive, or neglectful behaviors such as sex with a minor by an adult. Child protection statues pertain more to the responsibilities of mandated reporters and the state child protection agency. At the Federal level, the Child Abuse Prevention and Treatment Act defines child maltreatment. The Act is primarily concerned with matters such as research, funding, and agency oversight. (Administration for Children and Families, 2009) State funding for related programs depends upon the state meeting minimum criteria established by the Act.

The act provides the following definitions:

The term "child abuse and neglect" means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm;

The term "sexual abuse" includes:

1. the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or
2. the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children;

The term "withholding of medically indicated treatment" means the failure to respond to the infant's life-threatening conditions by providing treatment (including appropriate nutrition, hydration, and medication) which, in the treating physician's or physicians' reasonable medical judgment, will be most likely to be effective in ameliorating or correcting all such conditions, except that the term does not include the failure to provide treatment (other than appropriate nutrition, hydration, or medication) to an infant when, in the treating physician's or physicians' reasonable medical judgment--

1. the infant is chronically and irreversibly comatose;
2. the provision of such treatment would--
   1. merely prolong dying;
   2. not be effective in ameliorating or correcting all of the infant's life-threatening conditions; or
   3. otherwise be futile in terms of the survival of the infant; or
3. the provision of such treatment would be virtually futile in terms of the survival of the infant and the treatment itself under such circumstances would be inhumane. (42 U.S.C. 5106g)

State criminal statues regarding abuse and neglect of children define various forms of abuse and neglect for the purposes of responding to specified crimes. The statutes define these crimes based on factors such as the age of the child, the level of force used, the relationship between the victim and perpetrator, and the specifics of the behaviors involved. Punishment is more severe for crimes against children that are more vulnerable (i.e., younger) and more closely related, and for more extreme acts such as those involving penetration.

Federal statutes come into play for crimes involving certain Native American children, crimes that occur on Federal property, shipment and possession of child pornography, and other factors such as interstate trafficking.

Rates of Abuse and Neglect

The reader should have some skepticism regarding reported rates of child abuse and neglect. For example, at a time when rates were said to be cut by half, interviewing methods had changed in such a way that it was less likely to be disclosed to the researchers. After this, rates were said to double, but deaths only rose a small amount. (Murray, 2001) This is very unlikely and gave further credibility to critics of the research methods.

Even small changes in definition can have significant impacts on statistics from study to study and year to year. Nonetheless, when they are politically or financially useful, politicians and others will treat them as factual.

So long as we consider the available statistics in context, that is, in terms of how they were generated and how this will affect them, we can at least get some ideas about the nature and prevalence of child maltreatment.

NCANDS data: According to the Office on Child Abuse and Neglect (Goldman, Salus, Wolcott, & Kennedy, 2003), "Knowledge of the scope of the problem is drawn primarily from data reported by State child protective service (CPS) agencies to the National Child Abuse and Neglect Data System (NCANDS). Not all maltreatment, however, is known by the authorities." According to this source, "For every 1,000 children in the population in 2000, approximately 12 were victims of maltreatment.

The report describes reported child victimization rates categorized by the major types of maltreatment from the 2000 NCANDS: (ibid)

Neglect. More than half of all reported victims (62.8 percent) suffered neglect (including medical neglect), an estimated rate of 7 per 1,000 children.

Physical abuse. Approximately one-fifth of all known victims (19.3 percent) were physically abused, an estimated rate of 2 per 1,000 children.

Sexual abuse. Of all reported maltreated children, just over one-tenth (10.1 percent) had been sexually abused, an estimated rate of 1 per 1,000 children.

Psychological maltreatment. Less than one-tenth (7.7 percent) were identified as victims of psychological maltreatment, or less than 1 per 1,000 children.

Keep in mind that some children are reported as victims of more than one type of maltreatment.

Fracture data from primary care: Because physicians are more likely to report fractures that are suspected to result from abuse, statistics on this phenomenon can shed light on the incidence rates of abuse. According to Leventhal, Martin, and Asnes (2008),

The Kids' Inpatient Database can be used to provide reasonable estimates of the incidence of hospitalization with fractures attributable to child abuse. For children less than 12 months of age, the incidence was 36.1 cases per 100,000, a rate similar to that of inflicted traumatic brain injury (25-32 cases per 100000).

The abstract to their study provides a number of statistics by age range:

Among children less than 36 months of age who were hospitalized with fractures, the proportions of cases attributable to abuse were 11.9% in 1997, 11.9% in 2000, and 12.1% in 2003. The proportions of cases attributable to abuse decreased with increasing age; for example, in 2003, the proportions attributable to abuse were 24.9% for children less than 12 months of age, 7.2% for children 12 to 23 months of age, and 2.9% for children 24 to 35 months of age. In 2003, the incidence of fractures caused by abuse was 15.3 cases per 100,000 children less than 36 months of age. The incidence was 36.1 cases per 100,000 among children less than 12 months of age; this decreased to 4.8 cases per 100,000 among 12- to 23-month-old children and 4.8 cases per 100,000 among 24- to 35-month-old children.

Fatalities: The NCANDS estimates that 1,200 children known to CPS died as a result of abuse and neglect in 2000. "Over two-fifths of these children (43.7 percent) were less than 1 year old. Child maltreatment fatalities were more frequently associated with neglect (34.9 percent) than with other types of maltreatment, including physical abuse." (ibid)

Perpetrators: The report indicates that 78.8 percent of children in the data system were maltreated by a parent. Since the data concerns maltreatment by caregivers, this is to be expected. Caregivers include, "babysitter, daycare worker, residential facility staff, relatives, or household members..." (ibid) 59.9% of perpetrators were women, with nearly 42% of them being under the age of 30. However, fathers comprised the larger portion of those perpetrating sexual abuse.

Unreported incidence: The Third National Incidence Study of Child Abuse and Neglect (NIS-3) estimated rates of unreported child maltreatment by surveying "community-level" professionals such as educators medical professionals, and mental health workers in 1993. It is an attempt to determine accurate rates of abuse and neglect, rather than merely the numbers of cases that come to the attention of authorities. Their report estimates that less that one-third of abuse and neglect leading to harm had been investigated by child protective agencies. (ibid)

The Adverse Childhood Experiences (ACE) Study, a major survey of adults, "indicated that 11% experienced psychological abuse, 11% physical abuse, and 22% sexual abuse during childhood. (Nygren, Nelson & Klein, 2004)

Causes of Maltreatment

According to a report for the US Preventive Services Task Force (Nygren, Nelson & Klein, 2004), "Frequently cited factors associated with child abuse and neglect include low income, low maternal education, nonwhite ethnicity, large family size, young age of the mother, single-parent status, parental psychiatric disturbance, and presence of a stepfather, among others. As the number of risk factors increases, the proportion of children maltreated also increases." These factors could be boiled down to social class (in terms of poverty, education, early pregnancy, etc.), family disruption (e.g., single parent), and psychiatric issues that affect parental capacity.

Parents who act out violently or who are neglectful in the home are likely to abuse drugs or, especially, alcohol, as well as to have cognitive impairments (that affect impulse control and ability to solve problems with verbal intelligence), and symptoms of trauma. They are also likely to be under stress levels that exceed their capacity to manage, especially given that many of the parents have a limited capacity to tolerate stress in the first place.

In induced medical illness (Munchausen by proxy syndrome) a high rate of personality disorders was found. It was also found that in suspected cases of this syndrome, a very high percentage could be verified by covert video surveillance which revealed actions such as strangulation. (Southall, Plunkett, Banks, Falkov, & Samuels, 1997)

Emotional Abuse and Witnessing Violence

As with neglect, emotional abuse can be a difficult area to assess and draw conclusions about in many cases. The laws regarding emotional abuse leave quite a bit to judgment. This is because it is very difficult to define. The key is in considering whether it is damaging to the child, such as when it interferes with the child's development. Appendix C "Abuse and Neglect Definitions, Example and Signs" provides a list of specific examples of emotional abuse.

Suspicion of Neglect

Lack of supervision often comes to the attention of medical professionals through traumatic injuries or ingestion of harmful substances. This is not proof of inadequate supervision, but is a cause for concern. (Hymel, K. P. and Committee on Child Abuse and Neglect, 2006)

Many injuries are unavoidable or unpredictable. However, epidemiologic studies tell us that many injuries to young children result from inadequate supervision. (ibid) A challenge for those responding to suspicion of neglect is that there is no uniform definition that spans cultures. Legal definitions cannot be relied on in many cases because circumstances involving suspected neglect involve too many variables and shades of judgment, and recollection by parties involved is imperfect or biased. Nonetheless, the clinician should be aware of the legal guidelines and those provided by the child protective services agency in their area.

The following points are helpful in judging how to respond to suspected neglect.

1. The capacity of the child for developmentally appropriate judgment: Parents may need assistance in altering their expectations of a child with impairments that affect his or her judgment, such as hyperactivity. Even with appropriate supervision, such children will experience a higher rate of injury. Such difficulties may result from "physical, developmental, genetic, behavioral, emotional, cognitive, or psychiatric disabilities" (ibid)
2. Caregiver judgment and capacity: Factors such as the time of day or duration of inadequate supervision will shed light on the capacity of the caregiver for judging the supervision needs of the child. The caregiver's reasoning may show judgment problems. Inappropriate placement of blame, a significantly impaired fund of knowledge about risk factors such as poisons, or persistent developmentally inappropriate expectations are examples. Poor judgement may include a lack of supervision in relatively dangerous circumstances or activities such as in water. Past behaviors such as criminal activity or drug abuse may not be current concerns, but should be taken into account.
3. Behaviors of the child individually or with others: Lack of supervision often results in the child being free to engage in activities such as vandalism, parties involving drugs, sex, and violence, and theft, and to be involved with other children, teens, or adults that engage in destructive behavior. Unfiltered Internet access without supervision is a more recent concern.
4. Concern by the child or others serve as major red flags: Children may express discomfort regarding their own level of supervision. This may include past allegations, investigations, or proven neglect.
5. Absence of adequate safety and emergency response knowledge that is developmentally appropriate: Children that are unfamiliar with basic safety knowledge or behaviors such as how to call 911, their caregiver, or how to respond to a fire are vulnerable to injury. Children should know how to respond to phone calls or a knock on the door when they are unsupervised. Likewise, they should know how to respond to strangers when in the community.
6. Accessibility: The accessibility of someone to respond to a call from the child, such as a trusted neighbor, and arrangements to make sure that this is consistent.
7. Caregiver capacity: The expectations upon the caregiver must be appropriate. A frail, elderly grandmother may not be able to respond adequately to the children's needs. High levels of depression or other mental disorder may raise concern about the capacity to respond properly. The number of children and their ages, behaviors, and any special needs must be weighed against the designated caregiver's capacity. An older child may have responsibilities that are excessive for his or her age or development.

Effects of Abuse

Physical abuse has medical outcomes that depend on the nature and intensity of the physical abuse. It is the injuries of child abuse that often bring the child to the attention of authorities because bruises or other signs of injury are observed by medical professionals or others in the community.

An often neglected consideration is cognitive impairment resulting from head trauma (as well as the psychological conditions that result from physical abuse, such as PTSD and impaired sleep). Many cases of physical abuse involve one or more strikes to the head that can cause concussive injuries to the brain.

Cognitive impairment can have great effects on development. The nature of the impairment depends upon the injury to the brain. Brain trauma may cause problems such as AD/HD, bipolar disorder, dissociation, and learning disabilities. Behavioral and conduct problems may result from problems with peers, teachers, and others, and from impaired judgment and ability to use forethought.

Substance Abuse: A childhood abuse history is strongly correlated with substance abuse, and substance abusers with an abuse history are more likely to exhibit dissociation. This can have significant treatment implications.

Dissociation: Research is suggesting that individuals who can process trauma at or close to the time it occurs are more resilient. Dissociation, on the other hand, appears to be a defense that does not assist with processing. Peritraumatic (at the time of the trauma) dissociation is a strong risk factor for future psychological and adjustment problems in individuals with a history of abuse.

Dissociation is a strong factor in an abuse survivor becoming abusive or violent. It is likely that dissociation is associated with other cognitive deficits and impulse control or emotional stability problems known to be associated with violence and resulting from brain trauma either from PTSD or physical impacts.

The self is integrated during preschool years. This suggests that factors interfering with development such as abuse occurring during that period of life is likely to impair this process, leading to a tendency for dissociation that is independent of PTSD or head trauma.

Psychological Abuse: A great deal of research has addressed the question of mental health and developmental outcomes of adverse childhood events including maltreatment such as psychological abuse and witnessing domestic violence. Such experiences have been shown to be associated with psychiatric disorders, including mood disorders, suicidal ideation and acts, dissociation, substance abuse, teen delinquency, eating disorders, and adjustment problems, including relational difficulties. Post traumatic stress disorder affects this population in proportion to the degree of threat, violence, intensity, and duration of these experiences.

Health problems have also been shown to be a risk factor, including autoimmune diseases.

Some studies have attempted to control for possible genetic factors, and have found these negative outcomes to be largely independent of genetic inheritance. Even in a study of verbal abuse by teachers toward grammar school students found a strong association that was largely independent of previously existing problems or poor relationships with teachers. The study showed a significant effect on subsequent student teacher and peer relationships.

One conclusion was that, Children who are relatively well adjusted are at low risk of becoming the target of verbal abuse by the teacher. If they do, however, these children are the most vulnerable to subsequent developmental difficulties. (Brendgen, Wanner, & Vitaro, 2006) They found that, "verbal abuse by the teacher is significantly related to subsequent delinquent behavior and academic difficulties in early adolescence..." (ibid)

In a review of US National Comorbidity Survey Replication data, researchers found the fraction of psychiatric disorders and suicidal ideation and acts attributable to adverse childhood experiences such as abuse to be 20% to 32% with women in the higher range of vulnerability. (Afifi, Enns, Cox, Asmundson, Stein, & Sareen, 2008)

Regarding adolescents, a large study of adolescents in grades 7 to 12 by Hibbard, Ingersoll, & Orr (1990) offered these conclusions: "Almost 20% of the students reported some form of physical and/or sexual abuse, with more girls than boys reporting sexual abuse... Some problem behaviors (alcohol use) and emotions (trouble sleeping, difficulty with anger) were common among all adolescents and some were strongly associated with a history of abuse (especially, considering or attempting suicide, running away, laxative use, and vomiting to lose weight).

Child Sexual Abuse
Definitions, Scope, and Effects of Child Sexual Abuse

Clinical Definitions

Clinicians can view abuse from the perspective of the results and emergent needs related to the abuse. This view can be informed by existing knowledge about the nature of traumatization and the developmental needs of children.

This is because abuse is a multifactoral phenomenon, and because there is much individuality in individual responses to abusive acts and situations. Families have highly varied and complex responses to abuse, and families in which abuse occurs have highly variable dynamics. This means that a general description of the abuse cannot capture the full nature of the abuse or a child's response.

Further, children respond to abuse in both long-term (developmental) and short-term ways that include behavioral, emotional, cognitive, and relational aspects. The highly variable levels of resilience among children and their families further complicate the assessment and results of abuse.

Additionally, the effects of abuse and the relational dynamics associated with the abuse vary along the age continuum of the victim.

Clinicians can also view abuse from the perspective of the dynamics of the abuse itself. This requires clearly distinguishing between abusive and nonabusive acts. This intent is complicated by the fact that legal language and concepts have so infiltrated the clinical lexicon that clinical thinking can be side tracked by legal and moral issues, rather than being informed by them.

Problems with language used: The use of the term abuse in child abuse presumes that the child has been made dysfunctional in some way, regardless of the actual facts, because the legal definition of abuse has been experienced. The term victim, likewise, implies harm that may or may not have taken place. The clinician who uses other terms may give the appearance of not accepting the legal framework, when he or she is actually attempting to discuss clinical issues independent of legal definitions.

The term adult-child sex is an attempt to be objective, but it sounds similar to terms used by individuals who are advocates for adult-child sex. It also implies that the child had a sexual experience. This is not necessarily true, in the sense that child sexual abuse is not necessarily sexually arousing or gratifying to a child, and primarily takes place to gratify the adult. When such sex is arousing or gratifying to the child, or when the child actively solicits or contributes to sex taking place (more likely in teens), acknowledging this may be interpreted as being a justification for the activity and a denial of the validity of relevant law or a desire to overlook potential negative outcomes.

For the purposes of this training, terms such as abuse, abuser, offender, and victim will be used with the understanding that negative clinical effects do not necessarily follow from the actions in question.

Context: On the border between external and internal factors is the context and meaning of the abuse as interpreted consciously and subconsciously by the victim. This significance comes from prevailing social mores, family attitudes, the victim's experiences with the abuser, authorities, and other people who react to the abuse or conspire to maintain secrecy.

See Appendix A: Sexual Acts for a clinical listing of sexual acts from least to most invasive. Appendix B: Circumstances of Sexual Abuse discusses circumstances such as dyadic relationships and child pornography in which sexual abuse may occur.

Differentiating Abusive From Nonabusive Sexual Acts

Three factors have been recommended to help the clinician make the distinction between abusive and nonabusive acts: power, knowledge, and gratification. Any of these factors can inform clinical assessment. Where there is a power differential, coercion can increase the abusiveness of a sexual experience. Obviously, differences in age, size, strength, and even authority can cause a power differential. Relational power such as a parent-child relationship can create a sense of obligation that can be used coercively. An abuser who is more sophisticated than the victim is in a position to manipulate the victim.

A knowledge differential, usually the result of age and maturational differences, can exist in various ways such as an older child who is manipulating a naive, younger child. A very general rule for children is an age differential of five years. For adolescents, it is ten years. Of course, statutory definitions will vary, and the unique circumstances may trump the age guideline.

Older adolescents are better able to understand the significance of sexual behavior and relationships. Generally, by age sixteen, an adolescent is considered a participant rather than a victim. However, other circumstances such as the degree of power differential, may yield a situation that has a highly negative impact on the person, despite their higher age level.

A gratification differential suggests coerciveness. Whether it is because it involves a child that is not physically sexually mature, or an individual who does not care to engage in an activity that they are being pressured or manipulated toward, there is a gratification differential. This suggests manipulation or coercion.

Legal Definitions

As with child abuse in neglect in general, laws pertaining to sexual abuse exist as child protection statutes and criminal statutes. Criminal statutes specify criminal penalties for specified sexual behaviors such as sex with a minor by an adult.

The Child Abuse Prevention and Treatment Act defines sexual abuse and exploitation. (Administration for Children and Families, 2009)

The act provides the following definitions: (ibid)

The term "child abuse and neglect" means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm;

The term "sexual abuse" includes:

1. the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or
2. the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children;

Scope and Nature of Child Sexual Abuse and Maltreatment

Underreporting: It is widely believed that maltreatment of children is underreported. This underreporting is attributed to the effect of sexual taboos on researchers and family members, as well as the intrinsic motivations to avoid potentially hostile and costly intervention by authorities. A large majority of adults victimized as children did not report their victimization when it was taking place. Many perpetrators report abusing scores or even hundreds of children prior to their first arrest. Female perpetrators and male victims of sexual abuse are particularly likely to be underreported because of perceptions regarding the significance of gender that reduce sensitivity to these situations.

Data sources: Data on rates of incidence and, to some degree, the dynamics of child abuse comes from research on adults who disclose their childhood abuse experiences, or who disclose their own perpetration as adults, statistical summaries derived from actual reports filed with child protection agencies, and studies of child maltreatment, particularly federally funded studies known as National Incidence Studies.

Incidence rates and demographics: Federal studies have yielded data on incidence rates. According to the Administration for Children and Families (2008):

An estimated 905,000 children were victims of maltreatment;

The rate of victimization was 12.1 per 1,000 children in the population; and nearly 3.6 million children received a CPS investigation or assessment.

This shows a 4% increase over the preceding four years. However, that increase follows a much greater decrease (39%) in abuse in a previous period (between 1992 and 1999) in which cases dropped from an estimated 150,000 cases to 92,000. An analysis of the causes strongly suggests that this was a real decline, not merely the result of changes in reporting or recording. Increased awareness and responsiveness in the public and professionals is a likely cause of this drop.

Nearly 75% of victims had no prior history of maltreatment. The victims were nearly split as to gender, and younger children had higher rates of victimization:

The rate of child victimization for the age group of birth to 1 year was 24.4 per 1,000 children of the same age group. The victimization rate for children in the age group of 1-3 years was 14.2 per 1,000 children in the same age group. The victimization rate for children in the age group of 4-7 years was 13.5 per 1,000 children in the same age group...

Nearly three-quarters of child victims (72.2%) ages birth to 1 year and age group of 1-3 (72.9%) were neglected compared with 55.0 percent of victims ages 16 years and older. For victims in the age group of 4-7 years 15.3 percent were physically abused and 8.2 percent were sexually abused, compared with 20.1 percent and 16.5 percent, respectively, for victims in the age group of 12-15 years old." (ibid)

The report offers percentages of types of reported maltreatment and sources of reports:

During FFY 2006, 64.1 percent of victims experienced neglect, 16.0 percent were physically abused, 8.8 percent were sexually abused, 6.6 percent were psychologically maltreated, and 2.2 percent were medically neglected. In addition, 15.1 percent of victims experienced such "other" types of maltreatment as "abandonment," "threats of harm to the child," or "congenital drug addiction." States may code any condition that does not fall into one of the main categories-physical abuse, neglect, medical neglect, sexual abuse, and psychological or emotional maltreatment-as "other." These maltreatment type percentages total more than 100 percent because children who were victims of more than one type of maltreatment were counted for each maltreatment.

The data for victims of specific types of maltreatment were analyzed in terms of the report sources. Of victims of physical abuse, 24.2 percent were reported by teachers, 23.1 percent were reported by police officers or lawyers, and 12.1 percent were reported by medical staff. Overall, 74.9 percent were reported by professionals and 25.1 percent were reported by nonprofessionals. The patterns of reporting of neglect and sexual abuse victims were similar-police officers or lawyers accounted for the largest report source percentage of neglect victims (27.1%) and the largest percentage of sexual abuse victims (28.1%). (ibid)

Studies on incidence of child sexual abuse are inconsistent because of the variety of methods used to gather data, varying definitions of sexual abuse, and special focuses of some studies. In studies involving interviewer-generated data, reporting is higher when the population studied matches the race and gender of the interviewer, most likely because of increased rapport. The inclusion of less extreme forms of abuse such as consensual or "wanted" acts and non-contact acts generates significantly higher rates.

Psychosocial Impact of Sexual Abuse on its Victim
Introduction

Our understanding of the psychosocial effects of child abuse upon its victims derives from clinical case studies and research that compares abused children and adults abused as children with populations that have not experienced abuse. There are many such studies.

Great variability: Although children are to be protected from violent and sexual encounters, there is no certainty that a given experience will have a traumatic impact on the child. Although we refer to some experiences as traumatic or abusive, their actual impact on an individual may or may not have traumatic results. This has been attributed to individual, familial, and cultural diversity, and to variables within the experience itself. On the other hand, longer-term effects such as cognitive distortions, later relational problems, and developmental effects may occur but may not be immediately apparent. On top of that, a nontraumatic sexual experience may result in behavioral changes such as premature sexual acting out which will have very negative effects on development because of individual and societal responses to such behavior.

Traumatogenicity: In order to understand the impact of sexual abuse, it is necessary to identify the aspects that are traumatogenic, rather than to see it as a fused entity that automatically damages mental health. This is because a sexual experience or relationship with an adult may or may not include any given traumatogenic factor. We must also expand our perception of it to include context, including the reactions of family members, authority figures, and the internalized mores and attitudes of the child.

No reliable syndrome: Because of the number of factors involved, and the highly diverse degrees of resilience among children, the results of sexual abuse do not constitute a reliable syndrome or even a certainty of a negative mental health or adjustment problem. The discussion of sexual abuse as being a matter of degree (in terms of factors such as intensity, duration, coercion, threat, and injury), is key to this perspective.

A number of factors make it difficult to assess the effect of sexual experiences of children.

The moral repugnance with which people view sex with children makes it very difficult to be subjective or to entertain politically incorrect hypotheses.

It is very difficult to believe that something that is morally repugnant could not have severe mental health effects.

People with sexual abuse histories that therapists are most likely to see, are those with mental disorder symptoms. This creates a highly biased "sampling" of reality, because it excludes individuals with sex abuse histories who are not suffering from mental disorders or adjustment problems. The feelings of the therapist about sexual abuse cause the therapist to assume that the symptoms were caused by the sexual abuse, even when it was not traumatizing, and the symptoms can occur for other reasons.

But it is an analysis of the components of the experience that provides clinical understanding of the dynamics and outcomes of sexual abuse. This allows the clinician to think in terms of verifiable clinical effects rather than seeing sexual abuse as a single, fused entity that requires all who experience it to require recovery and psychotherapy.

Many if not all of the effects associated with childhood sexual abuse stem from factors other than the sexual experience or even adult relational experience itself. Negative mental health outcomes tend to be attributed to sexual abuse because it is a convenient explanation that reduces the stigma of mental disorders by creating a victim status for the person with the disorder.

A contemporary understanding of genetics suggests that families in which sexual abuse occur are more likely to have genetic mental disorder vulnerabilities. Thus, incidences of mental disorders in individuals exposed to sexual abuse as children may be more the result of multiple stressors and genetic vulnerability than with sexual abuse. Just as children are diverse in their capacity to tolerate stress, sexually abused children may have diverse symptoms, most of which can also be produced by other forms of stress, or no symptoms or developmental problems at all.

Child interviewing techniques and some forms of psychotherapy have been shown to be harmful to children's self perceptions, mental health, and to produce false testimony that disrupts their lives and those of their family members. (These were discredited and are not considered accepted standards of interviewing or treatment, but were commonplace in the past.)

Legal vs. clinical entity: While child sexual abuse is a clearly described legal entity, it does not suffice as a clinical entity. Any assessment of child abuse must be relevant to the actual family dynamics, any actual mental health symptoms, and case management considerations, rather than to a one-size-fits-all template for treatment. There is great diversity in the effects of abuse on children and their development. Abuse is referred to as traumatogenic, because it may cause or promote symptoms of psychological trauma.

Rather than a single phenomenon, child abuse must be thought of as a combination of experiences, each of which has one or more potentially trauma-inducing elements. To support a relevant treatment plan, assessment and treatment of an individual's child abuse history must pay special attention to elements such as the following: those that affect self perception; coercion; threats and harm; and vulnerabilities such as comorbidities and life problems.

Negative Outcomes

There is controversy regarding the psychological effects of sexual abuse. Research that does not focus on abuse with strong traumatogenic components, according to metastudies, shows small effect sizes. This is a strong contrast to dramatic claims made about the effects of sexual abuse. Some research studies that have found these small effect sizes used language that gives the impression that the authors were too intimidated by the politics of the subject to state this directly.

Meta-studies, even one that was biased toward a clinical population, indicate that the effects are not pervasive (in a fairly recent study, only 14% of victims showed elevated psychological distress or long-term effects. (Paolucci & Genuis, 2001) This is similar to a previous metastudy in that the effects were not large.

Surprisingly, neither of these meta-studies found that variables that one would expect to influence outcomes had a statistically significant effect. In the most recent metastudy, these included, "gender, socioeconomic status, type of abuse, age when abused, relationship to perpetrator, and number of abuse incidents..."

Nonetheless, there are numerous studies that show correlation between sexual abuse and negative outcomes such as obesity, sexual problems, and PTSD. Note that adrenal axis dysfunction, which is an aspect of PTSD, is associated with obesity, as is PTSD. In one study, women with a sexual abuse history had an elevated rate of obesity, but not until their early 20s. The association showed only a modest effect. Similarly, a metastudy of eating disorders in sexually abused women found only a "small, significant positive relationship." (Smolak & Murnen, 2002)

Politics and the Changing Research Landscape

Much fear has been created that studies showing weak correlation between abuse and adult dysfunction would be a wedge that would breakdown society's ability to protect children from abuse. In fact, defense attorneys and activist organizations made such attempts. However, such efforts have not gained traction. Congress even made a very strong statement decrying a specific study that was published. After this, such research has not been a typical feature of sexual child abuse defense. Now, research has metabolized the earlier work discussed above, and is focusing more on identifying more clearly the elements of child abuse that are traumatogenic and what treatment approaches are most helpful.

Finkelhor's Categories

Finkelhor divides potential abuse sequelae into four general categories: traumatic sexualization, stigmatization, betrayal, and powerlessness. This perspective may help the clinician determine what personal issues require attention in an abuse survivor who enters therapy. These categories refer to various experiences or symptoms that may occur and are summarized as follows:

Traumatic sexualization

• Aversive feelings about sex
• Overvaluing sex
• Sexual identity problems
• Behavioral manifestations can include hypersexuality, avoidance, or specific sexual problem behaviors or encounters.

Stigmatization.

• Guilt from feeling responsible for the abuse or even consequences of disclosure
• Dysfunctional and self-destructive behavior including substance abuse, high risk behavior or thrill-seeking, self-mutilation, suicidality, and provocation that elicits punishment.
• Finkelhor's colleague, Sgroi, refers to this as "damaged goods syndrome."

Betrayal.

• Inability to trust appropriate people, including nurturers.
• Anger and borderline behavior.
• Creating barriers to intimacy
• Manipulation
• Re-enactment that may include being involved in exploitive or otherwise harmful relationships

Powerlessness.

• Exaggerated feelings of powerlessness and vulnerability
• Self-perception as victim in a variety of situations
• Failure to assert and effectively manage situations in which victimization or something resembling victimization is a risk
• Overidentification with either victims or aggressors
• Dissociation, fleeing certain adult relational developments
• Anxiety, phobias, sleep difficulties, elimination disorders, eating disorders and other manifestations of anxiety and trauma
• Rather than victimization, behaviors may emphasize aggression and exploitation of others.

Positive or Neutral Outcomes

Many children do not appear to suffer developmental problems or psychiatric disorders as a result of abuses. In general terms, their resilience can be seen as having a threshold that was not crossed by the level and type of abuse that occurred. Also, many adults describe gaining wisdom through surviving abuse. Sometimes, this wisdom or personal strength is valued despite the existence of symptoms that were produced by the abusive experiences. This mirrors psychologically traumatogenic experience in general, as the majority of people who experience trauma do not become symptomatic. Also, less severe trauma is less likely to produce symptoms. The later in life, the less threatening, and the less repetitive the trauma is, the less likely it is to have long-standing and developmental effects.

Research that has discovered cohorts that were not symptomatic has created much controversy, and those professionals who have published it or discussed it objectively have been the targets of accusations that did not characterize those individuals fairly. The tendency was to frame them as having a pro adult-child sex agenda or other similar attitude, rather than as people reviewing legitimate research outcomes. An American Psychiatric Association medical director went so far as to imply that the research involved exposing children to sexual abuse, which it did not.

Assessment and Verification of Child Sexual Abuse
Introduction

Clinicians must take care to distinguish between attempting to verify abuse and their role in clinical assessment. Although therapists are mandated reporters, the law does not require them to investigate suspected abuse or neglect.

However, it is important to be sufficiently familiar with child abuse in order judge whether to make a report. For example, according to Kellogg (2009), our increasing understanding of normal child sexual behavior is changing how we respond to it. (Kellogg, 2009) we are discovering that some sexual behavior in children has been wrongly interpreted as precocious behavior that must have been the result of sexualization by an adult. When it occurs between two children (such as limited curiosity and touching), it is not helpful to respond in a heavy-handed way by involving the authorities. According to Kellogg:



Most therapists will not be in the position of making a final determination as to whether child abuse has occurred. However, many therapists will need to determine whether there is reasonable suspicion that requires them to make a report. Additionally, some therapists may contribute to legal verification of child sexual abuse because of their specialized training and experience, or merely by testifying to relevant facts of the case when called upon to do so.

Clinical indicators of child abuse may actually be caused by other stressors or disorders, or by non-sexual abuse. The following material discusses indicators of child abuse intended for verification, but some can also serve to identify clinical needs.

Behavioral Indicators

Child behavior can be used as one aspect of assessment for sexual abuse. However, it cannot independently constitute proof. Efforts to gain inclusion of Sexually Abused Child Disorder in the DSM III-R failed, in part, because it was not reliable enough as a defined syndrome. Behavioral indicators can be thought of as being high, medium, and lower probability signs that abuse may have occurred.

Behavioral indicators may be divided into sexual and nonsexual. They are also dependent upon age, with a very general distinction between children over and under ten years of age. Non-sexual behaviors, in particular, may result from stressors or congenital problems that have nothing to do with sexual abuse. Each item listed in that section may result from a very large number of alternative explanations that may include family stress such as substance abuse or conflict.

Sexual Indicators

Cautions in Assessment

Kellogg (2009) cautions clinicians not to pathologize or over-interpret developmentally normal sexual or para-sexual behaviors. The article provides the following guidance by describing a range of normal to worrisome sexual behavior:

Normal, common sexual behavior in children ages 2 to 6:
Touching or masturbating, viewing or touching a peer's or sibling's genitals, showing genitals to a peer and trying to view peer or adult nudity -- all behaviors that are "transient, few and distractible."

Less common but still normal behaviors
Rubbing against others, touching a peer or adult's genitals and crude mimicking of movements associated with sexual acts. Behaviors may be disruptive to others, are transient and "moderately responsive to distraction."

Uncommon behaviors observed in normal children
Explicit imitations of intercourse, asking a peer or adult to engage in specific acts and inserting objects into genitals. Such behaviors merit further assessment to rule out sexual abuse.

Rarely normal behaviors in children ages 2 to 6
Behaviors that involve children who are four years or more apart in age, are displayed on a daily basis, result in emotional distress or physical pain, include coercion or physical aggression, are persistent, and when the child becomes angry if distracted. These behaviors require immediate and effective intervention, the report said.

Probability Indicators

All Ages
The highest probability indicator is a self report of sexual abuse. Unless there is coaching or inappropriate forms of interviewing, false self reports are rare, particularly in younger children. False reports have been estimated to be in the range or one to five percent. (Faller, 1993)

Under Age Ten
High probability indicators indicate early sexual knowledge not normally possessed at that age. The more unlikely the knowledge (or the intimate or experiential nature of the knowledge) is, the higher the probability of sexual abuse in absence of an alternative explanation.

Statement of sexual knowledge. Likely to be made inadvertently (the style or nature of the statement may help distinguish it from sexual knowledge derived through other experiences, such as overhearing a discussion)

Sexual drawings (there is risk of adults making sexual inferences of non-sexual drawings, however)

Actual sexual interaction with others such as sexual aggression toward younger children or the appearance of an expectation that older persons will behave sexually toward the child. Sexual guarding that suggests a concern that an adult will begin sexual behavior, such as with a designated adult who is helping the child go to the bathroom.

Readily sexually active with peers, showing comfort or pleasure with active sexuality

Sexual themes with toys or animals

Excessive masturbation, especially when there are unusual factors such as the child causing self injury, being unable to stop, inserting objects, making moaning sounds, or showing thrusting motions indicative of participation with a more experienced and older individual.

Over Age Ten
Although they are referred to as high probability because of their sexual nature, there are often alternate explanations for these behaviors. Circumstances must be considered.

Sexual promiscuity (particularly girls)

Repeatedly being in the role of sexual victim (clearly a situation where circumstances must be considered)

Prostitution (there is a high likelihood that teen prostitutes have been sexually abused)

Non-Sexual Indicators

Younger Children

These indicators are lower probability than sexual indicators, because there are numerous potential causes other than sexual abuse. These indicators include:

• Sleep problems
• Enuresis or encopresis
• Regressive behavior
• Risk-taking or self-destructive behavior
• Impulsiveness and distractibility or difficulty concentrating
• Fear of being left alone or off the alleged offender, or people of a particular type or gender
• Firesetting
• Animal cruelty
• Pseudomaturity

Older Children

• Disordered eating
• Running away from home
• Substance abuse
• Self-destructive behavior such as suicidal gestures and self-mutilation
• Delinquency and criminal behavior
• Depression and isolation

All children

• Problems with peer relationships
• Difficulties with school
• Significant, sudden behavior changes

Medical Indicators of Child Sexual Abuse

While therapists are not to provide physical examination or medical diagnoses on physical findings, therapists will be exposed to medical information that they must understand on at least a basic level.

Although there are controversies regarding the interpretation of physical findings that are suggestive of sexual abuse, much progress has been made, and physical findings are considered a valid aspect of sexual abuse assessment. Prepubertal findings are more reliable than postpubertal findings because the odds of consensual sexual activity increase with age and sexual maturity. Note, however, that most sexually abused children do not have physical signs.

Significant progress has been made in the medical field in the determination of sexual abuse. Medical professionals are no longer limited to the presence or absence of a hymen as the indicator of possible sexual abuse. A variety of types of genital findings have been documented. In addition, notable progress has been made in identifying anal findings. Moreover, physicians are able to describe the effects of different kinds of sexual activity, and subtle findings can be documented using magnification (a colposcope or otoscope).

The highest probability physical indicators are pregnancy and sexually transmitted disease (STD). However, they still do not provide certainty regarding the age of the individual involved with the child. Again, the younger the child, the higher the likelihood of abuse. Infants may be born with a STD acquired from the mother pre- or perinatally. Some diseases are more likely to have been acquired through sexual activity than others, despite being categorized as a STD.

Genital Findings

High-probability findings include:

• Semen in the vagina (highest probability, but not common)
• Torn or missing hymen (The hymen is quite variable among girls, but absence or tear is a very high probability finding. Older girls may have nonabusive sexual experiences such as masturbation that can affect the hymen. Bumps, friability, which means readily crumbled or brittle, and clefts in the hymen may be indicative of abuse or other causes.)
• Other vaginal injury or scarring
• Vaginal opening greater than 5 mm (but there is individual variation)
• Injury to the penis or scrotum. (May include bite marks, abrasions, hickeys, redness, or bruises.)
• Bleeding from the vaginal opening.

Lower probability findings include:

Bear in mind that findings such as redness and swelling may be caused by alternate explanations such as poor hygiene, diaper rash, or possibly masturbation. Labial adhesions may be from a congenital condition. Vaginitis and urinary tract infections may be caused by poor hygiene or even a bubble bath. Urinary tract infections may result from taking antibiotics.

• Vaginal erythema (redness, typically due to healing of injuries)
• Increased vascularity (blood vessels)
• Synechiae (adhesion of parts such as the labia minora)
• Vulvovaginitis (inflammation and infection)
• Chronic or recurring urinary tract infections

Anal Findings

High-probability findings include:

• Destruction of the anal sphincter
• Perianal bruising or abrasion
• Shortening or eversion of the anal canal
• Fissures to the anal opening
• Wasting of gluteal fat (rare, most likely in male adolescent prostitutes)
• Funneling (wider externally than internally, rare, most likely in male adolescent prostitutes)
• Rarely, the absence of anal sphincter control may occur. This can indicate chronic anal penetration.
• In very young children, there may be shortening or eversion (some turning outward or inside out) of the anal canal.
• Perianal fissures or scars may indicate abuse, but abnormalities at the 12 o'clock or 6 o'clock positions may have resulted from a large stool.

Lower probability findings include:

• Perianal erythema, increased pigmentation, and venous engorgement occur in many children who have no abuse history. Poor hygiene may be responsible for the first two of those findings.
• Perianal erythema (redness, typically due to healing of injuries)
• Increased perianal pigmentation
• Perianal venous engorgement (increased size of blood vessels)
• Reflex anal dilation (gaping or twitching of the anal sphincter; may occur as a result of lower bowel being full of stool; gaping of 20mm or more is likely to result from a history of anal penetration)

Other Sources of Evidence

Suspect's Confession

Although it is unusual for an abuser to confess, this is a highly definitive finding. Fear of consequences including a change of status in society and one's family are extreme motivations for an abuser to cover up and deny abuse. Some suspects will feel that they must acknowledge something when confronted with clear evidence. In this case, equivocal statement may provide a partial confession. The abuser may have an excuse such as excessive drinking or some kind of misunderstanding. They are especially likely to understate the number of times or extent of the sexual activity.

Materials and Circumstances

The circumstances surrounding the case may provide evidence. Materials such as pornography may suggest the possibility of abuse, in conjunction with other evidence. Although the possession of pornography is commonplace, the type of pornography or where it is located may at least constitute supportive evidence, especially child pornography. However, it does not constitute proof of abuse.

Eye Witnesses

Sometimes eye witnesses are motivated to collaborate with the abuse in covering up abuse. Spouses may be concerned with the loss of income and status, may be in denial, or may be consciously or unconsciously attached to the family balance that is obtained through the dynamics associated with the abuse. However, children or adults may come forward with information and observations that support allegations of abuse.

Interviewing Suspected Victims

Interviewing children to verify sexual abuse is a specialized area. Only those with specialized training and experience are to conduct such interviews. However, therapists can gather sufficient information to determine whether to make a report. The guidelines here are relevant for this purpose as well. This section will provide only a brief overview.

Key process objectives to such interviewing serve to gain accurate information. To achieve this, suggestion and coercion must be eliminated, as children can produce inaccurate information under those circumstances. This issue has been a source of tremendous, costly, and highly traumatizing controversy. It was a very serious problem that has subsided largely as a result of lawsuits and government investigations during a time that the mental health field and child protective workers did not adequately understand these dynamics.

It is important to avoid retraumatizing or over-stressing children in connection with abuse investigation. Excessive and redundant interviewing techniques are potentially harmful and lend themselves to manipulative interviewing that can produce false positives. The child welfare system and justice system are working to avoid excessive stress by not involving multiple staff persons and agencies in the interviewing process.

Younger children require special techniques and tools, with special regard to their suggestibility, as their brains are in an early stage of development in which fantasy and reality are merged to some degree. However, even preschool children are generally able to tell a fact of their experience from a fantasy. Therapists not trained to work with younger children should not feel obligated to attempt an interview for verification of sexual abuse. The mandated reporting laws do not require efforts to validate suspicions or claims that pose any significant risk of a negative clinical outcome or require extensive efforts above normal clinical assessment and process.

Except for those who are highly defensive, parents will allow the therapist to interview the child individually. However, younger children may be unwilling to respond to interview questions or play that is overly directed by a stranger, so it may take time to build enough rapport. The therapist can best establish rapport with the child by not being too attached to a preconceived agenda, allowing the interview to flow according to the attention and capacity of the child. Sitting at the eye level of the child, communicating within the child's vocabulary, and playing with toys can begin this rapport building.

The therapist will need to sort out fantasy and irrelevant information that is provided in a non-chronological manner by most young children. Breaks in the session or interview will be necessary when the child becomes fidgety. The therapist can directly address in a non-threatening but direct manner any fears the child appears to have.

Other developmental considerations include avoiding abstraction, principles, irony, and metaphor. It is important to be concrete. The therapist will have to get specific questions answered, but without asking any leading questions. The therapist might ask, "Tell me about your brother playing with you," while holding two dolls side by side, rather than, say, "Tell me what your brother does to you here," while pointing at a specific area of a doll. The therapist should not expect information to be attributed to specific times or even places. It can help to use reference points that are familiar to the child, such as a major holiday. People may even be confused by younger children.

Observations of the child, including signs of mental disorder and maltreatment may contribute to the overall picture. This should be considered in terms of context. Variables such as a dangerous neighborhood or homelessness may create signs that can be misinterpreted.

Therapists who interview younger children to assess for child abuse will learn skills such as working with anatomically correct dolls and play therapy methods that allow uninhibited and relevant information to emerge without traumatizing the child.

Causes of Sexual Abuse
Introduction

A good way to discuss causes of child sexual abuse is in terms of offender profiles.

Sex Abuse Offender Profiles and Contexts

Because males engage in most sexual acts with children, most attention and research on child sexual abuse has been on men. Specific profiles have been found among these men, and emerging science suggests a number of etiological factors play roles in these behaviors.

Pedophiles vs. other profiles: The most fundamental distinction, which is often lost on the public and policy makers, is between pedophiles and other men who have had sex with children. A substantial percentage of men are aroused by images depicting children or sexual acts involving children. (Nagayama Hall, Hirschman, & Oliver, 1995) This has been learned through self reports by men and through plethysmography (the use of a device called a plethysmograph to measure penile engorgement that indicates biological sexual arousal). However, only a small percentage of men have sex with children, and a small percentage of them experience and act out their attraction to children to the level that is considered pedophilia.

Pedophilia as a sexual orientation? The nature of the attraction experienced by pedophiles bears a strong resemblance to a sexual orientation. For example, treatment of pedophilia has challenges and success rates that match that of the controversial sexual orientation change therapy for homosexuals. Pedophiles reliably report a much higher likelihood of early erotic interest in children from an early age. Research has been designed to overcome the tendency of pedophiles to answer unreliably in their attempts to evade stigma. For example, subjects are asked if they recall desiring to see children without their clothes on when they themselves were children. Pedophiles are much more likely to recall such memories.

The idea that pedophilia is a sexual orientation is fraught with controversy because of the moral repugnance with which people view pedophilia. However, this view may prove to be clinically useful in understanding its chronic nature and how to craft the most effective responses in managing the public health issues involved. This requires that the clinician, while being aware of the legal issues, understands that clinical and legal issues are not the same.

There has been much speculation that childhood abuse is a major factor in the development of pedophilia, but research is not supporting this contention. Researchers have claimed that pedophiles have high rates of comorbid disorders. Cohen and Galynker (2002) state, "Studies have shown that pedophiles may share many psychiatric features beyond deviant sexual desire, including high rates of comorbid axis I disorders (affective disorders, substance use disorders, impulse control disorders, other paraphilias) as well as severe axis II psychopathology (especially antisocial and Cluster C personality disorders)." However, the stressors associated with pedophilia such as intense stigma and involvement with the criminal justice system make it very difficult to assert with certainty that pedophilia is part of a mental illness cluster of that kind, or the extent to which it is true.

On the other hand, emerging research is beginning to reveal underlying psychopathology that is a highly likely etiological factor in at least some pedophiles. Brain research indicates that a subset of pedophiles have cognitive deficits and delayed development, particularly in the area of social skills and verbal intelligence. It appears that this underlies a profile of pedophiles who identify with children and who are unable to establish rewarding intimate relationships with mature adults. This inability to be accepted by adults contributes to the individual's sex drive being directed toward younger people. This doesn't fully explain or support pedophilia as a sexual orientation in this subpopulation, but it does hint at the intensity with which these individuals would establish strong, habituated sexual feelings toward children.

This results in two major profiles that are likely to fall under the category of pedophilia: the developmentally impaired pedophile who identifies with children and the pedophile whose development is, overall, more age-normal, and whose pursuit of children will be more sophisticated. Most individuals in the former category may not have developed an attraction to children in a manner that resembles sexual orientation as opposed to the latter group.

Non-pedophile profiles: Of men who are not pedophiles, but who have one or more sexual acts with children, there are several profiles that do not resemble a sexual orientation and that appear to be more amenable to treatment.

Opportunity or lack of alternate outlet: Men who are not primarily attracted to children may use children for sexual gratification or even experience falling in love with older children (primarily teens) for reasons other than pedophilia. Roughly, these reasons fall into two categories. One category is sheer opportunity. In this case, the inhibitions pertaining to sex with children are overcome by the desire for an additional sexual outlet or even by the subjective experience of falling in love. Individuals who have poorer judgement and impulse control, or less mature perceptions of love and boundaries are especially likely to cross this line, as are individuals who tend to objectify people in general.

The other category is lack of a sexual outlet, as might occur when there is a high level of alienation between members of a couple. Again, there are likely to be other factors affecting the offender's judgement.

Impairment: Developmental and cognitive impairments have already been discussed. There are numerous ways that sexual impulses may be out of control in individuals who do not have a history of inappropriate sexual acting out. Examples include onset of cognitive disorders as a result of neurodegenerative illness such as Alzheimer's or more acute brain trauma, or the influence of alcohol or other drugs.

Dysfunctional family dynamics: A variety of family dynamics may contribute to, support, or help to hide incest or other sexual abuse. Dynamics can include the value of the child in absorbing sexual impulses that are not welcome by the other member of the couple, lack of recognition of normal family boundaries, impairment such as those resulting from drug abuse, and denial regarding the dysfunctionality of the offender. Family therapists will recognize the familiar dynamic of problems with the boundaries of the parental unit that result in children serving inappropriate roles.

Many offenders established their sexual patterns prior to being in their current family. Family dynamics should not be perceived as isolated causes of abuse, but rather, as contributing to it. Also, in contrast to denial, many family members are misled so well by an abuser that the abuse is, at least initially, unknown to the family members. This requires no dysfunctional family dynamics that support the abuse, especially since children can be manipulated not to discuss what is happening for a long period of time.

Issues with teens: Teenagers may seek out or accept sex with older individuals because of curiosity, a sense of prestige or being special (particularly when that adult is in a position of authority, provides access to alcohol or other drugs, or spends money on the teen). The increased independence of teens, and their developmentally appropriate desire to establish an identity separate from their family also contributes to this.

Given that, from the perspective of evolutionary psychology, younger individuals have traits that make them more attractive for sexual experiences, many adults will take advantage of this dynamic even though many of them are capable of relationships that are more mature and socially acceptable. The emphasis on youth in the media has also been implicated in helping to fuel this, and to lessen the perception of attractiveness of older adults.

Older adults in such relationships range from individuals for whom it was out of character to have crossed this line to antisocial individuals who are driven exclusively by more primitive desires for gratification.

Other situations: There are various other situations in which children or teens may be abused, such as prostitution, trafficking, and pornography.

Cycle of Abuse? A cycle of abuse is referred to in much of the literature on child sexual abuse. Research offers little support for the idea that the experience of child abuse creates a significantly elevated likelihood that the individual will develop into a sex offender. The cycle of abuse concept smacks of the politically motivated and fear-driven characterizations of sexual abuse that have been discussed earlier. The multi-generational dynamics of chronic multi-problem families appear to contribute to this perception, because sexual abuse is more likely to occur in these families as such families have members with more mental disorders, impulse control problems, boundary problems, and alcohol and drug problems.

Responding to Child Abuse and Neglect
Introduction

This course does not cover treatment of abuse, but we will review some treatment and case management considerations that are closely related to assessment and reporting. Treatment and case management must be orchestrated to be in the child's best interest. This can be very challenging. There is only a limited amount of research to draw upon in determining the best ways to proceed.

Treatment of child abuse can be a complex process. Orchestration of treatment in the child's best interest is a genuine challenge. There are not enough outcome studies of treatment effectiveness. Reliable research is difficult to conduct because of variables such as agency and court involvement and misrepresentations by family members and suspects. Case management can involve any number of additional entities such as other treatment providers, foster care providers, and representatives from the child protective services agency.

Generally, it is recommended that the offender be removed from the home rather than the child, because removal from the home is likely to further isolate and traumatize the child. Factors may determine, however, that it is in the best interest of the child. When there is separation, the ideal goal is reunification, barring contraindications. Factors that are considered in making this decision include the capacity of the family to supervise and protect the child, the extent of the abuse, and any impairments or personality disorder on the part of the offending parent. In a smaller number of cases, the family may remain intact throughout the process.

Case Management Considerations

Perceptions and Cooperation

Ideally, all professionals involved in the case will take pains to help the family members, including the child, understand the process and how to cope with it. This does not always happen, so the therapist must ensure that this happens as much as possible. This will improve the odds of each party taking a constructive role. Also, the therapist may be in the position of helping other professionals understand the needs and behaviors of the family members. Taking the lead in framing the situation for the family members and the professionals may help to avert unnecessary conflict, avoidance, or other dysfunctional responses. Therapists can help clients be persistent despite a slow-moving bureaucracy, or maintain their self esteem despite hearing belittling comments from less objective agency workers. There are many reasons to provide psychosocial education and other help in such trying circumstances. A key area is helping family members understand the realities of child abuse and likely outcomes. It is very difficult for family members to come to terms with one of their family members being abusive. Part of this involves helping family members determine ways that they can alter their behavior and family dynamics in order to prevent abuse and further the victim's recovery. Family members often have to work through feelings of shame, blame, and anger before they can begin to think constructively. The therapist can facilitate this process with an eye to expediting it and supporting good outcomes.

Decisions Prior to Implementing Treatment

The following are among key decision factors that must be made prior to initiating treatment:

What intervention will have the best odds of ensuring safety and preventing further abuse?

• Whether to separate the child or offender from the family
• The role of the courts
• Visitation
• The desirability of reunification
• Additional information that is needed
• When possible, long-term planning

Assessment of Parents and Other Family Members

The greater the health support within the family, and the greater the resources of the parents for taking responsibility for the children's emerging needs, the better the prognosis. Likewise, a milder and smaller-scale level of abuse is more promising than more serious abuse.

Factors such as the following are considered:

• Extent of sexual abuse
• Offender's level of taking responsibility
• Additional problems or diagnoses of the offender such as substance abuse, violence, mental illness, and mental retardation.
• Non-offending parent's handling of knowledge of sexual abuse and capacity to act and exercise judgement independently of the offender
• Quality of parenting and family's response to child's emerging needs and responsibilities posed by courts or agencies

The functioning and wishes of the child (generally, this factor can be given a good deal of weight)

Criminal Charges and Court Involvement

It is often considered advisable that criminal charges be filed, because a court order mandating treatment and other follow through will greatly increase the likelihood of compliance. Coerced compliance with treatment, contrary to common belief, does not eliminate the value of treatment. When there is a lack of compliance with treatment objectives, professionals can fall back on the court to assure safety or provide the offender with additional motivation through appearance before the court or additional sanctions or punishment.

On the other hand, there are potential drawbacks, such as the effect of an adversarial process on the willingness of the offender and other family members to make disclosures that are conducive to treatment. If the offender is incarcerated, treatment will be interrupted. However, where incarceration takes place, it is generally because the abuse is of a more serious nature. Courts have safeguards in place to minimize the potentially traumatic impact of testimony on the child; however, it is reasonable to be concerned about the potential effect of the legal process on the child. Many children will gain a sense of personal power and closure by being heard and having words for their experience, while others may be overly stressed, particularly where cross examination is aggressive and the child finds the revelations they must make to be humiliating. The protracted nature of court proceedings can result on overly long, sustained levels of stress. Treatment can help to prepare children for the process, and to help them tolerate it and rebound.

Prognosis is much poorer when there is more than one offender in, or involved in, the family unit. Where both parents are offenders, reunification is much less likely to be advisable.

Visitation

Individual circumstances will help to guide the team in making recommendations related to visitation. Visitation is generally contraindicated until the victim has testified in court, if this is part of the plan. The child may need to be insulated from any other family members who are against the child providing testimony. While the child's desires regarding visitation are important, professional opinion should generally prevail where visitation is considered to be not in the best interests of the child. Once visitation is allowed, the level of supervision and any restrictions on time are usually relaxed over time so long as factors such as treatment compliance are consistent.

Legal Issues in Child Abuse Reporting

Introduction

Family law and related child abuse law have been undergoing a process of nationalization as model laws are produced and propagated. The result is that many states have very similar laws for reporting and responding to child abuse and neglect. Decisions by the Supreme Court that have contributed to this trend include those concerning issues of due process, full faith and credit, equal protection, the 10th Amendment, and privacy. Various organizations, including some involving justice system personnel, generate or contribute to model laws.

This section will provide a general discussion of issues and guidelines, and will follow this with specific examples from California law. The reader's state may vary in some ways from the guidelines provided below, so it is important to review law as established in the reader's state. We will look at controversies that have plagued the system, and show the kind of advice that advocates are providing to parents and caretakers to help prevent abuses by the system.

Reporting

Various professionals have duties to report reasonable suspicion of specified forms of child maltreatment. Other populations covered by such laws include the elderly and dependent adults such as those with developmental disabilities. Psychotherapists are among the mandated reporters. A major study conducted through the American Academy of Pediatrics (CARES) has shown that many primary care physicians do not report many cases of abuse. Even when they had a strong suspicion that injuries resulted from abuse, 27% of the time, they did not make a report. (Flaherty, Sege, & Hurley, 2008)

Flaherty, Sege, and Hurley (2008) describe the conditions that were most likely to trigger a report:



Reasonable suspicion: The therapist does not have to have legal proof of abuse, only reasonable suspicion. This means that there is sufficient indication that there may be abuse or a sufficient risk of abuse that the therapist is mandated to report the circumstances and parties involved. This only applies to the therapist when functioning within his or her professional duties. Therapists are not required to make a determination as to the lawfulness of the behaviors involved, e.g., whether or not they are criminal. If there is no present risk, the therapist probably does not have a reporting responsibility. (Crime and Violence Prevention Center, 2006) For example, if there was a pedophile residing in a child's home, but that individual is in prison, there is not a present risk. If that individual was slated to return to that home, then there would be present risk. If a client informs a therapist of past abuse by an individual who is currently residing with children, this would most likely reach the level of a mandated reporting situation, even though the report is of past abuse that has long ceased. This is because of the risk to the children in the abuser's current residence.

Making the report: The report must be made immediately to the appropriate agency, usually a child protective services agency. If there is immanent threat of harm, it may be more appropriate to first call the police. It is generally not acceptable for the therapist to give the responsibility to a supervisor or colleague, unless the therapist confirms that the report has been made without delay. No agency policies can remove this responsibility from the therapist, as state law trumps agency policy. Following the call, a written report is generally required within a specified time frame. If the therapist has doubt as to the appropriateness or legal requirement to make a report, consultation with child protective services without initially revealing the names of the parties involved is advisable. Note this action and the result in the casenotes. Some complicated situations may warrant a call to an appropriate attorney such as those provided by national clinical organizations.

Failure to report: A therapist who fails to fulfill a mandated reporting responsibility may be subject to criminal and civil liability. This means that the reader's state law may specify penalties. Also, harm directly resulting from the failure to report may be the basis for a successful lawsuit. Being in the clergy does not free the therapist from reporting responsibilities.

Tarasoff duty to protect: There can even be a Tarasoff duty in situations where an individual poses a threat to an identifiable party or group. This has resulted in a successful lawsuit against a psychiatrist who failed to warn a facility that a pedophile was working there. (Simon, 2003) The Tarasoff requirement that an identifiable party exist was fulfilled by the fact that the facility treated children, and the pedophile, a psychiatric intern, would have responsibility for treating children. This is not the only case of its kind. The Tarasoff obligation requires not only that a warning go to the party at risk (or appropriate caretakers), but also that the police are informed.

Confidentiality

Mandatory reporting requirements breach the duty to protect confidentiality up to a point. It is important to remember that this breach does not allow any additional breaches of confidentiality. For example, other parties not specified as recipients of the reported information may not be provided the information unless the normal conditions for providing clinical information are met. It is important to exercise care regarding confidentiality when facts of the case become public. At such times, journalists or other people may request information. The therapist must remember that public attention to a case has not reduced the therapist's obligation to refrain from breaking confidentiality by even so much as confirming or disconfirming facts when requested. The same problem comes up when a case has become a legal battle, and an attorney requests information without a release. The therapist must not respond until there is a release and it is in the best interest of the client, or there is a court order.

Mandatory reporting laws protect the therapist from lawsuits where the therapist is able to show that there was reasonable suspicion such that the disclosure was not capricious or motivated primarily by self interest.

The Role of Child Protective Services Agencies

Roles: Child protective agencies are charged with the following primary roles:

• Assess for safety (specific powers are specified regarding conducting investigations)
• Intervene to protect children
• Strengthen the ability of caretakers to protect their children
• Develop an integrated plan for management of situations in which child welfare is threatened. This includes either reunification or a safe alternative that is in the best interest of the child.

Activities: These agencies engage in a variety of activities in service of their mission. For example, they support collaboration among community agencies aligned with their mission. Protective agencies have various supportive mandates such as providing culturally sensitive services and working effectively with clinicians, the police, and the courts, and foster placements. Agency staff members are able to help clinicians and community members understand relevant laws and procedures.

Initial assessment: The agency conducts an initial assessment that results in a determination as to whether further intervention by the agency is necessary. This includes making a conclusion as to whether there is sufficient risk or existence of neglect or abuse to justify further agency involvement. Assessing the reliability of individuals making or denying allegations can be a challenging aspect of this investigation. The agency may take immediate action to avert an immanent threat to the child. This may involve the police.

When further involvement is indicated, the agency develops a plan that is based on the resources of the family and likelihood that the family can adequately strengthen its ability to care for and protect the child. This may include modifications to the living situation, such as exclusion of a family member who poses a threat to the child. The agency also takes measures to ensure that the child will recover from any physical or psychological symptoms of maltreatment. Ongoing assessment that determines when desired conditions are adequately in place leads to closing the case when it is appropriate to do so. Where there is an alternative placement of the child, a plan will be in place for permanency planning. This will have the goal of reunification with the family when appropriate.

Removal of the child: Agency workers are to be aware that removal of the child from the home poses its own threats to the functioning and development of the child. This must be weighed against the degree of certainty and the degree of threat to the child should the child stay home. In cases of removal from the home, workers must make efforts to reduce the negative impact of the loss and disruption of life that the child will experience. These strategies include involvement of the family members with the child at the highest level that is safe and feasible. Family members can even be involved in the placement and planning process in various ways, depending on their abilities. Workers can reassure children that they are not at fault and there is nothing wrong with them that is causing these events to take place. Ways that the welfare of the child is being considered may provide additional reassurance. Assurance regarding the time-limited nature of a change can help. The worker must ensure that the placement is aware of as much about the child's needs and preferences as possible. Children are typically even given a number with which they can contact their caseworker. Other family members may also need supportive consideration and services because of the traumatic nature of placement.

The System: Controversies and Progress

Concerns raised: Parents and parent advocates have raised concerns regarding the role of child protection agencies in investigating families, removing children, and preventing children from returning to their parents. Individual cases of inappropriate responses have shown that abuses by specific case managers can and do take place. Also, entrenched patterns of abuse and outright corruption have been proven in some agencies. Lawsuits, Grand Jury investigations, and other efforts have helped to uncover problems in need of reform. Many reforms have taken place in response to consent decrees, settlement agreements, and court orders stemming from class action lawsuits against child welfare agencies. (Kosanovich, & Joseph, 2005)

For example, state laws have been enacted that bolster due process protections by requiring warrants for entry to the home or removal of children. Policies pertaining to the identification of emergency situations have been refined to reduce false positives that cause unnecessary removals. Still, parents and community workers should remain vigilant about preserving clients' rights.

Reforms: Numerous policy and legislative changes have been proposed or put in place to prevent such problems. Also, fundamental reforms are being considered and many pilot programs put in place to improve the value of the system. For example, some protective services agencies have been tasked with electing an assessment track that focuses on bolstering family functioning in cases where it is not necessary to remove the child from the home. Modifications to the system such as the establishment of multidisciplinary community centers that include child protection workers are being carried out. (U.S. Department of Health and Human Services, 2001).

Effect on reporting: Reporting of suspected abuse and neglect by primary care physicians is affected by their perceptions, accurate or not, of protective services agencies. Referring to the CARES study, Flaherty, Sege, and Hurley (2008) state that,



Various private and government agencies review child welfare issues such as removal and foster placement, and provide recommendations that are used in improving agency operations or making changes in the law. For example, data can compare the leading factor that correlates with child abuse, which is poverty, with the rate of removal. A high rate of removal relative to the poverty rate is possible evidence of overzealousness. Further, those rates can be compared with recidivism. This sheds light on the effectiveness of intervention. The National Coalition for Child Protection Reform, funded by the Annie E. Casey Foundation, uses data from the Child Welfare Research Center at the University of California at Berkeley Center for Social Services Research, CMS/CWS Dynamic Report System, available online at: http://cssr.berkeley.edu/CWSCMSreports/ to publish such comparisons. (National Coalition for Child Protection Reform, 2008) The reports are available at www.NCCPR.org.

Judgment calls: Clinicians should consider getting to know the current reputation of their local child protection agency. If the agency has a pattern of over-reacting or manipulating family members, the clinician may need to consider being very cautious in making reports and taking extra pains to educate parents about how to preserve their rights.

Some child welfare reforms have been undertaken in response to consent decrees, settlement agreements, and court orders resulting from class action lawsuits brought against State or local child welfare agencies.

This is a very sensitive area, because the rights of families and the needs of children must be balanced in situations where the clinician often will not have enough information to act with certainty. With a good agency and caseworker, the clinician can be confident that an appropriate and accurate investigation and response will take place. However, if the clinician does not trust the agency, conservative reporting practices may backfire by allowing risk or harm to continue.

Foster care issues: Abuses and deaths that occur in foster placements are very alarming to parents who feel that their child's fate is thrown to chance when the child is removed from the home. This is yet another factor that must be weighed against the advantages of out of home placement. Parents should not be blamed for their concern, because these cases are reported in the news. The poorer the funding is for such services, the greater the concern, as limited funding is a barrier to acquiring able foster parents.

Domestic violence and failure to protect: Individuals who have experienced domestic violence have found the conflicting demands of the situation, the civil actions (child protection services), and criminal system (domestic violence) to be confusing. The child protective agency may remove children where there is the perception that the non-violent parent has failed to protect the children from exposure to violence or from witnessing violence. The court may require visitation by the violent partner independently of the actions of child protection. When adequate protection of the children is in place, the parents must do what they can to get an appropriate response from the child protection system.

Legal help and other support: Compounding the problem, many parents and caretakers who are investigated cannot afford legal help that would ensure that their rights are preserved. Caretakers who research the issue online will find horror stories that may not characterize their agency, and they will find an abundance of advice that may not be accurate, current, or constructive.

The clinician should not feel that they are abdicating the child's needs when they educate parents about how to get accurate legal information and support. It is a legitimate role for clinicians to assist clients in availing themselves of lawful options, entitlements, and resources as inappropriate. This can be done without operating outside of scope of practice so long as the clinician refrains from providing legal advice.

Advice to parents and caretakers

Appropriate responding by parents and caretakers: The following advice for parents and caretakers is written in plain language. It is based on the experiences of many parents and caretakers. It can be provided as a handout.

Communication



Responding to Actions and Demands



Working Through the Process



Spotlight on the Law: California

Overview

This section provides specific details of related state law in California at the time of this writing. Much of the law pertaining to abuse and neglect of children is known as The California Child Abuse and Neglect Reporting Act (CANRA) and is comprised of Penal Code sections 11164-11174.4.

Therapists are designated as "mandated reporters" that must report suspected or alleged neglect or abuse of children, dependent adults, and elders. The Penal Code defines children as being persons who are under eighteen years of age. Elders are those aged 65 years or older. Dependent adults are between the ages of 18 and 64, and whose physical or mental limitations limit their capacity for self care, specifically:



The Welfare and Institutions Code requires only that therapists disclose the information that they encounter during professional activities, and then only when the danger is current.

When there is suspected or alleged abuse of an adult residing in a long-term care facility (except in a state mental health hospital or a developmental center), the report is made to the designated ombudsperson or local law enforcement. When the report concerns a resident of a state mental hospital or a developmental center, the report is made to designated State Department of Mental Health or State Department of Developmental Services investigators designated for this purpose, or to the local law enforcement agency.

Because of the quantity of invalid allegations from persons with mental illnesses or dementia, the therapist is not required to report alleged abuse or neglect from these individuals when the clinician reasonably believes that the abuse did not occur. However, if there is corroborating evidence or information, this must be taken into consideration.

A failure to make a mandated report of child, elder or dependent adult abuse or neglect can be punished with up to six months in county jail, a fine of up to $1,000, or with a fine and imprisonment. The punishment is harsher for those who fail to report and this results in death or serious injury. These penalties also apply to a supervisor or other individual that interferes with an attempt or mandate to report. The punishment in such cases is up to one year in county jail, a fine of as much as $5,000, or both.

It is within the law for agencies to have policies that affect how reporting is managed, but such policies must not conflict with the law. Neither being in the clergy nor being ignorant of the law will insulate a therapist from punishment for failure to comply.

When two or more mandated reporters suspect or learn of allegations of abuse, only one needs to make the report. But both must ascertain that the report has been made, or make the report on their own. The report must take place immediately.

Sexual Abuse Definitions from California Penal Code

Child molestation is addressed in the sections regarding lewd and lascivious acts. These are intentional touching of any part of a child's body, with the intent of arousing, appealing to, or gratifying the lust, passions or sexual desires of that person or the child.

Charges are brought under this law for severely exploitive behavior, such as molestation of young children.

Lewd and lascivious is clearly defined:

• Any lewd and lascivious touching of a minor accomplished with the use of force, violence, duress, menace or fear of immediate and unlawful bodily injury to the victim or another.
• Any lewd and lascivious touching of a child under 14 years old, if the other person is 14 years old or older, irrespective of consent.
• Any lewd and lascivious touching of a child 14 years old, if the other person is 24 years old or older, irrespective of consent.
• Any lewd and lascivious touching of a child 15 years old, if the other person is 25 years old or older, irrespective of consent.

California defines sexual abuse as "sexual exploitation" or "sexual assault."

The California Penal Code defines sexual assault:

As used in this article, "sexual abuse" means sexual assault or sexual exploitation as defined by the following:

(a) "Sexual assault" means conduct in violation of one or more of the following sections: Section 261 (rape), subdivision (d) of Section 261.5 (statutory rape), 264.1 (rape in concert), 285 (incest), 286 (sodomy), subdivision (a) or (b), or paragraph (1) of subdivision (c) of Section 288 (lewd or lascivious acts upon a child), 288a (oral copulation), 289 (sexual penetration), or 647.6 (child molestation).

(b) Conduct described as "sexual assault" includes, but is not limited to, all of the following:

(1) Any penetration, however slight, of the vagina or anal opening of one person by the penis of another person, whether or not there is the emission of semen.

(2) Any sexual contact between the genitals or anal opening of one person and the mouth or tongue of another person.

(3) Any intrusion by one person into the genitals or anal opening of another person, including the use of any object for this purpose, except that, it does not include acts performed for a valid medical purpose.

(4) The intentional touching of the genitals or intimate parts (including the breasts, genital area, groin, inner thighs, and buttocks) or the clothing covering them, of a child, or of the perpetrator by a child, for purposes of sexual arousal or gratification, except that, it does not include acts which may reasonably be construed to be normal caretaker responsibilities; interactions with, or demonstrations of affection for, the child; or acts performed for a valid medical purpose.

(5) The intentional masturbation of the perpetrator's genitals in the presence of a child.

The California Penal Code also defines sexual exploitation:

(c) "Sexual exploitation" refers to any of the following:

(1) Conduct involving matter depicting a minor engaged in obscene acts in violation of Section 311.2 (preparing, selling, or distributing obscene matter) or subdivision (a) of Section 311.4 (employment of minor to perform obscene acts).

(2) Any person who knowingly promotes, aids, or assists, employs, uses, persuades, induces, or coerces a child, or any person responsible for a child's welfare, who knowingly permits or encourages a child to engage in, or assist others to engage in, prostitution or a live performance involving obscene sexual conduct, or to either pose or model alone or with others for purposes of preparing a film, photograph, negative, slide, drawing, painting, or other pictorial depiction, involving obscene sexual conduct. For the purpose of this section, "person responsible for a child's welfare" means a parent, guardian, foster parent, or a licensed administrator or employee of a public or private residential home, residential school, or other residential institution.

(3) Any person who depicts a child in, or who knowingly develops, duplicates, prints, or exchanges, any film, photograph, video tape, negative, or slide in which a child is engaged in an act of obscene sexual conduct, except for those activities by law enforcement and prosecution agencies and other persons described in subdivisions (c) and (e) of Section 311.3.

Definitions from California Welfare and Institutions Code

The California Welfare and Institutions Code lists forms of abuse that therapists must report:

In respect to minors, a psychotherapist is mandated to report non-accidental injury inflicted by others; sexual abuse; unjustifiable mental suffering (as in a young child witnessing domestic violence); neglect; cruelty; statutory rape (minor under 16 and other 21 or older, even if consensual); lewd and lascivious conduct (minor under 16 and other 10 years older, even if consensual); consensual sexual contact between minors (where one is 14 years of age and the other is under 14 years of age).

The code addresses abuse of dependent elders and adults:

In respect to elderly or dependent adults, a psychotherapist is mandated to report physical abuse, including sexual assault; misuse of physical or chemical restraint; neglect; fiduciary abuse; neglect; and isolation.

Emotional Abuse in California Law

Although therapists are not required to report emotional abuse, the law protects therapists from liability when they report it. Emotional abuse is a gray area, so it is left to the therapist's clinical judgement to determine whether it is reportable. California law indicates that therapists should consider emotional damage when deciding whether to report emotional abuse, and says, "Any mandated reporter who has knowledge of or who reasonably suspects that a child is suffering serious emotional damage or is at a substantial risk of suffering serious emotional damage, evidenced by states of being or behavior, including, but not limited to, severe anxiety, depression, withdrawal, or untoward aggressive behavior toward self or others, may make a report to an agency specified in Section 11165.9."

In contrast to emotional abuse as an optional reporting condition, the law refers to "unjustifiable mental suffering" as a form of abuse that must be reported. An example is, "a young child witnessing domestic violence."

Appendix A: Clinical Description of Sexual Acts

The sexual acts that will be described in this section are abusive clinically when the factors discussed in the previous section (on power, knowledge, and gratification differentials discussed in the body of the course) are present as the examples illustrate. The sexual acts will be listed in order of severity and intrusiveness, the least severe and intrusive being discussed first.

Non-contact Acts

Offender making sexual comments to the child - Example: A coach told a team member he had a fine body, and they should find a time to explore one another's bodies. He told the boy he has done this with other team members, and they had enjoyed it.

Offender exposing intimate parts to the child, sometimes accompanied by masturbation. Example: A grandfather required that his 6-year-old granddaughter kneel in front of him and watch while he masturbated naked.

Voyeurism (peeping). Example: A stepfather made a hole in the bathroom wall. He watched his stepdaughter when she was toileting (and instructed her to watch him).

Offender showing child pornographic materials, such as pictures, books, or movies. Example: Mother and father had their 6- and 8-year-old daughters accompany them to viewings of adult pornographic movies at a neighbor's house.

Offender induces child to undress and/or masturbate self. Example: Neighbor paid a 13-year-old emotionally disturbed girl $5 to undress and parade naked in front of him.

Sexual Contact

Offender touching the child's intimate parts (genitals, buttocks, and breasts). Example: A father put his hand in his 4-year-old daughter's panties and fondled her vagina while the two of them watched "Sesame Street."

Offender inducing the child to touch his/her intimate parts. Example: A mother encouraged her 10-year-old son to fondle her breasts while they were in bed together.

Frottage (rubbing genitals against the victim's body or clothing). Example: A father, lying in bed, had his clothed daughter sit on him and play "ride the horse."

Digital or Object Penetration

Offender placing finger(s) in child's vagina or anus. Example: A father used digital penetration with his daughter to "teach" her about sex.

Offender inducing child to place finger(s) in offender's vagina or anus. Example: An adolescent boy required a 10-year-old boy to put Vaseline on his finger and insert it into the adolescent's anus as initiation into a club.

Offender placing instrument in child's vagina or anus. Example: A psychotic mother placed a candle in her daughter's vagina.

Offender inducing child to place instrument in offender's vagina or anus. Example: A babysitter had a 6-year-old boy penetrate her vaginally with a mop handle.

Oral Sex

Tongue kissing. Example: Several children who had attended the same day care center attempted to French kiss with their parents. They said that Miss Sally taught them to do this.

Breast sucking, kissing, licking, biting. Example: A mother required her 6-year-old daughter to suck her breasts (in the course of mutual genital fondling).

Cunnilingus (licking, kissing, sucking, biting the vagina or placing the tongue in the vaginal opening). Example: A father's girlfriend who was high on cocaine made the father's son lick her vagina as she sat on the toilet.

Fellatio (licking, kissing, sucking, biting the penis). Example: An adolescent, who had been reading pornography, told his 7-year-old cousin to close her eyes and open her mouth. She did and he put his penis in her mouth.

Anilingus (licking, kissing the anal opening). Example: A mother overheard her son and a friend referring to their camp counselor as a "butt lick." The boys affirmed that the counselor had licked the anuses of two of their friends (and engaged in other sexual acts with them). An investigation substantiated this account.

Penile Penetration

Vaginal intercourse. Example: A 7-year-old girl was placed in foster care by her father because she was incorrigible. She was observed numerous times "humping" her stuffed animals. In therapy she revealed that her father "humped" her. There was medical evidence of vaginal penetration.

Anal intercourse. Example: Upon medical exam an 8-year-old boy was found to have evidence of chronic anal penetration. He reported that his father "put his dingdong in there" and allowed two of his friends to do likewise.

Intercourse with animals.

Appendix B: Circumstances of Sexual Abuse

Circumstances of Sexual Acts

Professionals need to be aware that sexual acts with children can occur in a variety of circumstances. In this section, dyads, group sex, sex rings, sexual exploitation, and ritual abuse will be discussed. These circumstances do not necessarily represent discrete and separate phenomena.

Dyadic sexual abuse

The most common circumstance of sexual abuse is a dyadic relationship, that is, a situation involving one victim and one offender. Because dyadic sex is the prevalent mode for all kinds of sexual encounters, not merely abusive ones, it is not surprising that it is the most common.

Group sex

Circumstances involving group sex are found as well. These may comprise several victims and a single perpetrator, several perpetrators and a single victim, or multiple victims and multiple offenders. Such configurations may be intrafamilial (e.g., in cases of polyincest) or extrafamilial. Examples of extrafamilial group victimization include some instances of sexual abuse in day care, in recreational programs, and in institutional care.

Sex rings

Children are also abused in sex rings; often this is group sex. Sex rings generally are organized by pedophiles (persons whose primary sexual orientation is to children), so that they will have ready access to children for sexual purposes and, in some instances, for profit. Victims are bribed or seduced by the pedophile into becoming part of the ring, although he may also employ existing members of the ring as recruiters. Rings vary in their sophistication from situations involving a single offender, whose only motivation is sexual gratification, to very complex rings involving multiple offenders as well as children, child pornography, and prostitution.

Sexual exploitation of children

The use of children in pornography and for prostitution is yet another circumstance in which children may be sexually abused.

Child pornography

This is a Federal crime, and all States have laws against child pornography. Pornography may be produced by family members, acquaintances of the children, or professionals. It may be for personal use, trading, or sale on either a small or large scale. It can also be used to instruct or entice new victims or to blackmail those in the pictures. Production may be national or international, as well as local, and the sale of pornography is potentially very lucrative. Because of the availability of video equipment and Polaroid cameras, pornography is quite easy to produce and difficult to track.

Child pornography can involve only one child, sometimes in lewd and lascivious poses or engaging in masturbatory behavior; of children together engaging in sexual activity; or of children and adults in sexual activity.

It is important to remember that pictures that are not pornographic and are not illegally obscene can be very arousing to a pedophile. For example, an apparently innocent picture of a naked child in the bathtub or even a clothed child in a pose can be used by a pedophile for arousal.

Child prostitution

This may be undertaken by parents, other relatives, acquaintances of the child, or persons who make their living pandering children. Older children, often runaways and/or children who have been previously sexually abused, may prostitute themselves independently.

Situations in which young children are prostituted are usually intrafamilial, although there are reports of child prostitution constituting one aspect of sexual abuse in some day care situations. Adolescent prostitution is more likely to occur in a sex ring (as mentioned above), at the hand of a pimp, in a brothel, or with the child operating independently. Boys are more likely to be independent operators, and girls are more likely to be involved in situations in which others control their contact with clients.

Ritual abuse

This is a circumstance of child sexual abuse that has only recently been identified, is only partially understood, and is quite controversial. The controversy arises out of problems in proving such cases and the difficulty some professionals have in believing in the existence of ritual abuse.

As best can be determined, ritual sexual abuse is abuse that occurs in the context of a belief system that, among other tenets, involves sex with children. These belief systems are probably quite variable. Some may be highly articulated, others "half-baked." Some ritual abuse appears to involve a version of satanism that supports sex with children. However, it is often difficult to discern how much of a role ideology plays. That is, the offenders may engage in "ritual" acts because they are sadistic, because they are sexually aroused by them, or because they want to prevent disclosure, not because the acts are supported by an ideology. Because very few of these offenders confess, their motivation is virtually unknown.

Often sexual abuse plays a secondary role in the victimization in ritual abuse, physical and psychological abuse dominating. The following is a non-exhaustive list of characteristics that may be present in cases of ritual abuse:

• costumes and robes: animal, witch's, devil's costumes; ecclesiastical robes (black, red, purple, white);
• ceremonies: black masses, burials, weddings, sacrifices;
• symbols: 666, inverted crosses, pentagrams, and inverted pentagrams;
• artifacts: crosses, athames (daggers), skulls, candles, black draping, representations of Satan;
• bodily excretions and fluids: blood, urine, feces, semen;
• drugs, medicines, injections, potions;
• fire;
• chants and songs;
• religious sites: churches, graveyards, graves, altars, coffins; and
• torture, tying, confinement, murder.

Most allegations of ritual abuse come from young children, reporting this type of abuse in day care, and from adults, who are often psychiatrically very disturbed and describe ritual abuse during their childhoods. Issues of credibility are raised with both groups. Moreover, accounts of ritual abuse are most disturbing, to both those recounting the abuse and those hearing it.

Appendix C: Abuse and Neglect Definitions, Examples, and Signs

Introduction

The following material is adapted from The Department of Health and Human Services' Third National Incidence Study of Child Abuse and Neglect (NIS-3)

Physical Neglect

• Refusal of health care: failure to provide or allow needed care in accordance with recommendations of a competent health-care professional for a physical injury, illness, medical condition, or impairment.
• Delay in health care: failure to seek timely and appropriate medical care for a serious health problem that any reasonable layperson would have recognized as needing professional medical attention.
• Abandonment: desertion of a child without arranging for reasonable care and supervision.
• Expulsion: other blatant refusals of custody, such as permanent or indefinite expulsion of a child from the home without adequate arrangement for care by others or refusal to accept custody of a returned runaway.
• Inadequate supervision: leaving a child unsupervised or inadequately supervised for extended periods of time, or allowing the child to remain away from home overnight without knowing or attempting to determine the child's whereabouts.
• Other physical neglect: may include inadequate nutrition, clothing, or hygiene; conspicuous inattention to avoidable hazards in the home; and other forms of reckless disregard for the child's safety and welfare (e.g., driving with the child while intoxicated, leaving a young child unattended in a car).

Educational Neglect

• Permitted chronic truancy: habitual absenteeism from school averaging at least 5 days a month if the parent or guardian is informed of the problem and does not attempt to intervene.
• Failure to enroll or other truancy: failure to register or enroll a child of mandatory school age, causing the child to miss at least 1 month of school, or a pattern of keeping a school-aged child home without valid reasons.
• Inattention to special education need: refusal to allow or failure to obtain recommended remedial education services or neglect in obtaining or following through with treatment for a child's diagnosed learning disorder or other special education need without reasonable cause.

Emotional Neglect

• Inadequate nurturing or affection: marked inattention to the child's needs for affection, emotional support, or attention.
• Chronic or extreme spouse abuse: exposure of the child to chronic or extreme spouse abuse or other domestic violence.
• Permitted drug or alcohol abuse: encouragement or permission of drug or alcohol use by the child.
• Permitted other maladaptive behavior: encouragement or permission of other maladaptive behavior (e.g., chronic delinquency, severe assault) under circumstances where the parent or caregiver has reason to be aware of the existence and seriousness of the problem but does not intervene.
• Refusal of psychological care: refusal to allow needed and available treatment for a child's emotional or behavioral impairment or problem in accordance with a competent professional recommendation.
• Delay in psychological care: failure to seek or provide needed treatment for a child's emotional or behavioral impairment or problem that any reasonable layperson would have recognized as needing professional psychological attention (e.g., suicide attempt).

Sexual Abuse

Definition and Examples

Child sexual abuse generally refers to sexual acts, sexually motivated behaviors, or sexual exploitation involving children. Child sexual abuse includes a wide range of behaviors, such as:

• Oral, anal, or genital penile penetration
• Anal or genital digital or other penetration
• Genital contact with no intrusion
• Fondling of a child's breasts or buttocks
• Indecent exposure
• Inadequate or inappropriate supervision of a child's voluntary sexual activities
• Use of a child in prostitution, pornography, Internet crimes, or other sexually exploitative activities

Sexual abuse includes both touching offenses (fondling or sexual intercourse) and nontouching offenses (exposing a child to pornographic materials) and can involve varying degrees of violence and emotional trauma. The most commonly reported cases involve incest, or sexual abuse occurring among family members, including those in biological families, adoptive families, and stepfamilies. Incest most often occurs within a father-daughter relationship; however, mother-son, father-son, and sibling-sibling incest also occurs. Sexual abuse is also sometimes committed by other relatives or caretakers.

Signs of Sexual Abuse

The presence of a single sign does not prove child abuse is occurring in a family; however, when these signs appear repeatedly or in combination you should take a closer look at the situation and consider the possibility of child abuse.

Consider the possibility of sexual abuse when the child:

• Has difficulty walking or sitting
• Suddenly refuses to change for gym or to participate in physical activities
• Reports nightmares or bedwetting
• Experiences a sudden change in appetite
• Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior
• Becomes pregnant or contracts a venereal disease, particularly if under age 14
• Runs away
• Reports sexual abuse by a parent or another adult caregiver

Consider the possibility of sexual abuse when the parent or other adult caregiver:

• Is unduly protective of the child or severely limits the child's contact with other children, especially of the opposite sex
• Is secretive and isolated
• Is jealous or controlling with family members

Physical Abuse

Definition and Examples

Generally, physical abuse is characterized by physical injury, such as bruises and fractures that result from:

• Punching
• Beating
• Kicking
• Biting
• Shaking
• Throwing
• Stabbing
• Choking
• Hitting with a hand, stick, strap, or other object
• Burning

Although an injury resulting from physical abuse is not accidental, the parent or caregiver may not have intended to hurt the child. The injury may have resulted from severe discipline, including injurious spanking, or physical punishment that is inappropriate to the child's age or condition. The injury may be the result of a single episode or repeated episodes and can range in severity from minor marks and bruising to death.

As Howard Dubowitz, a leading researcher in the field explains: "While cultural practices are generally respected, if the injury or harm is significant, professionals typically work with parents to discourage harmful behavior and suggest preferable alternatives."

Signs of Physical Abuse

The presence of a single sign does not prove child abuse is occurring in a family; however, when these signs appear repeatedly or in combination you should take a closer look at the situation and consider the possibility of child abuse.

Consider the possibility of physical abuse when the child:

• Has unexplained burns, bites, bruises, broken bones, or black eyes
• Has fading bruises or other marks noticeable after an absence from school
• Seems frightened of the parents and protests or cries when it is time to go home
• Shrinks at the approach of adults
• Reports injury by a parent or another adult caregiver

Consider the possibility of physical abuse when the parent or other adult caregiver:

• Offers conflicting, unconvincing, or no explanation for the child's injury
• Describes the child as "evil," or in some other very negative way
• Uses harsh physical discipline with the child
• Has a history of abuse as a child

Emotional Abuse

Definition and Examples

Psychological maltreatment, also known as emotional abuse, refers to "a repeated pattern of caregiver behavior or extreme incident(s) that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs."

• Spurning (e.g., belittling, hostile rejecting, ridiculing)
• Terrorizing (e.g., threatening violence against a child, placing a child in a recognizably dangerous situation)
• Isolating (e.g., confining the child, placing unreasonable limitations on the child's freedom of movement, restricting the child from social interactions)
• Exploiting or corrupting (e.g., modeling antisocial behavior such as criminal activities, encouraging prostitution, permitting substance abuse)
• Denying emotional responsiveness (e.g., ignoring the child's attempts to interact, failing to express affection)
• Mental health, medical, and educational neglect (e.g., refusing to allow or failing to provide treatment for serious mental health or medical problems, ignoring the need for services for serious educational needs)

Signs of Emotional Abuse

The presence of a single sign does not prove child abuse is occurring in a family; however, when these signs appear repeatedly or in combination you should take a closer look at the situation and consider the possibility of child abuse.

Consider the possibility of emotional maltreatment when the child:

• Shows extremes in behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression
• Is either inappropriately adult (parenting other children, for example) or inappropriately infantile (frequently rocking or head-banging, for example)
• Is delayed in physical or emotional development
• Has attempted suicide
• Reports a lack of attachment to the parent

Consider the possibility of emotional maltreatment when the parent or other adult caregiver:

• Constantly blames, belittles, or berates the child
• Is unconcerned about the child and refuses to consider offers of help for the child's problems
• Overtly rejects the child

Citations

Legal Citations

Child Abuse Prevention and Treatment Act, Sec. 111. [42 U.S.C. 5106g]

Case Law

No. 06-4638, Smith et al. v. Williams-Ash, Sixth Circuit Court of Appeals

Supreme Court of Missouri In the Interest of: P.L.O. and S.K.O., minor children. SC85120 3/30/2004

Publications Cited

Administration for Children and Families. (2009). Child Abuse Prevention and Treatment Act. U.S. Department of Health and Human Services.

Administration for Children and Families. (2008). Child Maltreatment 2006. U.S. Department of Health and Human Services.

Afifi, T. O, Enns, M. W., Cox, B. J., Asmundson, G. J. D., Stein, M. B., and Sareen, J. (2008). Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98, 946-952.

Kosanovich, A. and Joseph, R. M. Child Welfare Consent Decrees: Analysis of Thirty-Five Court Actions from 1995 to 2005. The Child Welfare League of America and the American Bar Association Center on Children and the Law.

Cohen, L. J. and Galynker, I. I. (2002). Clinical features of pedophilia and implications for treatment. Journal Of Psychiatric Practice. 8(5), 276-289.

Crime and Violence Prevention Center. (2006). Child abuse protection handbook. California Attorney General's Office.

Faller. (1993). Child sexual abuse: Intervention and treatment issues. User manual series. U.S. Department of Health and Human Services, Administration for Children and Families, National Center on Child Abuse and Neglect.

Finkelhor, D. and Jones, L. M. (2004). Sexual abuse decline in the 1990s: evidence for possible causes. Juvenile Justice Bulletin - NCJ199298 (pgs. 1-12).

Flaherty, E. G., Sege, R. D., and Hurley, T. P. (2008). Translating Child Abuse Research Into Action. Pediatrics, 122 Supplement, S1-S5.

Goldman, Salus, Wolcott, and Kennedy. (2003). A coordinated response to child abuse and neglect: The foundation for practice user manual series. Office on Child Abuse and Neglect (HHS).

Hibbard, R. A., Ingersoll, G. M., and Orr, D. P. (1990). Behavioral risk, emotional risk, and child abuse among adolescents in a nonclinical setting. Pediatrics, 86(6), 896-901.

Hymel, K. P. and Committee on Child Abuse and Neglect. (2006). When Is Lack of Supervision Neglect? Pediatrics, 118(3), 1296-1298.

Kellogg, N. D. (2009). Committee on Child Abuse and Neglect Clinical Report: The evaluation of sexual behaviors in children. Pediatrics, 124(3), 992-998.

Leventhal, J. M, Martin, K. D., and Asnes, A. G. (2008). Incidence of fractures attributable to abuse in young hospitalized children: Results from analysis of a United States database. Pediatrics, 122(3), 599-604.

Murray, D. (2001). It ain't necessarily so: how media make and unmake the scientific picture of reality. Rowman & Littlefield Publishers, Inc.

Nagayama Hall, G. C., Hirschman, R., and Oliver, L. L. (1995). Sexual arousal and arousability to pedophilic stimuli in a community sample of normal men. Behavior Therapy 26, 681-694.

National Coalition for Child Protection Reform. (2008). The 2007 NCCPR California rate-of-removal index.

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Paolucci, E. O. and Genuis, M. L. (2001). A meta-analysis of the published research on the effects of child sexual abuse. The Journal of Psychology, 135(1), 17-36.

Rind, B. and Tromovitch, P. (2006). National samples, sexual abuse in childhood, and adjustment in adulthood. Archives of Sexual Behavior, December.

Simon, R.I. (2003). The Law and Psychiatry. Focus, 1, 349-372.

Smolak, L. and Murnen, S. K. (2002). A meta-analytic examination of the relationship between child sexual abuse and eating disorders. International Journal of Eating Disorders, 31(2), 136-150.

Southall, D. P., Plunkett, M. C. B., Banks, M. W., Falkov, A. F., and Samuels, M. P. (1997). Covert video recordings of life-threatening child abuse: Lessons for child protection. Pediatrics, 100(5), 735-760.

U.S. Department of Health and Human Services. (2001). National Study of Child Protective Services Systems and Reform Efforts.

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