ISSUES IN THE EVALUATIQN AND TREATMENT OF CHILD SEXUAL ABUSE

by David S. Wachtel, Ph. D.

Clinical Psychologist

Prepared for the Child Abuse Seminars in the 245th Judicial District Court, Houston, Texas

May 5, 1995 and December 15, 1995

Introduction

    Once viewed as a relatively-infrequent problem, the sexual abuse of children is now seen as a major societal problem in terms of its prevalence and its consequences for both the victim and the family.  The increase in reporting of these events is likely a function of the interaction of several important factors.  Research has provided the necessary methodology and empirical evidence to identify some of the associated risk factors and manifestations of sexual abuse such that detection and identification by professionals and family members is more-readily accomplished.  The increased stresses on families have also likely resulted in increases in the incidences of sexual abuse.  In addition, the changes in society that both encourage more-open discussion and expression of previously-taboo subjects--such as sexuality--while also sensitizing (and at-times over-stimulating) children and adults to sexual issues and behavior has likely contributed to both increased reporting and occurrences of sexual abuse, as well as some increased possibility of misdiagnosis and incorrect or inappropriate responses.

    The purpose of this paper is to focus on some of the more-important issues involved in evaluation and treatment of child sexual abuse.  The first section will discuss a consensual definition and continuum of sexual abuse of a child, and the factors that can influence its traumatic consequen­ces.  The next section reviews the guidelines established for conducting sexual abuse evaluations with particular emphasis on what must be done differently from standard evaluations.  The difficult task of differentiating between true and false child sexual abuse allegations will then be discussed.  In addition to discussing characteristic patterns of true and substantiated allegations, differences between unintentional and intentional false allegations will be presented.  Some of the recent research on children’s memory and recall will then be reviewed, particularly as these findings relate to how children present their stories of being sexually abused. The final section will address some of the major therapeutic issues and interventions in the treatment of child sexual abuse.  A trauma-based model will be presented as a useful framework for conducting treatment of sexually-abused children and their families.

Defining Child Sexual Abuse and Its Impact

    Development of a comprehensive definition of Child Sexual Abuse is an important issue in the evaluation and treatment process.  It should include a conceptual model and quantifiable characteristics that can provide understanding, meaningfulness and predictability of the events and the consequences for the individual.

    Finkelhor (1987) defined child sexual abuse as “sexual activity involving a child…(that) occurs within a relationship where it is deemed exploitive by virtue of an age difference or caretaking relationship that exists with the child…(and/or) it occurs as a result of threat or force”.

    Veltkamp and Miller (1994) stated that sexual abuse is defined as “any contact or interactions between a child and an adult in which the child is sexually stimulated or is being used for the sexual stimulation of the perpetrator or another person”.  These include: (I) sexualized or eroticized fondling or caressing; (2) using a child to sexually stimulate the parent; (3) sexual stimulation of the child; (4) sexual exploitation of the child (e.g., child pornography); (5) intercourse or oral-genital contact; and (6) rape.

    The consequences of child sexual abuse are evident in predictable short-term arid long-term emotional, physical and behavioral changes.  The type and severity of psychological damage has been found to be greater and more complex: (1) when the child is younger at the tine of the trauma; (2) the longer the abuse goes on: (3) there is greater aggressiveness; (4) there is greater threat used; (5) when the perpetrator is mown to the child (heightening the betrayal); (6) the abuse occurs more frequently; and (7) when the child is not believed or protected.

    Veltkamp and Miller (1994) also report that greater psychological damage is likely when: (1) there is greater overt symptomatology and functional impairment; (2) generic and sexual-abuse-specific negative reactions occur from parents, siblings, and the community; (3) the victim internalizes the blame and anger rather than placing it appropriately towards the perpetrator; and (4) the child appears to take the side of the abuser—a phenomenon that occurs more frequently in intrafamilial sexual abuse.

    The multidimensional nature of both the traumatic event and its consequences for the victim will be manifested in a broad range of psychological symptomatology.  These can be categorized as (1) generic symptoms; (2) trauma-specific symptoms; and (3) sexual-abuse-specific symptoms.   Generic symptoms include “commonplace” difficulties such as depression, anxiety, school/work underachievement, substance abuse and problematic relationships.

    Trauma-specific symptoms include behaviors that are frequently observed in individuals suffering from Post-traumatic Stress Disorder, but do not include a sexualized element.  Included in this duster are more-phobic type behaviors and disturbances in functioning that can include sleep disturbances and nightmares; intrusive thoughts and flashbacks; panic attacks and phobias; exaggerated startle response and agitation; hypervigilance; regressive behaviors, such as bedwetting; and exaggerated clinging and/or social withdrawal.

    While not always evident and not necessarily essential in determining whether sexual abuse has actually occurred, the presence of sexual-abuse-specific symptoms can be a critical factor in differential diagnosis and treatment.  Sexual traumatic behavior can include genital play, masturba­tion, seductive behaviors, and inappropriate sexual knowledge (Myers, 1992).  Friedrich Grambach, Broughton, Kruper, and Beilke (1991) evaluated behavioral differences between sexually-abused and nonabused children.  They reported that sexually-abused children were significantly-more-likely to attempt to perform oral sex, asking to have sex, masturbating with an object, inserting objects into the anus/vagina, initiating intercourse, making sexual sounds, french kissing, undressing others, asking to watch sexually explicit programs and imitating sexual play with dolls.

    Physical indicators of sexual abuse can also range from generalized to trauma-specific symptoms.  Nonspecific symptoms can include genital pain, itching or irritation; difficulty walking or sitting; and a history of physical complaints to the doctor over time.  Trauma-specific symptoms reported have included early-adolescent pregnancy; sexually-transmitted diseases (STDs); semen present during examination; torn, stained, or bloody clothing; and evidence of trauma (e.g., bruises or bleeding) in the mouth, anus, external genitalia, or vaginal area.

Evaluation Guidelines and Issues

    The dramatic increase in allegations of child sexual abuse in recent years has led to the development of guidelines for conducting evaluations.  The American Academy of Child and Adolescent Psychiatry (AACAP) in 1988 and the American Professional Society on the Abuse of Children (APSAC) (1940) provide criteria for evaluators and the evaluation process.  With respect to the evaluators, the need for specialized training and expertise in evaluation of sexual abuse is emphasized.  Separation of evaluation and treatment roles is also strongly recommended.

    APSAC emphasizes that the evaluation process must be conducted within a framework that does not assume that the allegation of sexual abuse is true, but rather considers all alternative explana­tions for the apparent sexual-abuse behavior.  The child victim, the alleged perpetrator, the nonabusing parent(s), and other relevant individuals should be interviewed independently and privately.  Particularly with regards to evaluating the child victim, the potentially-traumatic nature of the evaluation should be minimized.  This would include keeping the number of interviewers and interviews to a minimum; conducting the evaluation within a safe comfortable, nonthreaten­ing environment; and use of age-/developmentally-appropriate language and interviewing strate­gies, both verbal and nonverbal.  Questioning about the alleged sexual abuse should be conducted in a direct manner, but within the context of a general, initially-nondirective interview process.

    As mentioned above, the investigation of an allegation of sexual abuse must also be recognized as a traumatic event for all the participants, the child as well as family members.  Establishment of specific boundaries to keep this trauma to a minimum and to differentiate its effects from those caused by sexual abuse is essential.  These boundaries should include structuring the assessment to he therapeutic; limiting the number of interviewers; conducting the assessment over several sessions; and using a variety of assessment modalities (e.g.. verbal and nonverbal) and structured, controlled settings.

    Finally; AACAP and APSAC both address the uses of anatomically-correct dolls and of psychological testing in sexual abuse evaluations.  With regards to use of anatomically-correct dolls, their use is recommended for assessing general body knowledge and not as a definitive indicator of abuse. Psychological testing of the child (especially pre-schoolers) was considered to be of limited utility. It was considered potentially useful in evaluating the alleged perpetrator and the accuser--particular when conditions exist that increase the possibility of a false allegation.

    In a previous article (Wachtel, 1995), I discussed the need for both general and situation-specific assessment instruments to answer specific referral questions, such as in child custody cases.  This also applies to sexual abuse allegations as well.  General- and sexual-abuse risk factors and indicators of sexual abuse have been identified through more-general psychological tests such as Draw-A-Person, Kinetic Family Drawing, MMPI-2, Thematic Apperception Test, and the Rorschach Inkblot Technique.  When administered and interpreted by a trained Psychologist, they can aid in differential diagnosis in sexual abuse evaluations.

    Some sexual-abuse-specific instruments have been developed. These include Friedich’s Child Sexual Behavior Inventory (SBCI), Gardner’s Sex Abuse Legitimacy Scale, and statement validity analysis (SYA) and criterion-based content analysis (CBCA).  While all have limited research support at this time, they too can provide meaningful information within the context of a compre­hensive evaluation by an experienced clinician

    A comprehensive evaluation must incorporate empirical findings of differentiating risk factors and test results with diagnostic interviews and testing of the significant individuals involved in the specific case.

Distinguishing Between True, Unsubstantiated, and False Allegations of Sexual Abuse

    A significant shift has occurred in the evaluation of child sexual abuse in recent years.  This shift involves movement away from the medical model to the forensic model of evaluation.  The medical model had (and does) often maintain several key assumptions that—while relevant within a clinical context for guiding treatment—can potentially bias the evaluation findings and pose both psychological and legal problems for the alleged victim, the accuser, and the alleged perpetrator.  These assumptions include: that the alleged abuse did occur; the descriptions of the traumatic event are completely accurate and recalled correctly; neither the child nor the accuser had lied or had suspect motivations for accusing another of abusing a child; and the alleged perpetrator is consciously or unconsciously denying that he or she committed the abuse.

    As noted above, the forensic model of evaluating allegations of child sexual abuse operates from a neutral stance.  It does not assume that the allegation is true; that the descriptions and recall are accurate; that the victim and/or accuser are being honest truthful, and have no hidden agendas; or that the alleged perpetrator’s statement that he or she did not do it are not true.  The conclusion that the abuse actually occurred is not arrived at until alternative explanations for the child’s unusual behavior and symptoms have been ruled out and there is substantive and corroborating evidence to support its occurrence. The difference between a “true” allegation and an unsub­stantiated one typically will involve the lack of corroborating data, even though no adequate alternative explanations can account for the behavior and symptoms exhibited by the child.

    As described by Myers (1992), the presence of (1) a core of sexual symptoms strongly associated with abuse; (2) nonsexual abuse symptoms often seen in sexually-abused children; and (3) medical evidence of sexual abuse would meet the criteria for substantiating the truthfulness of a sexual abuse allegation.  Unfortunately, many cases of child sexual abuse do not and cannot provide such clear-cut indicators as Myers describes.  This is particularly true with respect to the lack of medical/physical evidence to support the allegations.

    There is, however, a growing body of knowledge and research that certain characteristics of the presentation of the allegation can assist in differentiating true from false allegations of sexual abuse.  These characteristics fall into the categories of: (1) who presents the allegation; (2) how s/he behaves during the presentations; and (3) descriptions of the sexual abuse incident(s).

    The likelihood that the allegation of sexual abuse is true is increased when the child makes the initially outcry, rather than a parent or adult; and is not a pre-schooler and thus can provide a more-articulate description of the abuse (AACAP, 1988).  Further, the child’s demonstration of appropriate levels of hesitation and anxiety at disclosing the abuse; fears about retaliation for disclosure; guilt feelings about participation and consequences to the perpetrator; does not constantly look to the parent for guidance in telling what happened; and hesitation and discomfort to confront or be around the perpetrator have been found to be strongly associated with true allegations (AACAP, 1988; Gardner, 1987; Green, 1986).  Harrison (1991) also reported that delayed or conflicted disclosure and some efforts to retract or recant the allegation are also more likely to be present when the abuse did occur.

    Certain actions and reactions of the adults--be they parents or other caregivers--appear to have diagnostic significance in substantiating true sexual abuse allegations.  Breese, Stearns, Bess and Parker (1986) found differences in the behavior of mothers of children who had actually been abused by their fathers when compared with mothers where the allegations turned out to be false.  They observed that the mothers of the abused children were primarily concerned with their child’s welfare and not in attacking the fathers.

    In addition, Breese et al. reported that these mothers: (1) expressed remorse for not adequately protecting the child; (2) were willing to consider other possible explanations for their children’s behaviors or statements that had originally evoked concern; (3) were willing to let the child be interviewed without being present; (4) were concerned about the impact on the child if s/he was required to testify; and (5) were willing to discontinue lie investigatory process if the allegation could not be substantiated as long as the child’s well-being continued to be monitored through therapy or some other appropriate activity.

    The descriptions of the sexual abuse have also been found to aid in differentiating true from false allegations.  In general, the greater the consistency of content and overtime of the story, the greater the probability that abuse did occur.  In addition, quite-specific descriptions of the abuse, with details that are provided in age-appropriate language, include some idiosyncratic or sensorimotor detail, and are from the child’s perspective are consistently found in actual abuse cases (AACAP, 1998).

    Hoorwitz (1992) described other variables that have been observed when child sexual abuse had actually occurred.  These included: (1) the reason for disclosure at the particular point in time or the lack of such disclosure until much later is credible; (2) the scenario is typical of sexual abuse (as opposed to other trauma); (3) there is little variability in descriptions of the time sequence and positioning during the abuse; (4) congruence exists between the time reported and time required for the abuse to have occurred; and (5) the stories were characterized by coherence and redundancy of detail.  He goes onto refer to true stories as characterized by “messy reality”--i.e., “A real story is messy with details, potential tangents, and incomprehensible allusions, all of which will be compatible with one another and resonate with redundancy” (p. 93).

    The need to ascertain whether child sexual abuse did occur is dramatically emphasized when an allegation is made during a separation, divorce and/or custody/visitation dispute.  Even though studies have indicated that only about 2% of all custody cases include such allegations, they have also reported that up to 35% of such allegations have been found to be false.

    Reports of prior and/or current abuse can occur at these tunes for a number of reasons.  With respect to prior abuse, the child can feel safer to disclose the abuse following separation and to prevent visitation with the abusing parent (MacFarlane, 1989).  Morris (1989) reported that there is an increased possibility that child can be sexually abused at the time of separation and/or divorce. He cited several factors: (1) the marriage is no longer available to contain inappropriate expression of the parents sexual impulses; (2) the emotional devastation felt by the parent can lead to turning to the child for emotional support and to have needs met; (3) the child may move into the parent’s bed, resulting in greater proximity and availability; and (4) the parent displaces and directs anger at the ex-spouse note the child, who also acts as a trigger for the feelings.

    False allegations of child sexual abuse fail into two major categories: unintentional and intention­al.  Unintentional allegations are more likely to occur with a pre-school nonverbal child whose statements and/or behavior are misinterpreted by a well-meaning adult (MacFarlane, 1988). Adults may incorrectly allege abuse due to (1) having inadequate knowledge of normative child development and childhood sexual behavior; (2) a lack of understanding of the context in which the behavior occurred; (3) basing conclusions of inconsistent or noncorroborating reports; and/or (4) inadequate or incomplete evaluations.  In these circumstances, the absence of significant symp­toms and of the factors characterizing actual child sexual abuse described above increase the probability that abuse did not occur.

    An unintentional sexual abuse allegation can also come from a child.  A previously-sexually­ abused child may misinterpret an adult’s behavior as abusive and unintentionally allege abuse, particularly if she or he had not been treated for the original sexual abuse.  In these cases, a comprehensive evaluation would still be necessary to filly assess the allegation.  This should include a thorough review of the child’s development and history, along with information regarding the child’s current functioning by adults currently involved with her or him. A lack of corroborating information and/or incongruities and inconsistencies in the stories and presentations would indicate that the abuse likely did not occur.

    Intentional false allegations do occur, however, and are designed to cause significant distress and harm to the alleged perpetrator, and typically will cause at-least some emotional damage to the child.  These allegations will typically come from an individual who is experiencing significant emotional difficulties and deficits in effective coping strategies to deal with unresolved emotional and interpersonal issues.  While there may be a situational component involved, such as the devastating impact of a separation or divorce or a highly-contentious custody dispute, it is likely that the individual who intentionally makes a false allegation has some pre-existing personality and family-of-origin issues that contribute to such inappropriate and destructive acts.

    Adults who intentionally allege sexual abuse of a child knowing that it has not occurred have been found to exhibit significant characterologic difficulties, including strong paranoid and/or histrionic tendencies (Green, 1986).  They are also more likely to attempt to inculcate a Parental Alienation in their attempts to punish the other adult (usually a spouse or ex-family member), to threaten the child with abandonment (whether emotional or physical) for being disloyal and showing some attachment towards the alleged perpetrator, and to prevent the anticipated rejec­tion or abandonment by the child.

    In Breese et al.’s 1986 study, mothers whose allegations of sexual abuse were questionable or intentionally false demonstrated a number of differentiating characteristics.  They were more likely: (1) to be focused on attacking the father; (2) insist on being present during the interviews with the child and attempt to prompt the child; (3) rigidly reject any other possible explanations for the child’s behavior, statements, or symptoms; (4) eager for the child to testify regardless of the cost/impact on the child; (5) will shop for other professionals who will verify her suspicions and will subject the child to multiple evaluations; and (6) demand the investigation continue regardless of its impact on the child.

    Children and teen-agers can also purposely falsely accuse an adult (usually a parent) of sexually abusing them.  Mikkelsen, Guthiel and Emens (1992) reported four subtypes of false allegations. Type I occurred in the context of a custody dispute, and made up a significant majority of the allegations.  Type II allegations were produced by seriously-psychologically-disturbed children, a number of whom were described as manifesting psychotic conditions.  Type III involved children or adolescents who were consciously attempting to manipulate the system.  The last type of allegation—Type IV—was referred to as “Iatrogenic” or evaluation/treatment-induced allega­tions. Contamination errors, inappropriate evaluation errors, and misinterpretations were among the more common problems found.  In addition, adolescents who were angry and/or attempting to cover up their own sexual behavior were more likely to falsely accuse another of sexually abusing them (AACPA. 1988).

Accuracy and Suggestibility in Children’s Reports of Sexual Abuse

    The accuracy of children’s memory and the factors that influence recall has particular relevance to substantiating an allegation of sexual abuse. The increased focus on possible false allegations and the controversy regarding the issue of “repressed memories” have intensified the discussion regarding the accuracy and reliability of children’s reports and recollections of sexual abuse. Challenges can arise as a result of charges that children as a group are less-credible witnesses and inconsistencies between the child’s behavior and the abuse and (Myers, 1992).

    Ceci and Bruck (1993 1995) have extensively reviewed the research on children’s memory and the influences of suggestibility and expectancy sets on recall.  They concluded that “children can encode and retrieve large amounts of information, especially if personally experienced and highly meaningful” (Ceci and Bruck, 1993).  They further noted that children’s recall is highly relevant, although the accuracy of their recall can be affected by a number of cognitive and social/environ­mental factors.

    They found that memory accuracy is improved by a number of factors.  These included: (1) mat­uration and improved memory skills; (2) greater sensibility of their material; (3) greater saliency/meaningfulness of the event; (4) action-based events, particularly when the child participates; and (5) when given a more-structured recognition rather than a free-recall task.  While these findings would seem to strongly support the credibility of children’s reports of being abused, the research on suggestibility and influence add important qualifiers. They found that (1) younger children were more suggestible; (2) children can be made to make false and/or inaccurate reports, even about crucial, personally-experienced, central life events; and (3) when the motivation set pro­vided is to lie, children are more likely to lie.

    As one might imagine, the accuracy of memory and factors that can influence recall are of great significance in allegations of child sexual abuse. The traumatic, painful nature of the sexual abuse trauma produces natural reactions to want to not remember and to block out the memories.  Con­sequently, inconsistencies and incongruities can occur when children have been sexually abused.  Difficulties in recall, delayed reporting of the abuse, and retractions and recantations of allegations are not infrequent occurrences in these situations.  Summit (1983) proposed the Child Sexual Abuse Accommodation Syndrome (CSAAS) as a framework for understanding the presence of these behaviors when a child has been abused.  This Syndrome is characterized by manifestations of (1) secrecy; (2) helplessness; (3) entrapment and accommodation; (4) delayed, conflicted, and unconvincing disclosure; and (5) retraction.  It must be recognized, however, that while CSAAS helps to explain delays in reporting and denial of abuse, it does not provide definitive proof that the abuse did occur.

    Myers (1992) offers some additional information to explain inconsistencies, delays, and recanting in child sexual abuse cases.  He identifies four major factors.  The first factor is that in cases where there have been multiple incidents of sexual abuse overtime, it is not uncommon for the confusion and disorientation that occurs in trauma to result in details to become mixed up.  However, the essential characteristics of the abuse and the stories remain intact.  The child’s ambivalent (conflicted) feelings towards the perpetrator can also produce inconsistencies in reporting and recalling the abuse.  This is more likely to occur when the perpetrator is a parent who has shown attention to the child and who is threatened with being removed from the child’s world.

    Younger children are also more likely to exhibit inconsistencies in their reports of being sexually abused as a function of the relatively-immature level of cognitive development.  In particular, young children are more likely to: (a) have greater difficulty tracking their own story and keeping it consistent; (b) be unaware of the other’s perspective and stay focused on what is being asked; (c) have difficulty understanding the interviewer’s statements or messages; (d) provide more trouble in assessing what they do or do not know or understand, in terms of sexual knowledge and exposure as well as what is being asked of them; and (e) have difficulty with cause-and-effect.  Finally iatrogenic factors, such as age- and developmentally-inappropriate questions can also result in reporting and recall difficulties (Myers, 1992).  In particular, as Ceci and Bruck (1993) point out, children’s memory and recall performance is better in structured recognition tasks, rather that in a free-recall situation.

Treatment Issues

    Child sexual abuse is a deeply-traumatizing experience, with its depth influenced by the nature, duration, severity and complexity of the traumatic events. As previously discussed in this paper, the degree of traumatization will also be influenced by the reactions of others to the initial outcry, and how and to what degree the child’s needs are met as they proceed through the predictable stages of trauma resolution and ‘normal’ (i.e., nontraumatic) development.

    Clinical and formal research investigations into the traumatic impact of child sexual abuse has led to identification a number of issues that must be addressed in treatment.  Finkelhor and Browne (1985) identified four “traumagenic” factors present in sexual abuse. These are: (1) traumatic sexualization; (2) stigmatization; (3) feelings of betrayal; and (4) feelings of powerlessness.

    Briere and Runtz (1993) identified a number of major areas that must be addressed in treatment.  These include: (1) the presence of Post-traumatic Stress Disorder (PTSD) and associated symptoms; (2) cognitive distortions that lead to overestimating danger and adversity in the present, with the individual acting as though she or he is still in the abusive situation; (3) altered emotionality, such as depression, anxiety, and rage; (4) disturbances in relationships; (5) difficulties with sexual intimacy; (6) avoidance through dissociation, substance abuse, and heightened risk of suicidal behavior; (7) tension-reducing activities that also involve re-enactments of the abuse, such as sexual promiscuity, eating disorders, and self-mutilation; and (8) impaired self-reference, including the capacity to soothe and comfort one’s self

    As with any trauma, treatment must be focused on identifying and treating both the original sources of the trauma and the self-defeating behavior patterns that develop in response to attempting to contain it.  All-too-often, the survival strategies developed to attempt to handle the overwhelming impact of the sexual abuse result in additional traumatic experiences (e.g., becoming involved in abusive and sexually-abusive relationships in adolescence and adulthood; multigenerational repetition of child sexual abuse).  Miller and Feibelman (1987) present a four-stage model to describe the stages of dealing with the trauma.

    Stage I is referred to as the Acute Physical and/or Psychological Trauma.  It is characterized by feeling overwhelmed, intimidated, and powerless; recurrent, intrusive thoughts; and acute cogni­tive disorganization and confusion, as well as dissociation.  Stage II, Denial or Avoidance of Traumatic Experience, involves conscious inhibition of thoughts and feelings about the abuse, as well as renewed cognitive disorganization and flashbacks; and avoidance of the trauma via unconscious denial and compulsive and addictive behavior.  Movement from avoiding into confronting directly the sexual abuse trauma and associated feelings and issues characterizes Stage Ill, Therapeutic Reassessment that includes adult support and Re-evaluation of the Psychological and Physical Trauma of the Abuse. And finally, Stage IV--Acceptance and Resolution--that includes better understanding of the abuse and its significance, along with coping strategies that facilitate self-acceptance without shame, doubt, or guilt.  At this point, the child is able to talk more openly about the abuse, can express her or his feelings and thoughts more freely; and can acknowledge and discharge her or his aggressive feelings toward the perpetrator.

    Thus treatment must address the need of the abused child and the significant others, adults and children, in her or his life.  Consequently, it should involve the child, the parents, siblings, and, in the cases of intrafamilial sexual abuse, the abusing parent.  It should consist of a combination of individual, marital, family, and group therapies and support groups as appropriate.  The develop­mental level of the individuals also must be considered.  Since the world of young children is primarily physical and behavioral, use of nonverbal interventions such as play therapy, drawing, etc. must be extensively employed.

    The short-term and long-term consequences on the emotional, physical, cognitive, social, and sexual development and growth all must be addressed for effective resolution of the trauma.  It must also be recognized, particularly in this era of managed care and the search for ‘quick fixes’, that treatment is a long-term process.  Although there may be periods when the sexual abuse victim and family members may not appear or even need to be in on-going therapy, the movement through different stages of life and the different developmental tasks involved at each stage will likely evoke some unresolved feelings and issues that must be addressed therapeutically.  The more obvious examples include: adolescence with its increased emphasis on relationships and sexuality; adulthood with its focus on intimacy, trust, and marriage; and parenthood, with the presence of children who activate memories of the parent’s childhood at different ages, including times of abuse. In addition, the “sleeper effects” that can result in delayed onset of the manifestation of symptoms must also be kept in mind. At the saint time, the child victim and the family must be provided with specific, concrete demonstrations of progress and that effective resolution of the trauma of sexual abuse is an achievable goal.

References

American Professional Society on the Abuse of Children Guidelines for      Pychosocial Evaluation of Suspected Sexual Abuse in Young Children. (1995).  In M. J. Ackerman, Clinician’s Guide to Child Custody Evaluations.  New York:  John Wiley & Sons, Inc.

Bresee,  P., Stearns, I., Bess, B., and Pecker, L. (1986).  Allegations of Child Sexual Abuse in Child Custody Disputes: A Therapeutic Assessment Model. American Journal of Orthopsychiatry, 56, 550-359.

Briere,   I & Runt; M. (I 993).  Child sexual abuse, long-term sequelae and implications for psychological assessment.  Journal of Interpersonal Violence, 3, 312-330.

Ceci, S. J. & Bruck, M. (1993).  Suggestibility of the Child Witness: A Historical Review and Synthesis.  Psychological Bulletin, 113, (3), 403-439.

Ceci, S. J. & Bruck, M. (1995).  Jeopardy in the Courtroom: A Scientific Analysis of Children’s Testimony.  Washington, D.C.: American Psychological Association.

Finkelhor, D. (1987).  The Sexual Abuse of Young Children: Current Research Reviewed.  Psychiatric Annals, 17, 233-241.

Friedrich, W. N. (1990). Psychotherapy of Sexual/v Abused Children and Their Families.    New York: W. W. Norton & Company.

Friedrich, W. N., Grambach, W. N., Broughton, D., Kruper, J. & Beilke, R. L. (1991). Norma­tive sexual behavior in children.  Pediatrics, 88, 456-464.

Gardner, R. A. (1987). The Parental Alienation Syndrome and the Differentiation between Fabricated and Genuine Child Sex Abuse.   Cresskill, NJ: Creative Therapeutics.

Green,   A. H. (1986). True and false allegations of sexual abuse in child custody disputes.  Journal of the American Academy of Child Psychiatry, 25, 449-456.

Guidelines for the Clinical Evaluation of Child and Adolescent Sexual Abuse. (1988).  Position statement of the American Academy of Child and Adolescent Psychiatry. Journal of the Academy of Child and Adolescent Psychiatry, 27, 655-657.

Harrison, K. W. & Maier, M. E. (1991). Abuse--Physical, Sexual, and Emotional:  Clinical Theory, Evaluation, and Treatment.   Paper presented at the Marriage Dissolution Institute of the Texas Bar Association, El Paso, TX.

Hodges, W. F. (1991).  Interventions for Children of Divorce: Custody, Access and Psychotherapy (Second Edition).  New York: John Wiley & Sons, Inc.

Hoorwitz, A. N. (1992).   The Clinical Detective: Techniques in the Evaluation of Sexual Abuse. New York:  W. W Norton & Company.

MacFarlane, K. (1988).  Child sexual abuse allegations in divorce proceedings.  In K. MacFarlane and I. Waterman (Eds.), Sexual abuse in young children: Evaluation and treat­ment.  New York: Guilford Press.

Mikkelsen, E., Guthiel, T., & Emens, M. (1992).  False sexual abuse allegations by children and adolescents:  Contextual factors and clinical subtypes. American Journal of Psycho­therapy, 55, 556-570.

Miller, T. W. & Feibelman, N. D. (1987).  Traumatic stress disorder: Diagnostic and clinical issues in psychiatry.  In T. W. Miller (Ed.), Stressful Life Events.  Madison, CT:  Inter­national Universities Press, Inc.

Morris, S.J. (1989). Sexually abused children of divorce.  Journal of the American Academy of Matrimonial Lawyers, 5, 27-46

Myers, J. E. B (1992). Legal issues in Child Abuse and Neglect. NewbuiyPark.CA: SAGE Publications.

Slap-Shelton, L, (1994).  Focus on Child Sexual Abuse.  In L. Slap-Shelton (Sr. Ed.), Child Therapy Today, Volume 1.  King of Prussia, PA:  The Center for Applied Psychology, Inc.

Summit, R. C. (19S3). The child sexual abuse accommodation syndrome. Child Abuse and Neglect, 7, 177-193.

Veltkamp, L. J. & Miller, 1. W. (1994).  Clinical Handbook of Child Abuse and Neglect. window.print();