School Response to Suspected Sexual Abuse Nina Livingston, M'D' Lisa MurphyCipolla, LMFT

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School Response to Suspected Sexual Abuse Nina
Livingston, M.D.Lisa Murphy-Cipolla, LMFT

• Hartford Regional Child Abuse Services
• Aetna Foundation Childrens Center at
• St. Francis Hospital Medical Center

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Hartford Regional Child Abuse Services

• Linked program at two area hospitals
• The SCAN Program at CCMC
• Mainly physical abuse and neglect evaluations
• The Aetna Foundation Childrens Center at
  St.Francis Hospital Medical Center
• Mainly sexual abuse evaluations

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Overview of Presentation

• Definition/epidemiology
• How sexual abuse presents
• Evaluation and investigation process
• Responding to new disclosures/concerns in the
  school setting
• Cases
• Questions/Discussion

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• Definition of child sexual abuse (CSA)
• Any sexual activity with a child when consent is
  not or cannot be given including
• Penetration
• Touching
• Exposure
• Voyeurism

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2007 National Child Abuse Stats

• 3.2 million reports on 5.8 million children
• 62 reports investigated
• 25 of investigations substantiated

U.S. Department of Health and Human Services,
Administration for Children, Youth, and Families
(2009) Child Maltreatment 2007, Washington, D.C,
US Government Printing Office
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U.S. Department of Health and Human Services,
Administration for Children, Youth, and Families
(2009) Child Maltreatment 2007, Washington, D.C,
US Government Printing Office
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U.S. Department of Health and Human Services,
Administration for Children, Youth, and Families
(2009) Child Maltreatment 2007, Washington, D.C,
US Government Printing Office
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Prevalence of child sexual abuse (CSA) Adult
retrospective studies

• Adult reports of contact sexual abuse in
  childhood
• Finkelhor 1994 20-25 women, 5-15 men
• Putnam 2003 16.8 women, 7.9 men
• Rates of 1/5 women, 1/10 men

Finkelhor (1994) Future of Children 4
31-53 Putnam (2003) Child and Adolescent
Psychiatry 42(3) 269-278
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Incidence of Substantiated CSA Child Protection
Services Data

• 2000-2004 rate of substantiated cases of CSA
  nationally 1.2/1000 children
• Discrepancy between these rates and adult
  retrospective reports suggest we are now
  diagnosing only 1 in 7 child victims of CSA

U.S. Department of Health and Human Services,
Administration for Children, Youth, and Families
(2006) Child Maltreatment 2004, Washington, D.C,
US Government Printing Office
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Risk factors for CSA

• Female gender
• Ages 7-13 (mean age 8)
• Presence of stepfather
• Living without one or both natural parents
• Impaired mother
• Witnessing domestic violence

Finkelhor, D (1993) Child Abuse and Neglect 17,
67-70
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How can we increase recognition?

• No evidence based screening tool exists
• CSA presents in one of three ways
• Child discloses abuse (70)
• Behavioral symptoms (30)
• Medical findings (8)

Heger et al (2002) Child Abuse and Neglect 26
(6-7) 645-659
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Childrens Advocacy Center (CAC) Aetna
Foundation Childrens Center at SFHMC

• Forensic interview
• Medical evaluation
• Family advocacy (support, education and referrals
  for non-offending adults)
• Therapy

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Effect of Development on Reporting
2004 CornerHouse sexual abuse interview training
materials
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The Disclosure Process

• Types of disclosure
• Accidental
• Purposeful

Sorenson and Snow (1991) Child Welfare 70 (1) 3-15
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The Disclosure Process

• Stages of Disclosure
• Denial
• Tentative
• Active
• Recanting
• Reaffirming

Sorenson and Snow (1991) Child Welfare 70 (1) 3-15
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Tentative Disclosure

• Forgetting I forgot
• Distancing It happened to Joe. It happened a
  long time ago
• Minimizing It happened one time
• Empowerment He tried to touch me, but I hit him
  and he ran away
• Dissociation When he touches me, I go to the
  pink forest
• Discounting I was just kidding

Sorenson and Snow (1991) Child Welfare 70 (1)
3-15
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Reasons for Recantation

• Pressure from perpetrator
• Pressure from family
• Negative personal consequences
• Judicial proceedings
• CPS or police investigator

Sorenson and Snow (1991) Child Welfare 70 (1) 3-15
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How often do children have diagnostic medical
findings?
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Rate of findings in children evaluated for
possible CSA

• Heger et al 2002 4 have diagnostic physical
  exam findings (n2384)
• Berenson et al 2000 2.5 (non-acute only)

Heger et al (2002) Child Abuse and Neglect 26
(6-7) 645-659 Berenson et al (2000) Am J Obstet
Gynecol 1527
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Why is the rate of physical findings so low?

• Fondling, oral and anal intercourse unlikely to
  leave findings
• Variations on penetration
• Tissues can stretch
• Injured tissues can heal rapidly with no residua
  - delays in disclosure allow healing
• Heppenstall-Heger 2003
• Kellogg 2004

Heppenstall-Heger et al (2003) Pediatrics 112 (4)
829-837 Kellogg et al (2004) Pediatrics 113 (1)
e67-e69
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96 exams in children evaluated for CSA normal.
Normal exam does not mean that nothing happened!
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Sexual Abuse challenges

• Secrecy
• No witnesses
• Rarely physical evidence
• Childs word against adults word
• Child as a court witness
• Pressure on child to recant

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Evaluation in school after disclosure

• Separate child from adult
• Get history from adult
• WHO is alleged perpetrator?
• WHAT happened? (Nature of contact)
• WHEN did it happen? (lt72 hrs ? ED/CAC)
• Any physical symptoms? (yes? ED/CAC)

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If essential history unclear, child gt 3 yrs may
need to be interviewed briefly

• Usually DCF interviewslet them do it
• If you must talk to child
• Child apart from parent
• Open questions only
• Record questions and answers
• Keep it brief!!

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Documentation

• Write down any statements by child word for word
• Document any physical injuries with measurements,
  description, and drawing.
• Give a copy of all of that to the DCF worker who
  responds to school

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We are Mandated Reporters
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What Must Be Reported

• Mandated reporters are required to report or
  cause a report to be made when, in the ordinary
  course of their employment or profession, they
  have reasonable cause to suspect or believe that
  a child under the age of 18 has been abused,
  neglected or is placed in imminent risk of
  serious harm. (Connecticut General Statutes
  17a-101a)

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Informing the Family

• Mandated reporters are under no legal obligation
  to inform parents that they have made a report to
  DCF about their child. However, depending on the
  circumstances, it may be necessary and/or
  beneficial to do so.
• Health care professionals may need to talk with
  parents to assess the cause of the childs
  injury(ies). Mental health professionals or
  members of the clergy may want to talk with the
  parents to offer support and guidance.
• However, in cases of serious physical abuse or
  sexual abuse, it may not be wise to talk with
  parents before reporting the case to DCF. This
  may put the child at greater risk and could
  interfere with a potential criminal
  investigation.
• Department of Children and Families

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Non-offending caregiver

• Stages of grief
• Impact of culture and history on the NOCs
  response
• Meet them where they are at
• Patience, patience, patience

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Cases

• Cases not included in handout

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Conclusions

• Disclosure of SA is a process, not an event
• If child presents after making disclosure
• Separate child from adult
• Obtain WHO, WHAT, WHEN from adult
• If you must talk to child, keep it brief
• Report all suspected cases to DCF and let them
  direct investigation

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How to contact us

• Childrens Center at SFHMC 714-5052
• Nina Livingston nlivingston_at_ccmckids.org
• Lisa Murphy-Cipolla lmurphy_at_stfranciscare.org