Child Sexual Abuse Examinations: Proposed Guidelines for a Standard of Care

Paul H. Jenkins and Robert J. Howell

A review of the literature regarding child sexual abuse examinations is presented and a proposal for a more objective and stringent standard of care is made. Current limitations in sexual abuse examinations include examiner bias, faulty procedures or diagnostic materials, and varied or conflicting roles of the judicial, social service, and mental health systems. Examiners in such cases should have adequate and specific training, be a neutral party appointed by the court, record the proceedings, and have access not onlv to the alleaed- victim, but also to the accused and to other parties during the examination.

Sexual abuse of children has been a difficulty arises in the investigator's at- growing national concern for the past tempt to expose the abuse to view. For several decades. Numerous books and obvious reasons, people involved in sex- articles have been written on the subject, ual abuse of children are not likely to and extensive campaigns have been volunteer this information to a re- launched in an effort to stem what some searcher, so most research concerning have referred to as a problem verging on the prevalence of sexual abuse uses ret- mass hysteria.' Sexual abuse of children rospective accounts of victims and ofi- is a serious problem that impacts its cially reported cases. Whether or not victims in many different ways.2 reported cases actually reflect the true Numbers depicting the actual inci- numbers is not an area of agreement dence and prevalence of sexual abuse among professionals. Support is for- are notoriously elusive. One problem in warded on both sides of the issue as to this area is defining sexual abuse.3 Defi- whether sexual abuse is under- or over- nitions in the literature range from ex- diagn~sed.~Finkelhor5 noted that 15 hibitionism to forcible rape. Another percent of female and six percent of male survey respondents reported hav- The authors are affiliated with Brigham Young Univer- ing been sexually abused. Although the sity. Address correspondence to: Robert J. Howell, Ph.D., Department of Psychology, 284 TLRB, Brigham true frequency of child sex abuse in the Young University, Provo, UT 84602. population is not known, the most reli-

Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 5 Jenkins and Howell able estimates range from about 10 to pressed memories for incidents that hap- 20 per~ent.~-~ pened decades ago, an issue that has One area of agreement for profession- spurred much controversy.12 To the de- als is that the number of child sex abuse gree that overreporting of child sexual allegations is increasing at an alarming abuse occurs, even more parents, fami- rate. In 1991, an estimated 2,694,000 lies, and children fall victim to the children were reported to Child Protec- courts. l3 tive Services agencies as victims of any Current Limitations and,Problems form of child abuse or neglect. Of these, approximately 15 percent, or 404,100, Examiner Bias People may become were sexual abuse cases. These numbers examiners in sex abuse cases for a num- represent a 40 percent increase since ber of different reasons. A common 1985.9 The numbers for 1992 are even theme for many people who decide to higher with an estimated 2,936,000 re- do these types of evaluations is child ported cases of any form of abuse and advocacy; they want to be able to do 17 percent, or 499,120, being sexual something for children. As noble as this abuse cases.'' There is also growing evi- may appear, it has the potential for in- dence that a substantial portion of these troducing biases into the system. For allegations are either unsubstantiated example, it is not uncommon to hear (not enough evidence to support the al- from those who set themselves up as legations), or false (allegations which child advocates that children never lie were honestly made but not true and and that false accusations would there- intentionally false allegations). Of the fore be extremely rare.14 All too often nearly 2.7 million reported cases for the assumption going into the evaluation 199 1, an average of only 39 percent were is that the accused is guilty, even before substantiated following an investiga- gathering any kind of information other tion. I' than the accusation itself. This reverses Whatever the reason for the dramatic the constitutional mandate that inno- increase in the number of alleged cases, cence of the accused is to be assumed. the resultant flooding of our judicial sys- Wideman" suggests that "the greatest tem with sex abuse cases is having a problem in criminal investigations today noted impact. The high rate of state is that investigators assume something intervention in abuse cases is meant to happened and then set out to prove protect endangered children. Unfortu- themselves right" (p. 36). This seems to nately, just the opposite occurs as those be particularly true in cases of sexual children in desperate need of protection abuse of children where emotions run and assistance are lost in an over- high and the natural inclination of most crowded and flooded system. Recent leg- outsiders is to favor the child.16 Several islation also makes it possible in many writers have mentioned the danger states for an adult to press charges of of examinations done by case workers sexual abuse based on formerly re- who have typically received little train-

6 Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 Sexual Abuse Examinations ing.8,17, 18 Often the examiner wants to incidences of coercion, manipulation, believe that the abuse took place and and pressure to lead the children to then filters out facts from the case that make statements about abuse.23 After are consistent with the preconceived the verdict was given in this case, the conclusions. Virtually any behavior or jurors stated that it was the leading na- "sign" in the child is taken as evidence ture of the questions posed to the chil- that abuse has occurred even when the dren that swayed their decision.24 A indicators used are probably no more growing body of research concerning than general indicators of childhood suggestibility of children and specifically stress or, in some cases, normal child- of child witnesses is emerging.25 While hood.19 The usual outcome for such an the McMartin case is an admittedly ex- approach to child abuse cases leads the treme example, basic principles of social child and evaluator alike to believe that psychology support the idea that when abuse has indeed occurred, obscuring questioned numerous times by adults the chance for a more objective exami- who are convinced that abuse has oc- nation.18, 20'21 Conversely, some evaha- curred, children conform their reports tors may be predisposed against believ- to the expectations of the adult.26Chil- ing that claims of sexual abuse are dren in sexual abuse cases are often sub- valid.22 jected to intense, repeated, and highly Even the titles chosen for examiners suggestive and leading questioning by in child sexual abuse cases suggest bias. persons the children perceive to be in Many of them call themselves "valida- authority. tors" or "corroborators." A quick look Use of Questionable Materials for in any standard English dictionary re- Diagnosis The use of aids such as dolls, veals that the meaning of both of these drawings, props, or other materials in terms has the feeling of proving some- the context of a sexual abuse evaluation thing or gathering evidence in support is controversial. Some propose that the of some conclusion. These terms should use of such materials is a useful and be abandoned in favor of more neutral necessary adjunct to an inte~iew~',~~ and objective terms like "examiners" or while others come down squarely on the "evaluators." issue that they are suggestive and should not be used.18 Of the items that could be Faulty Procedures used as aids in an examination, the larg- Suggestive and Leading Interviews est body of research centers around an- The way that children are interviewed atomically correct dolls. Some oppo- in sexual abuse cases has a high potential nents to the use of these dolls have lev- for introducing error and reducing the eled the complaint that the dolls are far reliability of the child's statements. from anatomically "correct" in that the Analysis of the taped interviews with breasts and genitals of the dolls are dis- children in the now famous McMartin proportionately large and e~aggerated.~ Preschool case in California shows many Because of this type of opposition, ana-

Bull Am Acad Psychiatry Law, Vol. 22, No. l, 1994 7 Jenkins and Howell tomically "detailed" or merely "anatom- anatomical dolls can be used as a diag- ical" have become preferred terms in nostic tool. reference to these dolls. Recent research, Multiple Roles and Goals Any child however, has shown that through extrap- sexual abuse case involves the interface olation of the measurements of 17 sets of three very different systems-judicial, of these dolls to adult human propor- social service, and mental health. All of tions, no exaggeration of the sizes of these systems have a different role to genitalia or breasts is apparent.29 play in the child sexual abuse case with A more salient problem with the an- very different objectives. Pogge and atomical dolls seems to be the lack of Stone33outline the possible conflicts that norms available and their suspected sug- may arise in the interaction of these gestibility. Very little agreement exists three systems in the handling of a case. among professionals as to the meaning The main role of the social service sys- tem is to protect the child from abuse. of a child's behavior with anatomical The legal system focuses on providing dolls.30A few studies are now starting to justice to all involved parties. The men- accumulate based on differences be- tal health system is concerned with treat- tween abused and nonabused children ment of the identified patient, whether in their behavior with the anatomical it be the victim or the perpetrator. Any dolls, but these differ widely in their of these three systems may be called on methodology, selection of subjects, and to perform investigations or evaluations conclusions. For example, August and to determine the truth of an allegation. Forman3' found that abused children This is where mixing the differing objec- display more sexually oriented behavior tives of the three systems may obscure with dolls when alone but less when with what must be an objective and impartial an adult than a nonabused sample. investigation. However, their "abused" sample consists Mental health professionals are often of "children who were referred for eval- faced with the conflict of roles between uation of possible intrafamilial sexual investigation and healing. They are not abuse" (p. 4 1). McIver, Wakefield, and detectives, but are often put into that Underwager """ "" * on the other hand role when asked to do evaluations and used verified sexual abuse cases in their to make some statement about the truth sample against a control group and or falsehood of an allegation based on found no differences. Everson and their expertise in human behavior. A Boat3' provide a summary of studies professional who is called on to perform done in this area. Suggestibility, model- a sexual abuse examination must re- ing, and lack of standardized design or member that the first principle of inves- procedure are other complaints that tigation is independence both in the have been made against the dolls. evaluator's not being aligned with any Clearly, more stringent research in this particular party involved and in freedom area is needed to establish norms before from biases regarding the allegation. It

8 Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 Sexual Abuse Examinations is vitally important to separate the roles This helps to ensure that the examiner of treatment, investigation, and advo- is somewhat distanced from the case cacy.17, 1s,26 For this reason, a child's emotionally and has no particular finan- therapist should not be the one to con- cial ties to either party involved. This duct an examination to determine the also gives the court some control in mak- truth of an allegation. Therapists should ing sure that a competent and trained remain centered on their objective examiner is appointed. In no case should which is to heal, while investigators must the examiner be the child's thera~ist.~~ be concerned with gaining uncontami- While it would be ideal to have com- nated data. This is impossible if the in- petent and trained examiners at every terview is conducted in a suggestive and phase of the investigation, disclosure by therapeutic way. Mixing the goals of a child of sexual abuse is most often therapy, investigation, and advocacy unexpected and with some trusted per- tends to confound all three. son rather than with an impartial ex- aminer. We have very little control over A Proposed Standard of Care the circumstances under which disclo- The Examiner Because of the com- sures of abuse take place. Our focus as plex and sensitive nature of child sexual trained professionals should be on what abuse cases, those who conduct exami- happens after that original disclosure, nations in this area must receive ade- during the course of an evaluation. quate specialized training. This training The Process A lack of any standard- must provide basic knowledge of child ized approach to child sex abuse exami- development and the special considera- nations is in part responsible for the tions of interviewing children who have difficulties that plague the field today. very different cognitive, memory, lin- Rogers" has proposed that "a standard guistic, and social abilities from those of in the field for a protocol for child sex adults.34Other fundamental topics to be abuse evaluations, based on a solid em- mastered include childhood sexuality, pirical and experiential foundation is historical trends of sex abuse, and basic sorely needed" (p. 59). Guidelines like social psychology. A more specific liter- those proposed by the American Acad- ature focusing on issues of the child as a emy of Child and Adolescent Psychiatry witness, suggestibility, and sexual abuse are beginning to emerge, providing a evaluations is arising and should be fa- starting point for a standard approach miliar to the e~aminer.~'.35 to such evaluations.'"he evaluation of The issue of examiner bias was dis- a child who is suspected to have been cussed previously. The type of training sexually abused is a complex and mul- and specialized knowledge suggested tifaceted task. All too often, important above will help to alleviate some of the parts of the process are omitted, result- bias problem. Another approach to lim- ing in an incomplete assessment at best iting the effects of examiner bias is to and unnecessary curtailment of rights in have the court appoint the examiner. many cases.

Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 9 Jenkins and Howell Recording of Interviews Often, the interviews. Additionally, it is important first official interview of a child concern- to safeguard against the possible risks of ing an allegation of sexual abuse is with obtaining such information. Videos someone who does not record the inter- could be used to harass or intimidate the view. This presents a situation in which child in the context of cross-examina- the interviewer often paraphrases or at- tion. They may also fall into the hands tributes statements to children when the of those who have little or no regard for statements were actually those of the the sensitive and confidential nature of inter~iewer.~~For those involved in the their content. Also, some viewers may case who are not in the initial interview, see the child's testimony as being more a videotaped recording is essential to credible because it is on the videotape.36 know with any degree of certainty what Other than that, there is no reason why went on in the interview. Some of the interviews done in connection with a advantages provided by documenting child sexual abuse examination cannot every interaction with the child on be videotaped or at least audiotaped. videotape are: (I) It preserves the integ- Advantages of using such outweigh the rity of the interview. (2) It decreases the possible negatives. Many experts in need for additional interviews, which the field agree that this should be an inte- have a learning effect on the child and gral part of a competent examina- increase costs. (3) It preserves direct tion. IS, 17, 38-40 quotes of the child in context while dem- Medical or Physical Examinations onstrating the affect of the child during The approach commonly used in phys- the interview. (4) It serves as a control ical abuse examinations gave rise to the device to keep interviewers honest by model used in sexual abuse examina- providing a means of training and feed- tions. In physical abuse cases, a medical back from other professionals. (Inciden- doctor is often the one to make a defin- tally, this is one of the main areas of itive diagnosis based on objective phys- resistance against the use of videotap- ical criteria that can be fairly explicitly ing). (5) Videotapes of interviews with ~utlined.~'Physical exams have become the child may be used to confront the a routine part of sexual abuse examina- accused. (6) When done correctly it can tions as well and often the physician's help to alleviate suspicion of the inves- findings are taken as conclusive evidence tigative process and provide a source of that abuse has occurred. Some doctors validation for the accuracy of the inter- are even instructed to always report their view. (7) It may be used as a therapeutic findings as "consistent with the history device following the investigation. (8) It of sexual abuse" whether or not there enables the legal profession to observe are actual physical findings, presumedly part of the process by which case workers lowering the chance that abuse will be and professionals make their decisions. discounted if it has indeed occ~rred.~'A Occasionally, resources will not per- problem with this approach is that phys- mit video recording of all investigative ical findings are rare in sexual abuse

10 Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 Sexual Abuse Examinations cases, and that many positive findings uments, personal communications, or are ambiguous and inconclusive about other types of evidence and be aware of sexual abuse, resulting in significant er- biases in these evidences (for example, a rors in diagnosis.43M~ram,~~ for exam- report from a therapeutic agency or ther- ple, found that in a sample of girls de- apist). A healthy skepticism should be termined to be abused by Child Protec- the stance of the examiner, adhering tive Services, 54 percent had either firmly to the objective of determining normal or nonspecific physical findings. the truth about the case. The examiner Another 45 percent had findings that should also request that any physical were defined as specific to sexual abuse evidence referred to be produced, such that included a hymenal opening of as pornographic pictures or videotapes, greater than one centimeter. Elsewhere arrest records, etc. Anything associated it was shown that any opening over four with the case and those involved in the millimeters is highly associated with sex- case can be a potential source of infor- ual abuse.45In only one percent of the mation to the examiner. sample was definitive evidence (sperm) Interviewing the Child As men- discovered. tioned earlier, interviewing children is Other types of sexual abuse not in- a specialized task requiring specialized volving penetration or ejaculation are experience and training. The special essentially invisible to medical exami- considerations of interviewing children nations. The hit rates for medical ex- should be continually a concern of the aminations in diagnosing sexual abuse examiner in a sexual abuse case. Time- appear to be just about what one would liness is another important general con- expect from chance or worse.43.44 For sideration in interviewing suspected vic- this reason, medical or physical exami- tim~.~'The sooner an examiner is able nations should be limited to obtaining to interview the parties involved, the less evidence that has already been reported other influences are brought to bear on in the initial ~ornplaint.~~Additionally, the interviewee. This is especially true physicians chosen to perform such ex- for cases in which therapy is to take aminations should possess specialized place. Investigative examinations should experience and training, and should un- be conducted, if possible, before the per- derstand the possible ramifications of son to be interviewed enters therapy. forensic examination^.^^ The actual format or procedure for Gathering Collateral Information interviewing the child in a sexual abuse One often overlooked part of an evalu- case has been proposed by a number ation is a complete psychosocial family of sources, and often each organization history including attitudes about nudity or institution accustomed to doing these and sex or other ways the child may interviews will have its own proto- have gained information about sex such col. 18,38,39,46,48-5 1 as sexually explicit videos." An exam- One important thing to remember iner should carefully review reports, doc- when interviewing the child is the afore-

Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 11 Jenkins and Howell mentioned issue of suggestibility. The mation the child has been exposed. A interviewer should take every precaution fairly direct question like, "Has anyone to minimize verbal and nonverbal cues told you what to say here today?" can to the child. A conscientious examiner be very revealing. This question should will make every effort to remain de- always be followed up with, "What were tached and rational with a fair degree of you told to say?" if the child's answer is skepticism throughout the procedure. affirmative. The child may have been The child should be interviewed alone told by a caretaker to tell the truth about whenever possible. If more than one what happened, or on the other hand adult is involved in the interview, con- the child may have been carefully fusion may arise as differing agendas will coached as to the details of the alleged prompt different lines of questioning. incident. The entire proceedings should always be Most professionals in this area agree videotaped or at least audiotaped. also that a discussion of truth and decep- , Hypnotic interviews are suspect be- tion is necessary early on in the inter- cause of the possibility of increased sug- view. Although this does not guarantee gestibility and the unsettled issue of that the child will tell the truth, at least memory distorti~n.~~?~~Erdel~i,~~ for ex- the examiner is reiterating the impor- ample, suggests that what some have tance of frank honesty in the interview. identified as recovered or enhanced Also, the courts will be more wary about memory under hypnosis may actually the child's testimony and the interview be paramnesia or confabulation. White- if this important issue is left out. house et aLs3showed that while hypno- Many children will have idiosyncratic tized subjects are more confident about terms for body parts and functions. This their reported memories, they are not is especially true of genitalia, breasts, more accurate than control subjects. buttocks, and anus. While it is true that The first step once the interview has the investigator should be aware of begun is one of rapport building which terms are used by the child, many and introductions. The examiner should ways of obtaining such information are make the child feel comfortable enough overtly suggestive and may draw undue to allow for disclosure while maintaining attention to sexual content. Usually, professionalism. At this point the pur- parents or other caretakers can provide poses for the interview are explained, this information prior to the interview. although the child is typically already Those terms that the child mentions in aware of why he or she is being inter- the free narrative part of the interview viewed. During this phase of the inter- can be clarified through direct question- view an informal assessment of the ing if the examiner is unsure of their child's verbal and cognitive abilities can meaning. aid the progression of the interview. An- The main material of the interview other important aspect of this part of the should be gained by encouraging free interview is finding out to what infor- narrative from the child. This is best

12 Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 Sexual Abuse Examinations accomplished by using nondirective, of children's statements are currently be- open-ended questions. Generally, the ing developed such as the Criteria- child knows why he or she has been based Content Analysis (CBCA) and brought to the interview and will begin the Statement Validity Assessment to talk about the alleged abuse without (SVA).18.36,55,56 ~h ese are semistandar- significant prompting. If the child is tan- dized instruments that have shown some gential or avoidant of the topic, the in- promise in assessing the credibility of terviewer may direct the child to the children's statements and may be useful issue of sexual abuse without being for differentiating fabricated versus legit- suggestive with an open invitation to imate sexual abuse allegations. More re- narrative such as, "I understand that you search is needed in this area. have some concerns about what has Interviewing Others In addition to been happening at home (school, etc.); the child, an evaluator should ask to see tell me about that." Important things to the accused, the child's caretaker(s), and listen for in the child's narrative include any other significant others (siblings, the details of the abuse (who, where, babysitters, etc.) who may have rele- when, how often, etc.), the child's feel- vance to the ~ase.~~,~'Even if this is not ings about sexual contacts, presence of possible, one should make this request secrets or threats and coercion, the and then document the request. Acces- child's feelings toward the accused, and sibility to all parties is an important part the general affect of the child (is this of a thorough investigation. disturbing to the child). Because of the Often, the interview with the present- limited cognitive and linguistic abilities ing adult (usually a mother or other of the child, clarifying questions are caretaker) precedes the interview with often necessary. Again, clarifying ques- the child. In this interview it is important tions should not be leading or suggestive, to determine whether any unusual or nor should they contain any information "red flag" circumstances exist (such as provided by another source. an ongoing divorce or custody battle). Some sort of a validity assessment This interview should be very specific should be performed on the child's state- about the nature of the complaint and ments (this is another important reason how the complainant came to under- to document the interview on video- stand or suspect that abuse had oc- tape). Often, this is done by noting con- curred. The circumstances and context sistencies and inconsistencies in the under which disclosure or discovery first child's account, especially as it fits or took place must be clarified. The inter- fails to fit with what the investigator view with the first reporter of the abuse knows about the case. Age appropriate- is likely to be the least swayed by con- ness of responses should also be a con- founding factors; however, the inter- sideration, as well as the affective re- viewer should also be aware of any other action of the child to what is being sources of information the first reporter described. More formal assessments may have had that are likely to have

Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 13 Jenkins and Howell been incorporated into the account of ten about psychological testing of the the original incident. As in the interview parties involved in sex abuse cases. The with the child, free narrative accounts literature is inconclusive about what a tend to be the most valid and useful. psychological profile looks like for the Making a decision about the truthful- typical victim or the typical perpetrator. ness of a sexual abuse allegation based This may be one reason that some states solely on examination of the child is like like California prevent the courts from a court convicting a person of a crime ordering psychological tests for parties after hearing only the arguments of the involved in sex abuse cases.37Still, test- prosecution. An interview with the ac- ing may provide useful information cused is essential not only to hear the about intellectual level, impulsiveness, other side of the story, but to give the adjustment, and overall level of func- accused a chance to directly answer tioning of the different parties that may the allegations. The four preconditions be very illuminating in the context of mentioned by Finkelhors may be useful the case. Some researchers have found in the assessment of the accused. Some the Rorschach inkblot test to be useful have advocated interviewing the accused in identifying sexually abused girls alone as well as in the presence of the against a control Further re- child and/or presenting adult.46This tac- search of this type is needed. . tic may reveal much about family dy- namics and may also reveal whether the Summary and Conclusions allegations have been inflated or exag- Examinations in child sexual abuse gerated. It could also show much about cases are complex and vulnerable to how the child feels about the accused. If many sources of error due to the highly an examiner does not have access to the sensitive and emotional nature of the accused, he or she should be very hesi- allegations. Examiners should use cau- tant to make any conclusions about tion to be sure that bias and suggestibil- whether or not the abuse has indeed ity are minimized at every phase of the occurred. evaluation, maintaining a stance of neu- Significant others can be a valuable trality and healthy skepticism until all source of cross validation and informa- of the data are in. Examiners in sexual tion to the investigator about the indi- abuse cases should have adequate train- viduals involved in the case. This is also ing and experience in working with chil- a chance to clarify hearsay information dren in general and sexual abuse in par- with the original source. For example, ticular. Examiners of such cases should the presenting adult may say something be court appointed partially to reduce like, "she told the babysitter. . ." When- the risk of bias or dual role conflicts, but ever resources allow, the examiner also to ensure that the examiner will should then find out from the babysitter, have access to all parties involved in the in this case, what was actually said. allegation. As a minimum requirement, Psychological Testing Little is writ- the examiner should evaluate not only

14 Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 Sexual Abuse Examinations the child, but the accused and the child's ory and Research. New York, Free Press, 1984 caretaker as well. If such contact is not 6. Finkelhor D: A Sourcebook on Child Sexual possible, the examiner should at least Abuse. Beverly Hills, CA, Sage, 1986 7. National Center for Child Abuse and Neglect document that an attempt was made. (NCCAN): Study of National Incidence and All such examinations and interviews Prevalence of Child Abuse and Neglect should be documented on videotape or (DHHS Publication No. HE 23-1210). Washington, DC, U.S. Dept. of Health and at least on audiotape. Human Services, 1988 Some may be concerned about the 8. Wakefield H, Underwager R: Accusations of expense of such an approach to con- Child Sexual Abuse. Springfield, IL: Charles C Thomas, 1988 ducting sexual abuse examinations. 9. Daro D, McCurdy K: Current Trends in Many public agencies lack the funds for Child Abuse Reporting and Fatalities: The Results of the 199 1 Annual Fifty-State Sur- adequate investigations. As we struggle vey. (Available from National Committee for to remedy this inconvenience, it would Prevention of Child Abuse. 332 S. Michigan do us well to remember the tremendous Ave. Suite 1600, Chicago, IL 60604-4357: Ph: 3 12-663-3520), 1992 cost to children, individuals, families, 10. McCurdy K, Daro D: Current Trends in and society of allowing inadequate or Child Abuse Reporting and Fatalities: The Results of the 1992 Annual Fifty-State Sur- biased investigations to take place. The vey. (Available from National Committee for relative costs of this versus other ap- Prevention of Child Abuse, 332 S. Michigan proaches are yet to be spelled out in hard Ave. Suite 1600, Chicago. IL 60604-4357; Ph: 3 12-663-3520), 1993 numbers. I I. Daro D, McCurdy K: Current Trends in The position of the examiner is not to Child Abuse Reporting and Fatalities: NCPCA's 199 1 Annual Fifty-State Survey. be a therapist or child advocate, but one (Available from National Committee for Pre- to arrive at objective conclusions based vention of Child Abuse, 332 S. Michigan on unbiased data. As sexual abuse ex- Ave. Suite 1600. Chicago, IL 60604-4357; Ph: 3 12-663-3520). 1992 aminations become more objective and 12. Loftus EF: The reality of repressed memo- less biased or emotionally charged, the ries. Am Psychol 48518-37, -1993 system for dealing with such allegations 3. Besharov DJ: "Doing Something" about child abuse: the need to narrow the grounds will function more cleanly and will bet- for state intervention. Haw J L Pub Pol'y ter serve the purpose for which it was 8:539-89, 1985 4. Faller KC: Is the child victim of sexual abuse intended. telling the truth? Child Abuse and Neglect 8:471-81, 1984 5. Wideman JC: Investigative procedures in al- References legations of child sexual abuse. Part I: the 1. Gardner RA: Sex Abuse Hysteria: Salem initial criminal investigation. Issues in Child Witch Trials Revisited. Cresskill, NJ, Crea- Abuse Accusations 1(4):35-43. 1989 tive Therapeutics. 199 1 16. Herzog PF: Child hehrsay vs the Confronta- 2. Browne A, Finkelhor D: Impact of child tion Clause: can the Sixth Amendment sur- sexual abuse: a review of the research. Psy- vive? Issues in Child Abuse Accusations chol Bull 99:66-77. 1986 l(4): 10-26, I989 3. Emery RE: Family violence. Am Psychol 17. Quinn K: Sexual Abuse: Investigation and 44:32 1-8, 1989 Validation. Unpublished manuscript. 1987 4. Terr LC: Debate forum-resolved: child sex 18. Raskin DC, Yuille JC: Problems in evalua- abuse is overdiagnosed. J Am Acad Child tion interviews of children in sexual abuse Adolesc Psychiatry 28:788-97, 1989 cases, in Perspectives on Children's Testi- 5. Finkelhor D: Child Sexual Abuse: New The- mony. Edited by Ceci SJ, Ross DF, Toglia

Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 15 Jenkins and Howell MP. New York, Springer-Verlag. 1989, pp the treatment of child sexual abuse. Profes- 184-207 sional Psychology: Res Prac 2 1:354-36 1. 19. Legrand R, Wakefield H, Undenvager R: 1990 Alleged behavioral indicators of sexual abuse. 34. Benedek EP, Schetky DH: Problems in vali- Issues in Child Abuse Accusations l(2): 1-5, dating allegations of sexual abuse. Part 1: I989 factors affecting perception and recall of 20. Benedek E: Examining children alleging sex- events. J Am Acad Child Adolesc Psychiatry ual abuse can be reliable by honing proper 26:9 12-5. 1987 techniques. Psychiatric News, May 19, 1989 35. Ceci SJ, Ross DF, Toglia MP (eds.): Perspec- 2 1. Kiefer L: Defense considerations in the child tives on Children's Testimony. New York. as witness in allegations of sexual abuse: Part Springer-Verlag, 1989 11. The child witness: legal competency. Is- 36. American Academy of Child and Adolescent sues in Child Abuse Accusations 1(2):48-57. Psychiatry: Guidelines for the clinical evalu- 1989 ation of child and adolescent sexual abuse. J 22. Everson MD, Boat BW: False allegations of Am Acad Child Adolesc Psychiatry 27:655- sexual abuse by children and adolescents. J 7, 1988 Am Acad Child Adolesc Psychiatry 28:230- 37. Rogers ML: Coping with alleged false sexual 5, 1989 molestation: examination and statement 23. Coleman L: Learning from the McMartin analysis procedures. Issues in Child Abuse Hoax. Issues in Child Abuse Accusations Accusations 2(2):57-68. 1990 1(2):68-7 1, 1989 38. Daly LW: The essentials of child abuse in- 24. Wideman JC: Investigative procedures in al- vestigation and child interviews. Issues in legations of child sexual abuse. Part 111: in- Child Abuse Accusations 3(2):90-8, 199 1 dictment and trial. Issues in Child Abuse 39. Glaser D. Frosh S: Child Sexual Abuse. Chi- Accusations 2(1):76-82, 1990 cago, Dorsey Press, 1988 25. Doris J (ed.): The Suggestibility of Children's 40. Walsh G: Investigative interviewing and the Recollections. Washington, DC, American use of anatomically explicit dolls in the de- Psychological Association, 199 1 tection of sexual abuse of children. Law So- 26. Wakefield H, Undenvager R: Interrogation ciety J 25:48-53. 1987 of children. Issues in Child Abuse Accusa- 4 1. Helfer RE, Kempe RS: The Battered Child tions l(1): 14-28, 1989 (ed 4 rev). Chicago, University of Chicago 27. Leventhal JM, Hamilton J, Rekedal S, Te- Press, 1987 bano-Micci A, Eyster C: Anatomically cor- 42. Durfee M, Heger AH, Woodling B: Medical rect dolls used in interviews of young chil- evaluation, in Sexual Abuse of Young Chil- dren suspected of having been sexually dren. Edited by MacFarlane K. Waterman J. abused. Pediatrics 84:900-6, 1989 New York, Guilford Press, 1986, pp 52-66 28. Boat BW, Everson MD: Interviewing young 43. Fay R: A critical analysis of a medical report children with anatomical dolls. Child Wel- in a case of suspected child sexual abuse. fare 67:337-52, 1988 Issues in Child Abuse Accusations 3(4): 199- 29. Bays J: Are the genitalia of anatomical dolls 202, 199 1 distorted? Child Abuse Neglect 14: 17 1-5, 44. Muram D: Child sexual abuse-genital tract 1990 findings in prepubertal girls. 1. The unaided 30. Boat BW, Everson MD: Use of anatomical medical examination. Am J Obstet Gynecol dolls among professionals in sexual abuse 160:328-33, 1989 evaluations. Child Abuse and Neglect 12: 45. White ST. Ingram DL, Lyna PR: Vaginal 171-9, 1988 introital diameter in the evaluation of sexual 31. August RL, Forman BD: A comparison of abuse. Child Abuse Neglect 13:2 17-24, 1989 sexually abused and nonsexually abused chil- 46. Blush GJ, Ross KL: Investigation and case dren's behavioral responses to anatomically management issues and strategies. Issues in correct dolls. Child Psychiatry Hum Dev Child Abuse Accusations 2(3): 152-60, 1990 20:39-47, 1989 47. Wideman JC: Investigative procedures in al- 32. Everson MD, Boat BW: Sexualized doll play legations of child sexual abuse. Part 11: victim among young children: implications for the and subject interviews. Issues in Child Abuse use of anatomical dolls in sexual abuse eval- Accusations 2(1):7- 14, 1990 uations. J Am Acad Child Adolesc Psychiatry 48. American Professional Society on the Abuse 29:736-42, 1990 of Children (APSAC): Guidelines for psycho- 33. Pogge DL, Stone K: Conflicts and issues in social evaluation of suspected sexual abuse

16 Bull Am Acad Psychiatry Law, Vol. 22, No. 1, 1994 Sexual Abuse Examinations in young children. (Available from APSAC, 54. Erdelyi MH: Psychoanalysis: Freud's Cogni- 332 South Michigan Ave. Suite 1600, Chi- tive Psychology. New York, W. H. Freeman. cago IL 60604) 1990 1985 Sgroi SM (ed.): Handbook of Clinical Inter- 55. Rogers ML: Review of the current status of vention in Child Sexual Abuse. Lexington, the use of statement validity analysis proce- MA, Lexington Books, 1982 dures in sex abuse cases in the United States. Walker LEA: Psychological assessment of Issues in Child Abuse Accusations 2(2):69- sexually abused children for legal evaluation 75, 1990 and expert witness testimony. Prof Psychol: 56. Steller M: Recent Developments in State- Res Prac 2 1 :344-53. 1990 ment Analysis. Unpublished manuscript. Weissman HN: Forensic psychological ex- Free University of Berlin. Institute for Foren- amination of the child witness in cases of sic Psychiatry, Berlin, Germany, 1989 alleged sexual abuse. Am J Orthopsychiatry 57. Schultz LC: The social worker as an expert 6 1148-58, 199 1 witness in suspected child abuse cases: a Sheehan PW: Memory distortion in hypno- primer for beginners. Issues in Child Abuse sis. Int J Clin Exp Hypn 36:296-3 1 I, 1988 Accusations 1(2):37-47, 1989 Whitehouse WG. Dinges DF, Orne EC. Orne 58. Leifer M, Shapiro JP, Martone MW, Kassem MT: Hypnotic hypermnesia: enhanced L: Rorschach assessment of psychological memory accessibility or report bias? J Ab- functioning in sexually abused girls. J Pers norm Psychol 97:289-95, 1988 Assess 56: 14-28, 199 1

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