Treating victims of child sexual abuse

Abstract

"Anna" is a 9-year old girl, currently in third grade. She lives with her mother ("Ms. B") and her 14-year-old brother. At a recent visit to the pediatrician for a well-child appointment, Anna refused to remove her clothes and became extremely agitated when the physician started to examine her. She started crying and disclosed that her stepfather had been "hurting" her. On further inquiry, she said that he had been forcing her to engage in "sex stuff." Ms. B was visibly shaken and distressed by the disclosure, stating that she had no idea this had happened. She did acknowledge that she and her husband had been experiencing marital problems, which resulted in his movingout of the home temporarily about 6 months ago, but she was still seeing him, and he was still at the house frequently. Ms. B did not understand how this could have happened since she rarely left her children alone with her husband. Furthermore, she said that she and Anna have a very close relationship and that Anna would have shared this if it had occurred. Since Anna was extremely upset after her disclosure and Ms. B was having difficulty believing the allegations, the pediatrician recommended a referral to the local Child Advocacy Center (CAC) for a medical examination and forensic interview. CACs provide a safe, child-focused environment and include a multidisciplinary team of professionals, comprising medical, mental health, law enforcement, prosecution, child protective services, victim advocacy, and school personnel, who work together to coordinate services for children. In addition to providing medical evaluations and forensic interviews after abuse disclosures, CACs offer therapy and medical examinations, courtroom preparation, victim advocacy, and ongoing case management. While Ms. B was still in the office, the pediatrician contacted the CAC to schedule the evaluation and allow Ms. B to speak directly with the CAC to provide any required information. The pediatrician then explained to Ms. Bthat a report would have to be made immediately to the local child protective services (CPS) office, as physicians are mandated reporters in cases of suspected child abuse. Ms. B became increasingly hostile, angrily stating that she did not understand why Anna needed to be seen at the CAC and a report needed to be made, as this "really couldn't have happened." Because of her obligation as a mandated reporter, the pediatrician explained that the report was required and that the best plan would be for them to make the telephone call together. As the alleged perpetrator was a primary caregiver (the child's stepfather), the pediatrician made the report to the local CPS office. The CPS intake worker stated that a worker would be at their home that day to interview Anna and her mother and to establish a safety plan. Anna was scheduled for the CAC evaluation the following week, and the CPS worker told the pediatrician and Ms. B that she would also plan to attend that appointment, as a way to reduce the number of times Anna had to undergo in-depth interviews. The CPS worker indicated that she needed to contact law enforcement and asked Ms. B for specific information about her husband, which Ms. B refused to provide. The worker informed her that this would entail the police coming directly to her home to question her husband, to which Ms. B responded, "Do what you need to, but I won't help you." Despite Ms. B's anger and disbelief, she reluctantly allowed the pediatrician to conduct a cursory physical examination of Anna but deferred a genital examination until Anna could be seen at her local CAC for a medical examination. Ms. B did attend the CAC evaluation, stating that she just wanted to "get this over with so that everyone would leave [her] family alone." At the CAC evaluation, Anna was noted to have a normal genital examination with no signs of injury. Ms. B asked if this finally "proved" that the abuse never happened. The medical provider explained that the majority of children who are victims of sexual abuse do not have signs of injury regardless of the timing of the examination. In addition to the physical examination, a forensic interview was conducted at the CAC. The purpose of the forensic interview is to determine the details of the child abuse allegations, without asking leading questions or causing undue harm to the child, and to render an opinion on the credibility of the child's disclosures. During the course of the forensic interview, Anna said that her stepfather had started abusing her about a year ago and that it happened multiple times a week while her mother, a nurse at the local hospital, was working the evening shift. Anna indicated that her stepfather would read to her in bed and that one night he started touching her chest and rubbing her legs. He said this would help her to sleep. Over the subsequent months, the abuse increased in severity, involving vaginal penetration and forced oral sex. Anna stated that her stepfather warned her not to tell anyone and that no one would believe her, even if she did tell. He also told her that if her mother found out, he would go to jail and Anna would have to go to foster care. Anna also said that she had nightmares, felt scared "all the time," and was "really scared" of men. Ms. B also was interviewed and continued to express her anger and disbelief. She stated that she had "no idea" how this could possibly have happened. She admitted to marital problems but said that she and her husband were trying to work things out. She agreed to obtain treatment for Anna so that they could put the whole thing behind them. On the basis of the forensic interview, Anna was referred to a mental health provider housed at the CAC who could conduct a psychosocial evaluation and determine her treatment needs. Evaluation results indicated that Anna met DSM-5 criteria for posttraumatic stress disorder, including reexperiencing symptoms (e.g., nightmares, frequent stomachaches when reminded of the abuse), avoidance of thoughts, feelings, or reminders of the abuse, negative thoughts and feelings (e.g., self-blame about what happened, loss of interest in activities, feeling alone and isolated), and trauma-related arousal (e.g., increased irritability, difficulty sleeping and concentrating in school). Based on these findings, the therapist recommended trauma-focused cognitive-behavioral therapy (CBT) (1), an empirically supported treatment that includes the child and caregiver to address trauma-related symptoms through weekly sessions. An important component of trauma-focused CBT is the inclusion of the caregiver in sessions as a way to build support, teach the same skills being taught to the child, increase communication about the traumatic event, and increase the likelihood that skill acquisition would generalize to the home environment. This parallel treatment model also gives the therapist the opportunity to work with caregivers such as Ms. B who are having difficulty believing their child's allegations. While Ms. B was initially angry and disbelieving, she did want Anna to "be OK," and she brought her regularly to the treatment sessions. The therapist worked closely with Ms. B to address her anger and disbelief, providing extensive psychoeducation about why children do not disclose (e.g., shame, fear of not being believed, embarrassment, fear of the offender), sharing specific examples of what her husband had said to Anna and exploring the impact this has had on Ms. B directly. After about a month, Ms. B was more invested in treatment, and although she still struggled with believing "all this," she did separate from her husband. Anna evidenced some improvements but was still experiencing significant fear and anxiety, particularly around men, she was still having difficulty sleeping and concentrating in school, and she still had frequent stomachaches when she thought about what happened. As these symptoms were impeding her treatment progress, the therapist made a referral to a psychiatrist for a medication assessment. Anna was started on fluoxetine, which, after titration to 30 mg/day significantly improved her sleep and anxiety symptoms. She continued to engage in trauma-focused CBT, and after approximately 6 months, Anna's symptoms substantially improved. Ms. B was able to acknowledge the sexual abuse by her husband and was contemplating filing for divorce. Anna was tapered off fluoxetine approximately 12 months after initiating medication, which she tolerated well.