MANDATORY REPORTING OF CHILD SEXUAL ABUSE and OTHER ROLES FOR PSYCHOLOGISTS IN CSA CASES

1. MANDATORY REPORTING OF CHILD SEXUAL ABUSEand OTHER ROLES FOR PSYCHOLOGISTS IN CSA CASES L. Dennison Reed, Psy.D.

2. CAVEAT Although this presentation focuses on mandated reporting of child sexual abuse, reporting responsibilities also apply to other forms of child maltreatment, e.g., physical abuse, psychological abuse, medical neglect, etc.

3. The Prevalence of Child Sexual Abuse in the United States

4. The most methodologically sophisticated prevalence studies (using multiple screen questions and random samples) have found that at least: 20%of women report being sexually abused during childhood 5-10% of men report being sexually abuse during childhood (Finkelhor, 1994)

5. Prevalence of a CSA History in Clinical Populations 36-51%Inpatient and outpatient samples (across studies) 70%Randomly selected non-psychotic psychiatric Emergency Room patients(Briere & Zaidi, 1989)

6. Given the ubiquity of child sexual abuse, any psychologist who provides services to children or adults will almost certainly encounter clients who have suffered such abuse

7. Who is responsible for reporting child maltreatment? • Pursuant to Florida Statute 39.201(1)(a): “Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected. . . shall report such knowledge or suspicion to the department” [i.e., DCF’s central abuse hotline]

8. “Professionally Mandatory Reporters” “Although every person has a responsibility to report suspected abuse or neglect, some occupations [including mental health professionals] are specified in Florida law as required to do so. These occupations are considered ‘professionally mandatory reporters.’” Reporting Abuse of Children and Vulnerable Adults (2007). DCF. (Available on FPA’s web site)

9. Psychologists are required by law to notify the central abuse hotline when they: “know” or have a “reasonable cause to suspect” that a child has been abused/neglected Rarely would a psychologist “know” for a fact that a child was sexually abused, absent some highly reliable form of corroboration (e.g., the psychologist personally witnessing the abuse)

10. What distinguishes a “reasonable” suspicion from just ‘any’ suspicion? “. . . standards for reporting ‘reasonable’ suspicions imply a degree of discretion and evaluation. It is within a practitioner’s professional role to follow up suspicions with questions and queries in the context of evaluation or treatment.” Foreman & Bernet (2000)

11. What constitutes a "reasonable cause to suspect” ?? Vague legal thresholds for reporting child maltreatment create confusion . . .

12. Poor training of mandated reporters adds to the confusion . . . and frustration! .

13. “Mandated but not educated” Although every state in the country requires mandated reporters to reportknown or “reasonably suspected” child sexual abuse (and other maltreatment), only a few states require mandated reporters to complete any training at allwith regard to screening for child sexual abuse

14. Mental health professionals rarelyreceive adequate training with regard to screening for child sexual abuse As early as 1989, APA’s Ad Hoc Committee on Child Abuse Policy recommended that state licensing boards consider requiring a child abuse knowledge base for purposes of licensure, and recommended that the APA require course work or training experiences in child abuse for graduate program accreditation (L.E. Walker et al, 1989, p. 11). Yet, to this day, few licensing boards (including Florida’s) require such training. And APA-accredited graduate programs still do not require any coursework/training relating specifically to screening for child sexual abuse

15. Attempting to determine whether there exists a “reasonable cause to suspect” CSA can also be quite challenging

16. There are no empirically validated symptoms that are diagnostic of CSA • Symptoms vary widely among sexually abused children—who range from ‘asymptomatic’ (approx. one-third) to highly symptomatic • No symptoms are unique to sexually abused children, and the same symptoms observed in sexually abused children overlap with symptoms observed in non-sexually abused children Kendall-Tackett et al (1993)

17. Perpetrators of CSA rarely confess their clandestine abusive activities to psychologists or to anyone else who would be likely to report them to the authorities But, can psychological testing reliably identify child molesters who are denying their guilt?

18. “It is important to emphasize that there is no psychological test, method or technique that validly determines whether a person has or will engage in deviant sexual behavior”(Myers, 2005) Sex offender profiles are indistinguishable from profiles of non-offenders Sex offenders comprise a very heterogeneous group psychologically, ranging from “within normal limits” to blatantly psychotic on psychological testing; no single profile represents even the ‘majority’ of sex offenders

19. Medical Evidence in CSA Cases • In most cases of suspected child sexual abuse, medical evidence is not helpful in determining whether or not CSA occurred.

20. A normal physical exam is common among sexually abused children • Across studies, 50% of children who gave clear histories of sexual abuse had “normal” examinations. • Most of the “abnormal” findings in the remaining 50% were non-specific findings, which are notdiagnosticof sexual abuse.

21. Medical Findings Diagnosticof Child Sexual Abuse (or sexual contact) • “Diagnostic” medical findings include such things as: • Certain types of acute or healed genital or anal trauma • Certain STDs, e.g., gonorrhea, syphilis • Sperm taken from child’s body • Pregnancy

22. Diagnostic Medical Evidence of child sexual abuse is surprisingly rare • Recent studies have shown that 85-95%of children who have given clear histories of being sexually abused have NO medical findings of acute or healed trauma . Therefore, only 5% to 15% of such children DO have such medical findings. • Even penile penetration of the anus or hymen may not result in findings of injury Adams, J. (2005); Bays, J. & Chadwick, D. (1993)

23. Reasons for the absence of evidence of acute or healed genital/anal trauma among sexually abused children • Many forms of sexual activity do not result in physical trauma, e.g., fondling, oral sex, acts performed on the perp., “simulated intercourse” • The elasticity & structure of the hymen & anal sphincter permit penetration without trauma (especially when lubricants are used) • Even when there is trauma, healing occurs quickly in children, often between 24 hours and one week, and delays in obtaining medical exams are common among victims

24. Are Children’s Reports about Being Penetrated Accurate? • Not necessarily. Many children have a limited understanding of penetration. Children who were not penetrated sometimes report that something was put “in” them because it “felt” that way, e.g., they felt pressure against the vaginal introitus or the anus or some pain • Also, children and adults use the word “in” to refer to painful experiences-even those that do not involve penetration. “He punched me in the stomach.” • This sometimes explains why there is no medical evidence of penetration when a child appears to be alleging that penetration occurred.

25. Buyer Beware:Not all Medical Exams for CSA are competently performed • In a 1987 study involving 129 pediatricians and family practitioners, only 59% were able to correctly identify the hymen when shown a magnified photograph of a 6-year-old girl’s genitalia • In a 2008 study, overall less than half of a sample of Medical School Faculty and Residents in pediatrics, OB/GYN, and Family Medicine were able to correctly identify either normal features of female pre-pubertal genital anatomy or anatomic variants of normal. (Muram & Simmons,2008)

26. Child Protection Team Physicians & Nurse Practitioners are generally very competent at conducting medical examinations for Child Sexual Abuse • They usually have extensive training and experience in examining for CSA, documenting such examinations and testifying in CSA cases • Child Protection Teams also have state-of-the art equipment, e.g., colposcopes, digital cameras, rape kits

27. Although the statements of suspected child/victims are most often the dispositive factor in CSA cases, research suggests that evaluators’ judgments about the validity of such statements are often erroneous-especially in the direction of judging false statements as true • Hershkowitz et al. (2007) found that when 42 highly trained Israeli ‘youth investigators’ rated transcribed statements of high quality (NICHD) interviews as ‘likely false,’ they were correct 100% of the time. But when they judged statements ‘likely true,’ they were correct only 67% of the time [33% error rate]

28. Research has found that children’s accurate reports of events they personally experienced are sometimes indistinguishable from false reports produced by suggestive interviewing “Subjective ratings of children’s reports after suggestive interviewing reveal that . . . trained professionals in the fields of child development, mental health, and forensics . . . cannot reliably discriminate between children whose reports are accurate from those whose reports are inaccurate as a result of suggestive interviewing techniques . . . . The children who provided false reports spoke sincerely and provided accounts laden with emotion and perceptual details” (Ceci et al., 2007)

29. Fortunately, mandated reporters need not ‘know’ or be ‘convinced’ that a child was sexually abused before making an abuse report • If the mandated reporter has “a reasonable cause to suspect” CSA, the reporting threshold has been met and an abuse report must be made.

30. What kinds of ‘reasonably suspected’ CSA cases must be reported, and in what manner?

31. Abuse perpetrated by Caregivers FS 39.201(1)(a) mandates the reporting of known/suspected abuse perpetrated by “caregivers” only: “Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare . . . shall report such knowledge or suspicion to the department”

32. What if the suspected perpetrator is not a caregiver? • Florida Statute 39.201 (1)(a) does not mandate the reporting of known/suspected child sexual abuse perpetrated by non-caregivers. And when such reports are received by the Abuse Hotline, the reporter is transferred to the appropriate law enforcement agency. • Conflicts about reporting non-caregiver cases arise when reporting such cases entails breeching confidentiality, e.g., when the parents of a minor child do not want the abuse by a non-caregiver reported to the authorities

33. Reporting Suspected CSA perpetrated by Non-caregivers Woody (2006) suggests that, even though the reporting of suspected abuse by a non-caregiver is not legally mandated, “The report of child abuse should still be made. . .” (p. 5). Woody reasons that professional ethics and public policy potentially support that a psychologist should want to protect vulnerable children; therefore, taking reasonable steps to protect a vulnerable child are seemingly logical. And when the central abuse hotline transfers the psychologist to law enforcement or otherwise encourages a report to law enforcement, it would seem that the psychologist is likely shielded to some degree from liability, e.g., malicious prosecution (2009). Others caution that, when reporting suspected abuse by a non-caregiver involves breeching confidentiality, an abuse report should not be made.

34. Suspected CSA by Non-caregivers when Confidentiality is at Issue: To Report or Not to Report? • Psychologist face a dilemma when trying to decide whether or not to report suspected CSA perpetrated by non-caregivers when doing so would involve breeching confidentiality. • Optimally, these cases should be reviewed on a case-by-case basis. And psychologists would be wise to seek advice from knowledgeable colleagues and/or attorneys in such cases.

35. What manner of reporting can be used for making a report to the central abuse hotline? • Reports can submitted via phone, fax or via the web 24 hours a day, 7 days a week • Phone: 1-800-96-ABUSE (1-800-962-2873) • Fax: 1-800-914-0004 • Web reporting: http://www.state.fl.us/cf_web

36. Are psychologists who make “anonymous” child abuse reports acting in compliance withFlorida law? • NO. • “A professionally mandatory reporter of child abuse is required by Florida Statute to provide his or her name to the Abuse Hotline Counselor when reporting.” • Reporting Abuse of Children and Vulnerable Adults (2007) DCF

37. Qualified Confidentiality for Reporters F.S.39.202(5): “The name of any person reporting child abuse, abandonment, or neglect may not be released to any person other than employees of the department responsible for child protective services, the central abuse hotline, law enforcement, the child protection team, or the appropriate state attorney, without the written consent of the person reporting. This does not prohibit the subpoenaing of a person reporting child abuse, abandonment, or neglect when deemed necessary by the court, the state attorney, or the department, provided the fact that [the identity of] such person [that] made the report is not disclosed.”

38. How soon must a report of known or suspected CSA be made? • Pursuant to Chap. 39, Florida Statutes:A report to the abuse hotline is to be made “immediately” upon determining that the reporting threshold has been met (i.e., as soon as the reporter ‘knows’ or ‘reasonably suspects’ that a child has been abused)

39. Who is considered to be a “child” for reporting purposes? • Florida Statute 39.01(12) defines a “child” or “youth” as: any unmarried person under the age of 18 who has not been emancipated by order of the court”

40. Is “child-on-child” sexual abuse reportable? • YES. Pursuant to FL§39.201(2)(f):“Reports involving a known or suspected juvenile sexual offenderora child who has exhibited inappropriate sexual behavior shall be made and received by the department” • However, ‘inappropriate’ is subjective; and sexual ‘abuse’ by a minor should be distinguished from developmentally normal sexual activity, e.g., ‘playing doctor,’ consensual sexual activity between teenagers

41. Empirical data is now available regarding sexually abused and non-sexually-abused children’s sexual behaviors • Child Sexual Behavior Inventory (Friedrich, 1992) • Available through: Psychological Assessment Resources, Inc.PO Box 998Odessa, FL 33556 Ph. (800) 331-TEST

42. Description of the CSBI • The CSBI was developed to help distinguish between normal and abnormal sexual behaviors in children ages 2 to 12 years old. • The CSBI consists of 38 items relating to a broad range of affectional and sexual behaviors. Normative and clinical data was derived from reports of mothers/primary caregivers of children who were either believed to have been sexually abused or not abused

43. EXAMPLES OF DEVELOPMENTALLY ABNORMALSEXUAL BEHAVIORS IN CHILDREN AGES 2 -12

44. The following behaviors were observed in less than 2% of the non-sexually-abused sample of 2-12 year-olds (n = 1114): • Puts mouth on another child’s or adult’s sex parts [Only two children in the sample of 1,114] • Tries to have sexual intercourse with another child or adult • Asks others to engage in sex acts • Tries to French kiss others • Puts objects in vagina or rectum • Touches animals’ sex parts • Pretends toys are having sex

45. The presence or absence of developmentally ‘abnormal’ sexual behaviors alone is not sufficient for determining whether abuse occurred • Only about 1/3 of sexually abused children display abnormal sexual behaviors • Factors other than sexual abuse can account for abnormal sexual behaviors seen in non-sexuallyabused children (e.g., vicarious exposure to others engaging in sex) • In any case, further inquiry regarding the source of the behavior is generally warranted • Again, “inappropriate” sexual behavior must be reported if reasonably suspected

46. Certain Home Environments Lead to Increased Sexual Behavior in Non-Sexually-Abused Children • Observing parents or others engaging in intercourse/oral sex (strongest predictor of sexually intrusive behaviors, e.g., engaging in intercourse/oral sex with other children) • Observing parents or other adults naked • Bathing and sleeping with parents • Viewing adults having sex online or in other media (TV, magazines, videos) • Exposure to domestic violence (increased self-soothing behaviors such as masturbation)

47. EVIDENCE OF CSA THAT IS LIKELY TO FALL ABOVE OR BELOW THE REPORTING THRESHOLD

48. Evidence of child sexual abuse that is generally above the reporting threshold Unambiguous allegations of abuse made to the mandated reporter by the child (suspected victim) or by a perpetrator of CSA Ambiguous allegations by a very young child should be explored further (e.g., “Daddy touched my pee-pee” could refer to innocuous hygiene or medical practices)

49. Evidence of child sexual abuse that is generally above the reporting threshold • When a parent/caregiver tells a mandated reporter that their child made a non-ambiguous allegation of probable sexual abuse to the parent, this typically warrants an abuse report • For example: A 4-year-old boy spontaneously says, “Mommy, when Uncle Johnny babysits me, he likes to suck on my pee-pee; and he put his pee-pee in my mouth, too”

50. Third-party Allegations to Mandated Reporters (e.g., by the child’s parent) Take such reports seriously and assess the possibility of abuse within the scope of your normal professional role. If, after competently assessing for abuse, you do not suspect abuse, a discussion with the third party may resolve the situation (i.e., third party no longer suspicious; third party makes a report).