Child Sexual Abuse Forensic Interview and Extended Forensic Evaluation - Sexual Abuse Medical Assessment - Expertise and Evaluation

1. Child Sexual Abuse
Introduction
The forensic aspect of the evaluation of a child with
concern for abuse is one part of the very broad
topic of child maltreatment. The forensic evalua-tion
and investigation of potential child sexual abuse
requires the cooperation of a diverse group of profes-sionals,
including medical providers with varying
levels of expertise and requirements for supervi-sion,
law enforcement, social service personnel, and a
variety of mental health professionals. Psychiatrists,
psychologists, and other mental health professionals
may evaluate children for forensic or legal purposes,
either in private practice or as part of an interdisci-plinary
team. Forensic evaluators may assist the court
in determining what happened to the child and make
recommendations regarding placement or treatment.
Forensic medical providers often play a critical role in
the legal setting if physical findings were interpreted
as being evidentiary, or conversely to educate profes-sionals
and the court as to why a child who indeed
was sexually abused may have a physical examina-tion
interpreted as “normal”. Evaluators may be asked
to assess the credibility of a child who allegedly
was sexually abused. In civil law suits, mental health
professionals may testify about the cause, nature, and
extent of the child’s psychological injuries.
Definitions
Sexual abuse of children refers to sexual behavior
between a child and an adult or between two children,
when one of them is significantly older or when
coercion is used. The perpetrator and the victim may
be of the same sex or of the opposite sex. Sexual
behaviors may include touching of breasts, buttocks,
and genitals, whether or not the perpetrator or victim
are undressed. They may also include exhibitionism,
fellatio, cunnilingus, and penetration of the vagina
or anus with sexual organs or objects. Sexual abuse
may involve behavior over an extended period of
time or it may be an isolated incident. Developmental
factors must be considered in assessing whether
sexual activities between two children are abusive or
normative. In addition to touching, sexual abuse also
refers to sexual exploitation of children, for instance,
engaging in prostitution of minors or activities related
to pornography depicting minors.
The Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR)
[1] addresses the classification of child maltreat-ment
in the chapter, “Other Conditions That May Be
a Focus of Clinical Attention”, and in the section,
“Problems Related to Abuse or Neglect”. There are
separate diagnoses for physical abuse of a child,
sexual abuse of a child, and neglect of a child.
Also, there are separate numerical codes depending
on whether the focus of attention is on the perpe-trator
of the abuse or on the victim of the abuse.
These conditions and problems are listed on Axis I
of the multiaxial assessment of DSM-IV-TR.
In federal law, child sexual abuse means the
employment, use, persuasion, inducement, entice-ment,
or coercion of any child to engage in, or
assist any other person to engage in, any sexually
explicit conduct (or simulation of such conduct for
the purpose of producing a visual depiction of such
conduct) or the rape (and in cases of caretaker or
intrafamilial relationships, statutory rape), molesta-tion,
prostitution, incest with children, or other form
of sexual exploitation of children. A variety of
legal definitions and guidelines regarding child sexual
abuse exists at the state level, so clinicians should be
aware of the terminology and criteria used in their
own locale.
Epidemiology
Each year the Children’s Bureau, an agency within
the Department of Health and Human Services,
collects data on child maltreatment and the results
are published in an annual document called Child
Maltreatment [2]. The agency estimates that during
Federal fiscal year 2010, 3.3 million referrals,
involving the possible maltreatment of approxi-mately
5.9 million children, were reported to child
protective services. Of the 1.8 million reports that
were screened in and investigated, about 25%
were considered substantiated or indicated, and
about 70% were considered unsubstantiated. The
substantiated or indicated cases were distributed as
follows: neglect, 78%; physical abuse, 18%; sexual
abuse, 9%; psychological abuse, 8%; and medical

2. 2 Child Sexual Abuse
neglect, 2%. The data were analyzed for patterns of
maltreatment by the sex and age of victims. Rates
of many types of maltreatment were similar for
male and female children, but the sexual abuse rate
for female children was higher than that for male
children. Examining the age distribution of victims,
the 0–1 age group had the highest victimization
rate, and the rate of victimization declined as the
age of the victims increased. For example, the
abuse rate for infants (age 0–1) was 16.5 per 1000,
while the rate for children (age 4–7) was 13.5 per
1000. The highest rate of sexual abuse, however,
has been reported in the young adolescent (age
12–15) group. Although developmental disability,
race, socio-economic status, and gender are factors
known to influence the disclosure of sexual abuse,
mandated reporting of suspected abuse, and the
determination of allegations [3], all these figures are
approximations because the actual amount of abuse is
unclear.
Perpetrators and Patterns of Child
Sexual Abuse
There is enormous diversity among those who
perpetrate child sexual abuse [4]. Perpetrators
come from diverse backgrounds in terms of age,
sex, mental capacity, and socio-economic status.
Family members are often perpetrators of sexual
abuse. Other times, the perpetrator may be a
person entrusted with the care and well-being of
a child, such as relatives and baby-sitters. Both
men and women are perpetrators of sexual abuse.
Sometimes sex offenders themselves are children or
adolescents – for example, older siblings abusing
younger siblings, or adolescents who sexually abuse
or assault peers. Finally, one must include individ-uals
with mental illness or developmental disabilities
who may be the “perpetrators” of child sexual abuse
without a clear understanding of appropriate sexual
behavior and boundaries. Perpetrators may commit
child sexual abuse only once in their life or they may
serially abuse scores or hundreds of children. Some
perpetrators may be attracted to children of a partic-ular
gender, age, and physical appearance; others may
prey on children at large in a rather indiscriminate
manner.
Intrafamilial Pattern of Abuse
Incest may be strictly defined as sexual relations
between close blood relatives, for example, between
a child and the father, uncle, or sibling. Alternatively,
incest may be defined more broadly to include sexual
interactions between a child and a stepparent or
stepsibling. Although father–daughter abuse is the
most common form of incest, it may also involve
father and son, mother and daughter, and mother and
son.
Intrafamilial sexual abuse – as well as other sexual
abuse that occurs over a period of time – frequently
evolves through five phases [5]:
Engagement Phase
The perpetrator induces the child into a special
relationship.
Sexual Interaction Phase
The sexual behaviors progress from less to more
intrusive forms of abuse.
Secrecy Phase
The perpetrator threatens the victim not to tell.
Disclosure Phase
The abuse is discovered accidentally (when another
person walks in the room and sees it) or as a result
of the child’s reporting it to a responsible adult, or
because the child is brought for medical attention and
an alert clinician asks the right questions.
Suppression Phase
Often, the child may retract statements of the disclo-sure
because of family pressure or because of the
child’s own mental processes. That is, the child may
perceive that violent or intrusive attention is synony-mous
with interest or affection.
Close Associate Pattern of Abuse
The perpetrator of sexual abuse may be a person who
is not a parent or relative, but is entrusted with the

3. Child Sexual Abuse 3
care and well-being of a child. This group of perpe-trators
may include family friends, neighbors, baby-sitters,
scout leaders, clergymen, and other religious
leaders. In this circumstance, the pedophilic perpe-trator
typically grooms the child over a period of time.
He or she gains the friendship of the child through
enjoyable activities and gifts, introduces sexual activ-ities
that may seem innocent and even pleasurable,
and progresses to more intrusive activities. This type
of sexual abuse has a pattern that is similar to the
five phases of intrafamilial sexual abuse.
School is another setting where the close associate
pattern of sexual abuse may take place, with the
perpetrators in this case being teachers, coaches,
counselors, or principals. Both boys and girls may
be victims. Although this type of abuse may take the
form of coerced sexual activities, often, especially
for adolescents, it may appear to be a consensual
relationship between an underage student and a
teacher or other staff. Of note, corporal punishment
by school personnel still occurs in some states and
localities. This form of punishment, which usually
consists of an adult hitting the child’s buttocks with
a wooden paddle, may be perceived as a sexual
assault by some children.
Stranger Sexual Abuse
Children may be abducted and sexually abused by
strangers, which often involves more violence than
abuse by a family member or close associate. A
perpetrator may observe a playground and identify
a child who is not closely supervised. In this way,
a pedophile may molest hundreds of children before
he is apprehended. For each child victim, this is
usually a single, isolated experience. A solo sex ring
is a form of child sexual abuse that involves one
adult perpetrator and multiple child victims, who
may know about each other’s sexual activities with
the perpetrator.
With the proliferation of computers and the
Internet, cyberspace has become a fertile ground for
pedophiles to perpetrate their crimes on children [6].
This may include pedophiles’ producing and trading
child pornography over the Internet; interacting
with minors through chat rooms, often with the
goal of luring them into sexual activities; and
outright trafficking of children for sexual purposes.
Child pornography presents a unique investigative
challenge in that sexual maturity ratings do not
universally correlate to actual age.
Clinical Features of Child Sexual Abuse
Victims
Sexually abused children manifest a variety of
emotional, behavioral, and somatic reactions [7, 8].
These psychological symptoms are neither specific
nor pathognomonic because the same symptoms may
occur without any history of abuse. The psycholog-ical
symptoms manifested by abused children can be
organized into clinical patterns. Although it may be
helpful to note whether a particular individual falls
into one of these patterns, that in itself is not diag-nostic
of sexual abuse.
Anxiety Symptoms
This includes fearfulness, phobias, insomnia, and
nightmares that directly portray the abuse, somatic
complaints, and posttraumatic stress disorder.
Dissociative Reactions and Hysterical Symptoms
The child may exhibit periods of amnesia,
daydreaming, trancelike states, hysterical seizures,
and symptoms of dissociative identity disorder.
Depression
This may be manifested by low self-esteem and
suicidal and self-mutilative behaviors.
Disturbances in Sexual Behaviors
Some sexual behaviors are particularly suggestive of
abuse, such as masturbating with an object, imitating
intercourse, and inserting objects into the vagina or
anus. In contrast to these overly sexualized behaviors,
the child may avoid sexual stimuli through phobias
and inhibitions.
Somatic Complaints
This includes enuresis, encopresis, anal, and vaginal
itching, anorexia, bulimia, obesity, headache, and
stomachache.

4. 4 Child Sexual Abuse
Approximately one-third of sexually abused chil-dren
have no apparent symptoms. On the other hand,
the following factors tend to be associated with more
severe symptoms in the victims of sexual abuse:
greater frequency and duration of abuse, sexual
abuse that involved force or penetration, and sexual
abuse perpetrated by the child’s father or stepfather.
Other factors associated with poorer prognosis are
the child’s perception of being less believed, family
dysfunction, and lack of maternal support. Of note,
multiple investigatory interviews appear to increase
symptoms.
Evaluation Process
A forensic evaluation emphasizes collecting accu-rate
and complete data to determine – as objectively
as possible – what may have happened to the child.
The data collected in a forensic evaluation must
be preserved in a reliable manner through audio
recording, video recording, or detailed notes. The
results of the forensic evaluation are organized into
a report and that will be used in the court and read
by attorneys, a judge, and others. From the psychi-atric
and psychological perspective, the interview is
usually the primary source of information and the
physical examination is secondary. In practice, chil-dren
who may have been sexually abused are inter-viewed
first and later given a physical examination
and other tests.
In addition to interviewing the child, the evalu-ator
obtains a history from the parents (separately,
in most cases) and other pertinent informants. In
many evaluation settings, such as Child Advocacy
Centers (CACs), only “non-offending” caretakers are
present for the evaluation process. In the evaluation of
suspected sexual abuse, the examiner should consider
the possibility that the parents or other informants
are not telling the truth. For example, the mother
may wish to avoid the discovery of father–daughter
incest by blaming the child’s genital injury on another
child or a stranger. In another scenario, the mother
may fabricate an allegation of incest when the child
had never been abused at all, for example, to gain
advantage in a child custody dispute. The first version
protects a father who is guilty; the second version
implicates a father who is innocent.
The evaluator should determine the following
aspects of the history [9]:
• how the concern for sexual abuse originally arose;
• what (if any) subsequent actions and/or
statements were made;
• the emotional tone of the first disclosure (e.g.,
whether it arose in the context of a high level of
suspicion of abuse);
• the sequence of previous examinations, the tech-niques
used, and what was reported;
• whether the previous interviews were conducted
in a protocol-based and objective manner or if
they were likely to have distorted the child’s
recollections.
If possible, review transcripts, audiotapes, and
videotapes of earlier interviews. Seek a history of
sexual overstimulation (lax attitudes toward nudity
and sexual activity in the home), prior abuse, or other
traumas. Consider other stressors that could account
for the child’s symptoms. The examiner should also
ask about exposure to other possible male and female
perpetrators.
A psychosocial history should be collected and
organized, which includes:
• symptoms and behavioral changes that may be
related to the reported abuse;
• confounding variables, such as psychiatric
disorder or cognitive impairment, that may need
to be considered;
• the family’s attitude toward discipline, sex, and
modesty;
• developmental history from birth through periods
of possible trauma to the present;
• family history, such as earlier abuse of the
parents, substance abuse by the parents, spouse
abuse, and psychiatric disorder in the parents;
• underlying motivation and possible psycho-pathology
of the adults involved.
Collateral information may be useful in verifying
allegations of sexual abuse, and thus the evalu-ator
should consider requesting pertinent information
from the following, after obtaining authorizations:
protective services, school personnel, other care-givers
(e.g., baby-sitters), other family members (e.g.,
siblings), medical providers, and police reports.

5. Child Sexual Abuse 5
The Child Interview
Several structured and semi-structured interview
protocols have been introduced that are designed to
maximize the amount of accurate information and
minimize mistaken or false information provided
by children. These approaches include the cognitive
interview, which encourages witnesses to search their
memories in various ways, such as recalling events
forward and then backward. The interview protocol
developed at the National Institute of Child Health
and Human Development (NICHD) includes a series
of phases and makes use of detailed interview
scripts [10]. The American Professional Society on
the Abuse of Children recently published revised
practice guidelines on “Forensic Interviewing in
Cases of Suspected Child Abuse” [11]. The stepwise
interview (outlined later) is a funnel approach that
starts with open-ended questions and, if necessary,
moves to more specific questions [12].
In interviewing children who may have been
abused, it should be possible to follow a standard
protocol and also be flexible, considerate, and gener-ally
supportive. As when seeing any patient, the eval-uator
must size up the situation and use techniques
that are likely to help the child become comfortable
and communicative. One child might need a favorite
object (e.g., a teddy bear or a toy truck); another
might need to have a particular person included in
the interview. Some children are comfortable talking;
others prefer to draw pictures. The child might make
important comments while chatting during the break
time instead of during the structured interview.
Interview Process
The interviewer of the allegedly sexually abused child
should remember the following principles [9]:
• audiotape or videotape the interview, if possible;
• use a minimum number of interviews (perhaps
two or three), as multiple interviews may
encourage confabulation;
• avoid repetitive questions, either/or questions, and
multiple questions, and try to avoid leading and
suggestive questions;
• use restatement, that is, repeat the child’s account
back to the child (which allows the interviewer to
see if the child is consistent and ensures that the
interviewer understands the child’s report);
• conduct the examination without the parent
present (if the child is very young, consider
having a family member in the room);
• if a camera or microphone is present, inform the
child that people responsible for making them
safe may be watching, but that no family member
is observing the interaction;
• use an examination technique that is appropriate
to the child’s age and developmental level, such
as drawings and play re-enactment;
• determine the child’s terms for body parts and
sexual acts; do not educate or provide new terms.
Interview Content
The interview should not take the form of an interro-gation.
Note the child’s affect while discussing these
topics and be tactful in helping the child manage
anxiety. Young children may not be able to report
all of the relevant information. The examiner should
explore the following:
• whether the child was told to report or not report
anything;
• who the alleged perpetrator was;
• what the alleged perpetrator did;
• where it happened;
• when it started and when it ended;
• number of times the abuse occurred;
• how the child was initially engaged and how the
abuse progressed over time;
• how the alleged perpetrator induced the child to
maintain secrecy;
• whether the child is aware of specific injuries or
physical symptoms associated with the abuse;
• whether any photography or videotaping took
place.
The Stepwise Interview
The usual clinical interview may need some modi-fication
for evaluating a child who may have been
abused. The stepwise interview [12], which is
primarily intended for forensic evaluations, consists
of the following components:
Build Rapport
Build rapport and informally observe the child’s
behavior, social skills, and cognitive abilities.

6. 6 Child Sexual Abuse
Ask the Child to Describe Two Specific Past Events
This step assesses the child’s memory and models the
form of the interview for the child. Ask nonleading,
open-ended questions in the pattern that will occur
through the rest of the interview.
Establish the Need to Tell the Truth
Reach an agreement with the child that in this inter-view
only the truth (not “pretend” or imagination)
will be discussed. Explain to the child that it is fine
not to know the answer to a question. It is fine to
correct the interviewer.
Introduce the Topic of Concern
Start with general questions such as “Do you know
why you are talking with me today?” Proceed, if
necessary, to more specific questions such as “Has
anything happened to you?” Drawings may help
initiate disclosure.
Elicit a Free Narrative
Once the topic of abuse has been introduced, the
interviewer encourages the child to describe each
event from the beginning without leaving out any
details. If abuse has occurred over a period of
time, the interviewer may ask for a description
of the general pattern and then ask for an account
of particular episodes.
Pose General Questions
The interviewer may ask general questions to elicit
further details. These questions should not be leading
and should be phrased in such a way that the child
realizes an inability to recall or the lack of knowledge
is acceptable.
Pose Specific Questions if Necessary
Asking specific questions in a careful way may yield
helpful clarification. For example, the interviewer
may follow-up on inconsistencies in a gentle,
nonthreatening manner. Avoid repetitive ques-tions
or appearing to reward particular answers in
any way.
Use Interview Aids if Necessary
Anatomical dolls may be useful in understanding
exactly what sort of abusive activity occurred. The
dolls are not used to diagnose child abuse, only to
clarify what happened.
Conclude the Interview
Toward the end of the interview, the interviewer may
ask a few leading questions about irrelevant issues
(e.g., “You came here by taxi, didn’t you?”). If the
child demonstrates susceptibility to the suggestions,
the interviewer must verify that the information
obtained earlier was not contaminated. Finally, the
child is thanked for participating in the interview.
However, the child should not be complimented or
rewarded, as that may communicate that the child
has given “the correct answer” to the interviewer.
Forensic Medical Evaluation
The overall goal of this process is to identify any
potential medical issues, reassure a child of wellness,
create a forum where a child can ask questions
about his or her body, and obtain evidence where
applicable. A child should be referred for a forensic
medical evaluation when there is any suspicion of
abuse, even sexual play that has been interpreted
as confusing or concerning to a child or caretaker.
Children with physical signs or symptoms of geni-tourinary
problems or history of pain, bleeding, or
possible trauma should be evaluated on an urgent
basis depending on available resources and the
potential need for forensic evidence collection and/or
prophylactic medication. Whenever possible, the
physical examination should be conducted by the
available provider with the highest level of expertise,
in a setting where the child feels safe and comfort-able.
At times, with non-urgent examinations, this
will mean a cursory, head-to-toe examination for a
child presenting to the emergency department, while
deferring the forensic evaluation to the child abuse
pediatrician.
The medical evaluation may consist of the
following components, depending on the clinical
situation:

7. Child Sexual Abuse 7
Intake
The purpose of the intake is to obtain the most
objective and comprehensive information available
for optimal medical diagnosis and treatment. The
provider should learn from the referring multi-disciplinary
professionals the nature of sexual abuse
disclosed, timing of last contact, and any potential
risk factors such as HIV status of the reported
perpetrator.
Medical Interview
The medical provider gathers pertinent medical
information from the child or caretaker (medications,
hospitalizations, allergies, review of systems, etc.).
Further, the medical interview often provides an
opportunity to clarify some intake information
directly from the caregiver.
Medical History with Child
It is imperative that the medical provider explain the
examination to the child and directly gather from the
child the information relevant to medical diagnosis
and treatment. This is an interaction distinct from the
forensic interview, focusing on medical symptoms
and sexual activity aside from the abuse issues at
hand and answering questions the child or adolescent
may have. As in the objective and protocol-based
forensic interview, questions should be open-ended.
In some states, statements made for the purpose of
medical diagnosis and treatment may be admissible
and testified to by medical providers.
General Physical Examination
A head-to-toe inspection of the child’s body is
conducted with a second medical professional chap-erone
(nurse, medical assistant) and the patient appro-priately
covered with a gown. Close inspection of all
skin and mucosal surfaces (e.g., behind the ears and
inside the mouth) should be part of any child abuse
assessment. The provider must keep in mind that the
examination is of a child – not just the genitals – and
be comprehensive in the approach.
Genitourinary and Anal Examination
Details on this component of the evaluation are
beyond the scope of this article. Succinctly, the child
or adolescent is placed in the supine frog-leg or
supine stirrup position depending on age. Using labial
separation (gentle separation of the labia majora) and
labial traction (gentle downward pulling of the labia),
the genital structures are visualized and documented
using photo or video colposcopy. A speculum exami-nation
is not appropriate in the evaluation of a child or
adolescent in the context of sexual abuse. In boys, the
penis, testes, and scrotum are evaluated also utilizing
colposcopic documentation. The anus should be eval-uated
in the lateral decubitus position, with gentle
traction to allow natural relaxation of the external
sphincter. If the examiner interprets the examination
as evidentiary, the child must be examined in the
prone knee–chest position and specialized techniques
used on the hymen (normal saline, Q-tip technique)
to confirm the finding.
Collection of Forensic Evidence
Although most general evidence collection protocols
recommend the collection of forensic evidence within
96 h of a sexual assault, in prepubertal children, it
is rare to find forensic evidence beyond 24 h [13].
Collection of clothing and linens for analysis is more
likely to result in positive findings. In all cases, weigh
the benefit of collecting specimens based on the
likelihood of a positive finding against the possible
discomfort of the victim. Factors affecting the like-lihood
of identifying forensic evidence include time
since the incident, bathing, age of the victim, and type
of contact.
Testing for Sexually Transmitted Disease
When a prepubertal child with a history of or suspi-cion
of sexual contact is seen within 96 h, there is
debate as to whether baseline testing for a sexu-ally
transmitted disease (STD) is necessary. Should
testing be conducted, follow these steps:
• cultures for Neisseria gonorrhea (oral, vaginal/
urethral, and rectal);
• cultures for Chlamydia trachomatis (vaginal/
urethral and rectal);

8. 8 Child Sexual Abuse
• test vaginal secretions for Trichomonas vagi-nalis
and Candida species with any history of
discharge;
• test for syphilis [rapid plasma reagin (RPR)] and
blood borne hepatitis B virus (HBV), and hepatitis
C virus (HCV);
• test for human immunodeficiency virus (HIV)
[enzyme-linked immuno sorbent assay (ELISA)];
• follow-up cultures one to 2 weeks after the initial
exposure are recommended. Follow-up testing
for syphilis, HIV, and HBV is recommended
4–6 weeks after the initial exposure. Testing for
syphilis, HIV, HBV, and HBC is recommended
at 3 months after the exposure. Testing for HIV
and HCV is recommended at 6 months after the
exposure.
Prophylactic Medication for Sexually Transmitted
Disease and Pregnancy
Because of the low prevalence of STDs in the prepu-bertal
victim of sexual abuse, prophylactic treatment
is not traditionally recommended; yet current practice
dictates making this decision with the utmost caution.
It is strongly recommended to discuss risks and bene-fits
with caretakers and factor in the age and risk of
reported perpetrator, presence of findings on exam
(bleeding/bruising present higher risk), and familial
wishes. Consideration of prophylaxis for HIV should
be considered and discussed with infectious disease
specialists and explained in detail to families.
Interpretation of Medical Evidence
The majority of children presenting for medical
evaluations of sexual abuse have examinations
free of signs of acute or chronic trauma [14].
There exists a wide range of normal variants in
the genitourinary assessment of children as well as
medical conditions, such as urethral prolapse, that
may be interpreted erroneously to be evidentiary
for abuse. The medical provider should interpret
any perceived medical findings with the utmost
caution, using evidence-based practice and peer
review and/or supervision, depending on the level of
expertise [15]. Further, some infections considered
“sexually transmitted”, such as Herpes, may have
nonsexual routes of transmission, which must be
considered.
For the recommendations of the American
Academy of Pediatrics regarding the evaluation of
sexual abuse in children, see reference [16]. For
more information on the components of the forensic
medical evaluation, see http://www.childabusemd.
com. For treatment guidelines of the Center for
Disease Control and Prevention (CDC) regarding
STDs, see http://www.cdc.gov/std/. For additional
information regarding the interpretation of genital
findings, see Guidelines for Medical Care of Chil-dren
Who May Have Been Sexually Abused [15],
a collaborative effort of leading child abuse pedi-atricians
using evidence-based research to develop
best practices. Moreover, that document stresses
the importance of oversight and peer review for
clinicians who provide assessments for suspected
child sexual abuse.
Determining the Validity of a Case of
Sexual Abuse
The psychiatric evaluation of youngsters who may
have been sexually abused involves assessing the
child’s credibility. Although generally children tell
the truth when they talk about abuse, sometimes
children make false denials (saying they were not
abused, when actually they were) or false allegations
(saying they were abused, when actually they were
not) [17].
Possible Explanations of Denials of Abuse
A false denial or retraction may occur for several
reasons. The child may have been pressured by the
perpetrator or family members to recant the allega-tion.
The pressure may consist of bribery, mockery,
or threats of injury. The child may be protecting a
parent or other family member, even without external
coercion. The child might be frightened or distressed
by the investigation and decide to withdraw partic-ipation.
For instance, an interviewer could induce a
false denial by asking overly challenging questions.
A child may be inhibited by shame or guilt; the
child may mistakenly assume responsibility for what
happened. Finally, the child may have “accommo-dated”
to the abuse, consciously or unconsciously,
instead of objecting to it.

9. Child Sexual Abuse 9
Possible Explanations of Allegations of Abuse
A false allegation of abuse may also occur for several
reasons [18]. For example, sometimes a false allega-tion
arises in the mind of a parent or another adult
and is imposed on the child, and this may happen
in several ways. The parent may have misinterpreted
an innocent remark, a neutral piece of behavior, or
a benign physical condition as evidence of abuse
and induced the child to endorse this interpretation.
The parent and child may share a folie `a deux or
the child may simply give in and agree with a delu-sional
parent. A parent may have fabricated the story
and induced the child to collude in presenting it to
the authorities. Also, previous interviewers may have
asked leading or suggestive questions. An interviewer
who believes abuse occurred may unwittingly shape
a child’s responses until the child validates the inter-viewer’s
assumptions.
A false allegation of abuse may also occur through
unconscious or nonpurposeful mental mechanisms in
the child. For example, a young child may confuse
fantasy with reality. Although rare, older children and
adolescents may experience delusions about sexual
activities in the context of a psychotic illness. False
allegations occur through the mental mechanisms
of misinterpretation (when the child misunderstood
what happened and later reported it inaccurately) and
miscommunication (when the child misunderstood an
adult’s question and the adult may later misinterpret
or take the child’s statement out of context). Also,
through the process of confabulation, the child may
fill gaps in his memory with whatever information
makes sense to him at the time.
A false allegation of abuse may occur through
conscious or purposeful mental mechanisms in
the child, such as lying. Some children engage in
pseudologia or pathological lying, the enthusiastic
proliferation of falsehoods that may have no obvious
motivation. Through the mechanism of innocent
lying, younger children may make false statements
without appreciating their serious implications
because that seems to be the best way to handle
the situation they are in. Through deliberate lying,
children may choose to avoid or distort the truth for
some personal advantage. This happens more with
older children and adolescents.
Finally, through the mechanism of perpetrator
substitution, the child may have actually been sexu-ally
abused and exhibits symptoms consistent with
abuse but identifies the wrong person as the perpe-trator,
resulting in a false allegation. The child may
do this to protect the actual offender or the child may
displace the memories and accompanying affects onto
another individual.
Prognosis after Child Sexual Abuse
Neurobiological Consequences of Child Sexual
Abuse
Both severe physical abuse and repeated sexual abuse
may cause changes in the child’s developing brain
that persist into adulthood [19–21]. Adult survivors
of abuse are more likely to have abnormalities of their
electroencephalograms (EEGs), which indicate limbic
irritability. They are more likely to have a variety of
changes in the structure of the brain as visualized
by magnetic resonance imaging (MRI), including
decreased volumes of the anterior cingular cortex,
cerebellum, hippocampus, and amygdala. Decreases
in the midsagittal area of the corpus callosum have
been found in both children and adults with trauma
histories. These neurobiological effects of persistent
child maltreatment probably mediate the behavioral
and psychological symptoms that follow abuse, such
as increased aggressiveness, heightened autonomic
arousal, depression, and memory problems.
Psychosocial Sequellae of Child Sexual Abuse
In a forensic context, psychiatrists and psychologists
are sometimes asked to predict or estimate the prog-nosis
of a child who has been sexually abused. In
conducting such an assessment, the evaluator should
rely as much as possible on research, not one’s
personal opinion or speculation [22, 23]. Children
who have been sexually abused are more likely as
adults to have problems with anxiety, depression,
suicidality, substance abuse, and chronic medical
problems compared with children who were not sexu-ally
abused [24–26]. These long-term effects of
sexual abuse are not inevitable, however. The psycho-logical
effects of sexual abuse and other traumas may
be affected by the child’s genetic makeup as well as
by the amount and nature of support from the nonabu-sive
persons in the child’s life [27].
Chronic severe abuse can lead to a syndrome
known as complex posttraumatic stress disorder

10. 10 Child Sexual Abuse
(PTSD) or disorder of extreme stress not other-wise
specified (DESNOS). That disorder, which
was proposed for inclusion in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) is characterized by alterations in the
following: ability to modulate emotions; identity and
sense of self; ongoing consciousness and memory;
relations with the perpetrator and others; physical
and medical status; and systems of meaning. The
core of this disorder is a breakdown in the ability to
regulate internal states.
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11. Child Sexual Abuse 11
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