ChrldAburr & N&W. Vol. IS, PD. 593-595. Printed in the U.S.A. All rights reserved.
0145-2134/91 $3.00+ .M) 0 1991 Pergamon Press pit
1991 Copynght
BRIEF
COMMUNICATION
CHILD SEXUAL ABUSE RESEARCfi: A METHODOLOGICAL QUAGMIRE HARRIET L. DEMPSTER Principal
Officer (Child Protection),
Tayside
Regional
Council,
Dundee,
UK
JACQUIE ROBERTS Project
Head,
Polepark
Family
Counselling
Centre,
Tayside
Region,
Dundee,
UK
INTRODUCTION FINDING WAYS TO OFFER therapeutic help to sexually abused children is one of the significant challenges facing the helping professions today. Accordingly, evaluating the effectiveness of such treatment programs must have a place high on the research agenda. To date, however, there have been few attempts to apply a scientific approach to the outcome of therapy. There has been an over-reliance on descriptive accounts (Bentovim, Elton, Hildebrand, Tranter, & Vizard, 1988; Giarretto, 1979; Will, 1983). In an attempt to carry out systematic research and fill some gaps in the literature and with the ultimate aim of improving services to sexually abused children, we embarked on a research project to evaluate the effectiveness of one particular therapeutic service offered to sexually abused children. The purpose of this brief communication is to describe some of the issues that have arisen in an attempt to apply more scientific rigor to child sexual abuse research. Review of the Literature In a recent and extensive review of the literature for the Department of Health and Social Security, the paucity of experimental studies in this area was noted (Gough, Taylor, & Boddy, 1988). Haugaard and Repucci (1988, p. 387) also comment that the literature is replete with assumptions masquerading as facts. Finkelhor (1986) has given consideration to improving the quality of child sexual abuse research. He suggests specifically that sexually abused children in treatment could be compared with another group of nonabused children in treatment. He recognizes that the recruitment of such a comparison group might lead to an underestimation of the pathology associated with child sexual abuse.
Research
sponsored
Received
for publication
Requests for reprints Council, 28 Crichton
by the Child and Family December
Trust, Glasgow,
14, 1989; final revision
should be sent to Harriet Dempster, Street, Dundee, DDl 3RN, UK. 593
Scotland. received July 23, 1990; accepted Principal
July 24, 1990.
Officer (Child Protection),
Tayside
Regional
594
Harriet L. Dempster and Jacquie Roberts
There have been studies which have compared sexually abused children with a nonabused comparison group. However, they have been confined to samples of psychiatric in-patients (Deblinger, McLeer, Atkins, Ralphe, & Roa, 1989; Kolko, Moser, & Weldy, 1988). These studies were limited by recruiting from very “special” populations of children. In addition, Deblinger’s study placed reliance on a retrospective review of medical records not only to assign group status, that is, whether abusedj’nonabused, but also to evaluate behavioral symptoms.
METHOD We chose to study the service offered by a specialist team in the Department of Child Psychiatry located within Dundee Royal Infirmary. Since 1983, the team has taken referrals and offered help to sexually abused children and their families throughout Tayside Region in Scotland. The study employed an expe~mental design and used a variety of standardized measures of health, self-esteem, and behavior. It planned to follow up the progress of a group of sexually abused children compared with another group matched for sex and age who had been referred to the child psychiatry clinic for other reasons. We were interested in examining whether there was any difference between the two groups in relation to the standardized measures and whether as a result of treatment at the clinic there was any improvement. The definition of child sexual abuse employed was in line with the Operational Instructions for Social Work Staff of Tayside Regional Council ( 1988): Any child below the age ofconsent (16 years) may be deemed to have been sexually abused when any person by design or neglect involves the child in any activity intended to lead to sexual arousal and gratification of that other person. This definition holds whether or not there has been genital contact and whether or not the child initiated the behaviour.
We have a pool of an excess of 450 referrals to child psychiatry every year and therefore did not envisage any difficulty recruiting a comparison sample for this research. Despite the fact that the rate of referrals of sexually abused children had risen dramatically since the service had been set up in 1983, they still represented only about one-tenth of the total number of referrals to the clinic.
RESULTS During the initial period of the research (August 1988-August 1989), a total of 4 1 sexually abused children and young people were referred to the clinic. Of these, 23 were offered a therapeutic service and agreed to take part in the research. For a variety of reasons 18 children were lost to the research: 5 did not want to take part; 2 were referred for assessment only; and 11 from 8 families failed to show up for appointments. This represented a final response rate of 56%. In the study sample there were 20 girls and 3 boys whose ages ranged from 5- 17 years. During the same research period the researcher identified 35 children matched for sex and age, who were referred to the clinic for reasons other than sexual abuse. Of these, 12 cases were not recruited because they were not offered any ongoing treatment or they failed to show up for appointments. Two families did not agree to take part in the research. Three children had to be excluded from the comparison group because they were found to be victims of sexual abuse. The researcher was then able to recruit 18 children to the matched group. However, on
Sexual abuse research
595
closer scrutiny, a real question arose as to whether this group of children could be viewed as a comparison group. Two of the girls had experienced incidents of sexual abuse, which they disclosed during therapy. In a further six cases the therapist had definite concerns that sexual abuse might be at the root of the child’s problems even though there had been no disclosure. In summa~, for a signi~~nt propo~ion (1 l/35) of the matched compa~son group, sexual abuse could not be ruled out as a problem.
DISCUSSION The risk of false negatives among the comparison group raises serious methodological problems which we suspect are not exclusive to our study. Reviewing the study conducted by Kolko et al. (1988), we note that a signi~cant pro~~on (22 of the 103 children) had experienced both sexual and physical abuse. It would seem that this degree of overlap confuses the picture. Gale and colleagues (1988) studied sexually abused, physically abused, and nonabused children referred to a child and family community mental health clinic. They acknowledged that “it is possible that the (nonabused) group contains cases of unreported abuse.” The results are therefore about the difference between identified cases of sexual abuse and the other children. The differences are not necessarily the consequence of the sexual abuse itself. Can such studies, including our own, really claim to evaluate behavioral and emotional indicators of sexual abuse by the use of controlled comparison groups? Our findings are relevant to clinicians as they highlight the widespread prevalence of sexual abuse, and underscore the key role psychiatry plays in diagnosis. The research also raises the question of whether the possibility of sexual abuse should be routinely considered when the children are referred to the psychiatric service. Keeping an open mind to the possibility of sexual abuse of children who have not disclosed may be controversial, but we believe that the recognition of sexual abuse as an important child health issue is necessary if child psychiatry services are going to offer sensitive and effective help to disturbed and troubled children. Kolko et al. ( 1988) advocate that perhaps a routine evaluation of all forms of abuse should be part of the child psychiatry service offered to all children who come for help. We support this suggestion, as we believe it might result in getting more appropriate and timely help to children.
REFERENCES Bentovim, A., Elton, A., Hildebrand, J., Tranter, M., & Vizard, E. (1988). Sexua~ubuse in the~rni~~~ Asse.Tsme~tand treatment. Bristol: John Wright. Deblinger, E., McLeer, S., Atkins, M., Ralphe, D., & Roa, E. (1989). Post-traumatic stress in sexually abused, nhvsicahv abused. and nonabused children. Child Abuse & Neglect, 1X3). 403-408. Finkelhor, b. (1986). A sourcebook on child sexual abuse. Beverly Hills: Sage. Gale, J., Thompson, R. J., Moran, T., & Sach, W. H. (1988). Sexual abuse in young children: Its clinical presentation and characteristic patterns. Child Abuse & Neglect, 12, 163- 170. Giarretto, H. (1979). Humanistic treatment of father/daughter incest. In Sexual abuse ofchildren: Selected readings. Washington, DC US Department of Health and Human Services. Gough, D., Taylor, J., & Boddy, F. (1988). Child abuse ~nte~entjons:A review oftjterature. (Report to DHSS): Social Paediatrie and Obstetric Research Unit, University of Glasgow. Hauaaard. J.. & Reaucci. N. ( 1988). The sexual abuse ofchiidren: A ComBrehensive aide to know/edge and interventi& strategies. San Francisco: Jossey Bass. Kolko. D.. Moser. J.. & Weldv, S. (1988). Behavioral and emotional indicators of sexual abuse in child osvchiatric in-patients: A controlled comparison with physical abuse. Child Abuse cf. Neglect, 12(4), 529-541. __ Tayside Regional Council. (1988).Protecting children from abuse and neglect: Operational instructions for social work staff: Dundee: Author. Will, D. (1983). Approaching the incestuous and sexually abusive family. Journal of Adolescence, 6, 229-246.
0145-2134/91 $3.00+ .M) 0 1991 Pergamon Press pit
1991 Copynght
BRIEF
COMMUNICATION
CHILD SEXUAL ABUSE RESEARCfi: A METHODOLOGICAL QUAGMIRE HARRIET L. DEMPSTER Principal
Officer (Child Protection),
Tayside
Regional
Council,
Dundee,
UK
JACQUIE ROBERTS Project
Head,
Polepark
Family
Counselling
Centre,
Tayside
Region,
Dundee,
UK
INTRODUCTION FINDING WAYS TO OFFER therapeutic help to sexually abused children is one of the significant challenges facing the helping professions today. Accordingly, evaluating the effectiveness of such treatment programs must have a place high on the research agenda. To date, however, there have been few attempts to apply a scientific approach to the outcome of therapy. There has been an over-reliance on descriptive accounts (Bentovim, Elton, Hildebrand, Tranter, & Vizard, 1988; Giarretto, 1979; Will, 1983). In an attempt to carry out systematic research and fill some gaps in the literature and with the ultimate aim of improving services to sexually abused children, we embarked on a research project to evaluate the effectiveness of one particular therapeutic service offered to sexually abused children. The purpose of this brief communication is to describe some of the issues that have arisen in an attempt to apply more scientific rigor to child sexual abuse research. Review of the Literature In a recent and extensive review of the literature for the Department of Health and Social Security, the paucity of experimental studies in this area was noted (Gough, Taylor, & Boddy, 1988). Haugaard and Repucci (1988, p. 387) also comment that the literature is replete with assumptions masquerading as facts. Finkelhor (1986) has given consideration to improving the quality of child sexual abuse research. He suggests specifically that sexually abused children in treatment could be compared with another group of nonabused children in treatment. He recognizes that the recruitment of such a comparison group might lead to an underestimation of the pathology associated with child sexual abuse.
Research
sponsored
Received
for publication
Requests for reprints Council, 28 Crichton
by the Child and Family December
Trust, Glasgow,
14, 1989; final revision
should be sent to Harriet Dempster, Street, Dundee, DDl 3RN, UK. 593
Scotland. received July 23, 1990; accepted Principal
July 24, 1990.
Officer (Child Protection),
Tayside
Regional
594
Harriet L. Dempster and Jacquie Roberts
There have been studies which have compared sexually abused children with a nonabused comparison group. However, they have been confined to samples of psychiatric in-patients (Deblinger, McLeer, Atkins, Ralphe, & Roa, 1989; Kolko, Moser, & Weldy, 1988). These studies were limited by recruiting from very “special” populations of children. In addition, Deblinger’s study placed reliance on a retrospective review of medical records not only to assign group status, that is, whether abusedj’nonabused, but also to evaluate behavioral symptoms.
METHOD We chose to study the service offered by a specialist team in the Department of Child Psychiatry located within Dundee Royal Infirmary. Since 1983, the team has taken referrals and offered help to sexually abused children and their families throughout Tayside Region in Scotland. The study employed an expe~mental design and used a variety of standardized measures of health, self-esteem, and behavior. It planned to follow up the progress of a group of sexually abused children compared with another group matched for sex and age who had been referred to the child psychiatry clinic for other reasons. We were interested in examining whether there was any difference between the two groups in relation to the standardized measures and whether as a result of treatment at the clinic there was any improvement. The definition of child sexual abuse employed was in line with the Operational Instructions for Social Work Staff of Tayside Regional Council ( 1988): Any child below the age ofconsent (16 years) may be deemed to have been sexually abused when any person by design or neglect involves the child in any activity intended to lead to sexual arousal and gratification of that other person. This definition holds whether or not there has been genital contact and whether or not the child initiated the behaviour.
We have a pool of an excess of 450 referrals to child psychiatry every year and therefore did not envisage any difficulty recruiting a comparison sample for this research. Despite the fact that the rate of referrals of sexually abused children had risen dramatically since the service had been set up in 1983, they still represented only about one-tenth of the total number of referrals to the clinic.
RESULTS During the initial period of the research (August 1988-August 1989), a total of 4 1 sexually abused children and young people were referred to the clinic. Of these, 23 were offered a therapeutic service and agreed to take part in the research. For a variety of reasons 18 children were lost to the research: 5 did not want to take part; 2 were referred for assessment only; and 11 from 8 families failed to show up for appointments. This represented a final response rate of 56%. In the study sample there were 20 girls and 3 boys whose ages ranged from 5- 17 years. During the same research period the researcher identified 35 children matched for sex and age, who were referred to the clinic for reasons other than sexual abuse. Of these, 12 cases were not recruited because they were not offered any ongoing treatment or they failed to show up for appointments. Two families did not agree to take part in the research. Three children had to be excluded from the comparison group because they were found to be victims of sexual abuse. The researcher was then able to recruit 18 children to the matched group. However, on
Sexual abuse research
595
closer scrutiny, a real question arose as to whether this group of children could be viewed as a comparison group. Two of the girls had experienced incidents of sexual abuse, which they disclosed during therapy. In a further six cases the therapist had definite concerns that sexual abuse might be at the root of the child’s problems even though there had been no disclosure. In summa~, for a signi~~nt propo~ion (1 l/35) of the matched compa~son group, sexual abuse could not be ruled out as a problem.
DISCUSSION The risk of false negatives among the comparison group raises serious methodological problems which we suspect are not exclusive to our study. Reviewing the study conducted by Kolko et al. (1988), we note that a signi~cant pro~~on (22 of the 103 children) had experienced both sexual and physical abuse. It would seem that this degree of overlap confuses the picture. Gale and colleagues (1988) studied sexually abused, physically abused, and nonabused children referred to a child and family community mental health clinic. They acknowledged that “it is possible that the (nonabused) group contains cases of unreported abuse.” The results are therefore about the difference between identified cases of sexual abuse and the other children. The differences are not necessarily the consequence of the sexual abuse itself. Can such studies, including our own, really claim to evaluate behavioral and emotional indicators of sexual abuse by the use of controlled comparison groups? Our findings are relevant to clinicians as they highlight the widespread prevalence of sexual abuse, and underscore the key role psychiatry plays in diagnosis. The research also raises the question of whether the possibility of sexual abuse should be routinely considered when the children are referred to the psychiatric service. Keeping an open mind to the possibility of sexual abuse of children who have not disclosed may be controversial, but we believe that the recognition of sexual abuse as an important child health issue is necessary if child psychiatry services are going to offer sensitive and effective help to disturbed and troubled children. Kolko et al. ( 1988) advocate that perhaps a routine evaluation of all forms of abuse should be part of the child psychiatry service offered to all children who come for help. We support this suggestion, as we believe it might result in getting more appropriate and timely help to children.
REFERENCES Bentovim, A., Elton, A., Hildebrand, J., Tranter, M., & Vizard, E. (1988). Sexua~ubuse in the~rni~~~ Asse.Tsme~tand treatment. Bristol: John Wright. Deblinger, E., McLeer, S., Atkins, M., Ralphe, D., & Roa, E. (1989). Post-traumatic stress in sexually abused, nhvsicahv abused. and nonabused children. Child Abuse & Neglect, 1X3). 403-408. Finkelhor, b. (1986). A sourcebook on child sexual abuse. Beverly Hills: Sage. Gale, J., Thompson, R. J., Moran, T., & Sach, W. H. (1988). Sexual abuse in young children: Its clinical presentation and characteristic patterns. Child Abuse & Neglect, 12, 163- 170. Giarretto, H. (1979). Humanistic treatment of father/daughter incest. In Sexual abuse ofchildren: Selected readings. Washington, DC US Department of Health and Human Services. Gough, D., Taylor, J., & Boddy, F. (1988). Child abuse ~nte~entjons:A review oftjterature. (Report to DHSS): Social Paediatrie and Obstetric Research Unit, University of Glasgow. Hauaaard. J.. & Reaucci. N. ( 1988). The sexual abuse ofchiidren: A ComBrehensive aide to know/edge and interventi& strategies. San Francisco: Jossey Bass. Kolko. D.. Moser. J.. & Weldv, S. (1988). Behavioral and emotional indicators of sexual abuse in child osvchiatric in-patients: A controlled comparison with physical abuse. Child Abuse cf. Neglect, 12(4), 529-541. __ Tayside Regional Council. (1988).Protecting children from abuse and neglect: Operational instructions for social work staff: Dundee: Author. Will, D. (1983). Approaching the incestuous and sexually abusive family. Journal of Adolescence, 6, 229-246.
