Opinion
EDITORIAL
Why It Matters to Know the Relationship Between Child Abuse and Neglect and Sexual Offending Lucy Berliner, MSW
The link between child abuse and neglect and later problems has been addressed in many studies. An Institute of Medicine report1 reviewed child abuse and neglect outcomes and documented a broad range of deleterious effects on health, mental health, antisocial behavior, and social and economic Related article at functioning. The studies rejamapediatrics.com viewed had varying degrees of methodical rigor; prospective studies with control groups of nonabused children are most likely to definitively answer the important questions. The article by Widom and Massey2 in this issue of JAMA Pediatrics focuses on the relationship between child abuse and neglect and sexual offending using a prospective design. The results have important implications for abused and neglected children—not just children who have been sexually abused, but children who have been neglected and physically abused as well. The specific question Widom and Massey2 set out to address was whether being sexually abused in childhood conferred heightened risk to later commit sexual offenses relative to a matched control group of nonabused children. The findings show that abused and neglected children are at overall greater risk for sexual offending, but the results are accounted for mainly by the significantly increased risk among physically abused and neglected children. We have noticed a common assumption that sexually abused children are at a uniquely elevated risk for sex offending. This point of view may stem from assumptions about the causes of sex offending. The idea of a cycle of violence resonates because it makes sense intuitively. Assumptions may also be related to the sometimes higher rates of sexual abuse in the backgrounds of sex offenders compared with other criminals, especially juvenile sex offenders.3 A nontrivial minority of children who have been sexually abused do display some type of sexualized behavior or have sexual behavior problems.4 This is all superimposed on the fact that, in general, there is much more discomfort with sexual behavior compared with other challenging behaviors in children. The convergence of these forces has probably contributed to the belief in a relationship between sexual abuse and sexual offending. This view about sexual abuse and sexual offending can have a very serious stigmatizing impact on sexually abused children. In our clinic, we have seen many examples of situations where simply because it was known to a school, foster parent, or caseworker that the child had been sexually abused, agetypical behaviors in adolescents are perceived as signs of sexual offending. Behaviors that can be construed as evidence of jamapediatrics.com
grooming or predatory behavior include physical horsing around, making sexual comments, or coming on to a peer. We have seen children restricted from school activities outside the classroom (lunch, bathroom, and recess) for nothing more than these types of behaviors. And if the children have any sexual sequelae from their victimization, things get worse very quickly. In our experience, sexual misbehaviors or boundary problems provoke much stronger reactions than the aggressive or intimidating behaviors sometimes seen in physically abused children. Children have been expelled from school for minor sexualized behavior, have had their placements disrupted, have been placed in restrictive residential environments, and have been subjected to extreme supervision conditions (eg, alarms on doors and closed-circuit television). On the other hand, sexual abuse is associated with an increased likelihood of engaging in risky sexual behaviors,5 with the consequences almost entirely accruing to the survivors themselves, not others. Early onset of sexual activity puts them at risk for being exploited by older boys and men, increases the likelihood of teen pregnancy and sexually transmitted infections, and may convey that his or her only worth is as a sexual being. As has been documented,6 early sexual debut is correlated with a myriad of negative consequences including risky sexual behaviors, smoking and substance abuse, and antisocial behavior. Kastbom et al6 found that girls with early sexual debut had higher rates of sexual abuse histories. These deleterious effects have nothing to do with concerns that sexually abused children are dangerous to others. In terms of neglected and physically abused children, it will likely come as a surprise to many that they are also at heightened risk for sexual offending compared with the nonabused group. This article shows that there is not a specific correspondence between early experiences of abuse and neglect and the types of crimes committed subsequently. Overall, male abuse and neglect survivors, but not female survivors, are at risk for criminal behavior in general including sex offending. The results did not show any kind of specialization in the criminal behavior. So, what to do? Abused and neglected children, especially physically abused and neglected males, are at increased risk for criminal conduct including sex offending. Such a research finding will be most useful if it is disseminated with recommendations to the practice community: child welfare, public mental health, schools, and even primary health care professionals. If all of these health care professionals were grounded in the fact that there is no unique additional risk for sexual abuse survivors, they could provide psychoeducation JAMA Pediatrics Published online January 5, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015
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Opinion Editorial
to dispel misinformation and reassure parents and foster parents. This could lead to much less stigmatization and fewer draconian responses to these children. The focus could shift toward ensuring that sexual abuse survivors receive the proper care. After all, who knows what the consequences are for children who have been given the message by professionals that they are sexually dangerous? The other side of the findings is that much more attention should be paid to responding to behavior problems in abused children, especially physically abused and neglected children. Currently, only a minority of children who have behavior problems, including children in the child welfare system, receive psychosocial services.7 It is even less common that they are connected to evidence-based services. Early and effective interventions are the best available option for interrupting a trajectory toward severe behavior problems and involvement in the juvenile justice system. There are a myriad of evidence-based parent-mediated interventions for behavior problems of all kinds, including sexual behavARTICLE INFORMATION Author Affiliation: Harborview Center for Sexual Assault and Traumatic Stress, Seattle, Washington. Corresponding Author: Lucy Berliner, MSW, Harborview Center for Sexual Assault and Traumatic Stress, 325 9th Ave, MS 359947, Seattle, WA 98104 ([email protected]). Published Online: January 5, 2015. doi:10.1001/jamapediatrics.2014.3365. Conflict of Interest Disclosures: None reported. REFERENCES 1. Institute of Medicine; National Research Council. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press; 2014.
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ior problems, and many that have been shown to work with families and children in the child welfare system. For adolescents who are already involved in the juvenile justice system, there are effective interventions to reduce recidivism: ecological (eg, multisystemic therapy), family focused (eg, family-focused therapy), and group-based cognitive behavioral therapies (eg, aggression replacement therapy). These proven interventions should be widely available, especially for children in the child welfare system who have known histories of abuse and neglect. These are not children no one knows about. Not all abused and neglected children require formal psychosocial services. Sometimes, just ending the abuse and neglect and being in a safe home is sufficient. For those who do have problems and needs, the responses should never be stigmatizing and the services should be those that are effective for the clinically assessed problems the children are exhibiting. Such an approach might go a long way toward reducing the longer-term outcomes.
2. Widom CS, Massey C. A prospective examination of whether childhood sexual abuse predicts subsequent sexual offending [published online January 5, 2015]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2014.3357. 3. Seto MC, Lalumière ML. What is so special about male adolescent sexual offending? a review and test of explanations through meta-analysis. Psychol Bull. 2010;136(4):526-575. 4. Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull. 1993;113(1):164-180.
behavior: evidence from controlled studies, methodological critique, and suggestions for research. Clin Psychol Rev. 2008;28(5):711-735. 6. Kastbom AA, Sydsjö G, Bladh M, Priebe G, Svedin CG. Sexual debut before the age of 14 leads to poorer psychosocial health and risky behaviour in later life [published online September 12, 2014]. Acta Paediatr. doi:10.1111/apa.12803. 7. Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry. 2004; 43(8):960-970.
5. Senn TE, Carey MP, Vanable PA. Childhood and adolescent sexual abuse and subsequent sexual risk
JAMA Pediatrics Published online January 5, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015
jamapediatrics.com
EDITORIAL
Why It Matters to Know the Relationship Between Child Abuse and Neglect and Sexual Offending Lucy Berliner, MSW
The link between child abuse and neglect and later problems has been addressed in many studies. An Institute of Medicine report1 reviewed child abuse and neglect outcomes and documented a broad range of deleterious effects on health, mental health, antisocial behavior, and social and economic Related article at functioning. The studies rejamapediatrics.com viewed had varying degrees of methodical rigor; prospective studies with control groups of nonabused children are most likely to definitively answer the important questions. The article by Widom and Massey2 in this issue of JAMA Pediatrics focuses on the relationship between child abuse and neglect and sexual offending using a prospective design. The results have important implications for abused and neglected children—not just children who have been sexually abused, but children who have been neglected and physically abused as well. The specific question Widom and Massey2 set out to address was whether being sexually abused in childhood conferred heightened risk to later commit sexual offenses relative to a matched control group of nonabused children. The findings show that abused and neglected children are at overall greater risk for sexual offending, but the results are accounted for mainly by the significantly increased risk among physically abused and neglected children. We have noticed a common assumption that sexually abused children are at a uniquely elevated risk for sex offending. This point of view may stem from assumptions about the causes of sex offending. The idea of a cycle of violence resonates because it makes sense intuitively. Assumptions may also be related to the sometimes higher rates of sexual abuse in the backgrounds of sex offenders compared with other criminals, especially juvenile sex offenders.3 A nontrivial minority of children who have been sexually abused do display some type of sexualized behavior or have sexual behavior problems.4 This is all superimposed on the fact that, in general, there is much more discomfort with sexual behavior compared with other challenging behaviors in children. The convergence of these forces has probably contributed to the belief in a relationship between sexual abuse and sexual offending. This view about sexual abuse and sexual offending can have a very serious stigmatizing impact on sexually abused children. In our clinic, we have seen many examples of situations where simply because it was known to a school, foster parent, or caseworker that the child had been sexually abused, agetypical behaviors in adolescents are perceived as signs of sexual offending. Behaviors that can be construed as evidence of jamapediatrics.com
grooming or predatory behavior include physical horsing around, making sexual comments, or coming on to a peer. We have seen children restricted from school activities outside the classroom (lunch, bathroom, and recess) for nothing more than these types of behaviors. And if the children have any sexual sequelae from their victimization, things get worse very quickly. In our experience, sexual misbehaviors or boundary problems provoke much stronger reactions than the aggressive or intimidating behaviors sometimes seen in physically abused children. Children have been expelled from school for minor sexualized behavior, have had their placements disrupted, have been placed in restrictive residential environments, and have been subjected to extreme supervision conditions (eg, alarms on doors and closed-circuit television). On the other hand, sexual abuse is associated with an increased likelihood of engaging in risky sexual behaviors,5 with the consequences almost entirely accruing to the survivors themselves, not others. Early onset of sexual activity puts them at risk for being exploited by older boys and men, increases the likelihood of teen pregnancy and sexually transmitted infections, and may convey that his or her only worth is as a sexual being. As has been documented,6 early sexual debut is correlated with a myriad of negative consequences including risky sexual behaviors, smoking and substance abuse, and antisocial behavior. Kastbom et al6 found that girls with early sexual debut had higher rates of sexual abuse histories. These deleterious effects have nothing to do with concerns that sexually abused children are dangerous to others. In terms of neglected and physically abused children, it will likely come as a surprise to many that they are also at heightened risk for sexual offending compared with the nonabused group. This article shows that there is not a specific correspondence between early experiences of abuse and neglect and the types of crimes committed subsequently. Overall, male abuse and neglect survivors, but not female survivors, are at risk for criminal behavior in general including sex offending. The results did not show any kind of specialization in the criminal behavior. So, what to do? Abused and neglected children, especially physically abused and neglected males, are at increased risk for criminal conduct including sex offending. Such a research finding will be most useful if it is disseminated with recommendations to the practice community: child welfare, public mental health, schools, and even primary health care professionals. If all of these health care professionals were grounded in the fact that there is no unique additional risk for sexual abuse survivors, they could provide psychoeducation JAMA Pediatrics Published online January 5, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015
1/2
Opinion Editorial
to dispel misinformation and reassure parents and foster parents. This could lead to much less stigmatization and fewer draconian responses to these children. The focus could shift toward ensuring that sexual abuse survivors receive the proper care. After all, who knows what the consequences are for children who have been given the message by professionals that they are sexually dangerous? The other side of the findings is that much more attention should be paid to responding to behavior problems in abused children, especially physically abused and neglected children. Currently, only a minority of children who have behavior problems, including children in the child welfare system, receive psychosocial services.7 It is even less common that they are connected to evidence-based services. Early and effective interventions are the best available option for interrupting a trajectory toward severe behavior problems and involvement in the juvenile justice system. There are a myriad of evidence-based parent-mediated interventions for behavior problems of all kinds, including sexual behavARTICLE INFORMATION Author Affiliation: Harborview Center for Sexual Assault and Traumatic Stress, Seattle, Washington. Corresponding Author: Lucy Berliner, MSW, Harborview Center for Sexual Assault and Traumatic Stress, 325 9th Ave, MS 359947, Seattle, WA 98104 ([email protected]). Published Online: January 5, 2015. doi:10.1001/jamapediatrics.2014.3365. Conflict of Interest Disclosures: None reported. REFERENCES 1. Institute of Medicine; National Research Council. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press; 2014.
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ior problems, and many that have been shown to work with families and children in the child welfare system. For adolescents who are already involved in the juvenile justice system, there are effective interventions to reduce recidivism: ecological (eg, multisystemic therapy), family focused (eg, family-focused therapy), and group-based cognitive behavioral therapies (eg, aggression replacement therapy). These proven interventions should be widely available, especially for children in the child welfare system who have known histories of abuse and neglect. These are not children no one knows about. Not all abused and neglected children require formal psychosocial services. Sometimes, just ending the abuse and neglect and being in a safe home is sufficient. For those who do have problems and needs, the responses should never be stigmatizing and the services should be those that are effective for the clinically assessed problems the children are exhibiting. Such an approach might go a long way toward reducing the longer-term outcomes.
2. Widom CS, Massey C. A prospective examination of whether childhood sexual abuse predicts subsequent sexual offending [published online January 5, 2015]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2014.3357. 3. Seto MC, Lalumière ML. What is so special about male adolescent sexual offending? a review and test of explanations through meta-analysis. Psychol Bull. 2010;136(4):526-575. 4. Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull. 1993;113(1):164-180.
behavior: evidence from controlled studies, methodological critique, and suggestions for research. Clin Psychol Rev. 2008;28(5):711-735. 6. Kastbom AA, Sydsjö G, Bladh M, Priebe G, Svedin CG. Sexual debut before the age of 14 leads to poorer psychosocial health and risky behaviour in later life [published online September 12, 2014]. Acta Paediatr. doi:10.1111/apa.12803. 7. Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry. 2004; 43(8):960-970.
5. Senn TE, Carey MP, Vanable PA. Childhood and adolescent sexual abuse and subsequent sexual risk
JAMA Pediatrics Published online January 5, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015
jamapediatrics.com
