Meta-analysis of studies assessing the efficacy of projective techniques in discriminating child sexual abuse

OBJECTIVE: This meta-analysis of 12 studies assesses the efficacy of projective techniques to discriminate between sexually abused children and nonsexually abused children. METHOD: A literature search was conducted to identify published studies that used projective instruments with sexually abused children. Those studies that reported statistics that allowed for an effect size to be calculated, were then included in the meta-analysis. There were 12 studies that fit the criteria. The projectives reviewed include The Rorschach, The Hand Test, The Thematic Apperception Test (TAT), the Kinetic Family Drawings, Human Figure Drawings, Draw Your Favorite Kind of Day, The Rosebush: A Visualization Strategy, and The House-Tree-Person. RESULTS: The results of this analysis gave an over-all effect size of d = .81, which is a large effect. Six studies included only a norm group of nondistressed, nonabused children with the sexual abuse group. The average effect size was d = .87, which is impressive. Six studies did include a clinical group of distressed nonsexually abused subjects and the effect size lowered to d = .76, which is a medium to large effect. CONCLUSION: This indicates that projective instruments can discriminate distressed children from nondistressed subjects, quite well. In the studies that included a clinical group of distressed children who were not sexually abused, the lower effect size indicates that the instruments were less able to discriminate the type of distress. This meta-analysis gives evidence that projective techniques have the ability to discriminate between children who have been sexually abused and those who were not abused sexually. However, further research that is designed to include clinical groups of distressed children is needed in order to determine how well the projectives can discriminate the type of distress.     

Measuring abuse stress and negative cognitive appraisals in child sexual abuse: validity data on two new scales

The validity of two measures assessing degree of stress associated with sexual abuse was examined in a sample of 48 girls who had been sexually abused. The Checklist of Sexual Abuse and Related Stressors (C-SARS) assessed negative life events that were part of or were related to the abuse, and the Negative Appraisals of Sexual Abuse Scale (NASAS) assessed negative cognitive appraisals of threat, harm, or loss associated with the abuse. Total scores for victim reports of both stressful events and negative appraisals were positively and significantly related to two other measures of abuse severity: therapist ratings of abuse stress and the number of types of sexual abuse reported. Stressful event scores were also related to aggressive behavior problems, sexual concerns, and total symptom scores on the Child Behavior Checklist. Negative cognitive appraisal scores were related to victims' self-reports of depression, anxiety, and posttraumatic stress symptoms, and to parents reports of child depression and total symptoms. Regression analyses indicated that there were significant effects of negative appraisals on internalizing symptoms when controlling for the level of stressful events experienced. The results suggest that negative life events and negative appraisals associated with sexual abuse are valid constructs that help account for variability in mental health outcomes among child victims. The implications of these results and future research directions in examining variable outcomes among sexual abuse victims are discussed.     

Prevalence of post traumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both)

OBJECTIVE: The purpose of this study was to compare the prevalence of Post Traumatic Stress Disorder and other diagnoses in three groups of abused children, sexual only (N = 127), physical only (N = 43), and BOTH (N = 34). METHOD: The children, aged 7 to 13 years, were referred to the project from several sources at Arkansas Children's Hospital and from associated local agencies. The victims and caregivers were separately administered the Diagnostic Interview for Children and Adolescents, Revised Version (DICA). Additionally, caregivers and classroom teachers completed the Child Behavior Checklist (CBCL). Characteristics of the abuse were obtained from an investigative questionnaire. RESULTS: Both victims and caregivers endorsed high rates of disorders, with caregivers generally giving higher rates than children and boys having more externalizing diagnoses than girls. Children in the BOTH group had more diagnoses overall. Concordance between victims and caregivers was modest. PTSD was significantly comorbid with most affective disorders. On the CBCL, caregivers rated girls less disturbed than boys and the sexually abused only group less disturbed than the other groups. Teachers rated the boys more adversely than girls but did not see differences by abuse group. A younger age of onset of sexual abuse and coercion to maintain secrecy predicted a higher number of total diagnoses. Also, children who were physically abused by males had more diagnoses than those physically abused by females. CONCLUSIONS: Children who have been both physically/sexually abused appear to be at highest risk of psychiatric disturbance. PTSD, though common (circa one-third of victims), is generally comorbid with other affective disorders.     

Young school-age sexually aggressive children.

As the full spectrum of sexual abuse sequelae is becoming known, a subset of child victims has been noted to exhibit sexually aggressive behavior. Their sexual behavior far exceeds the mutual exploratory behavior normally seen in young children and resembles more closely the behavior of older sex offenders. We present data from the psychological evaluation of twenty-two 4- to 11-year-old children referred for sexually aggressive behavior, including intellectual, behavioral, projective, and parent–child relational quality. Behavior problem data from these children are contrasted with data from twenty-two 5- to 13-year-old boys who completed a sexual abuse treatment program. Some differences appear related to the development of sexual aggression (e.g., aggression level, nature of the abuse, and family functioning) and are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Factor-analytically derived scales for the Louisville Behavior Checklist.

The Louisville Behavior Checklist, an inventory for parents to rate children's behavior, was developed in 1965 from a factor analysis of an outpatient male population. This article reports on a factor analysis and scale revision that occurred 20 years later with a much larger clinical sample of boys and girls from a more diverse population using improved factor-analytic techniques. The results cross-validated five of the original factors, and two new factors emerged. No major differences were found between male and female factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Child Sexual Behavior Inventory: Normative and clinical comparisons.

A normative sample of 880 children was contrasted with a sample of 276 sexually abused children on the Child Sexual Behavior Inventory (CSBI), a 35-item behavior checklist assessing sexual behavior in children 2–12 yrs old. The CSBI total score differed significantly between the 2 groups after controlling for age, sex, maternal education, and family income, with sexually abused children showing a greater frequency of sexual behaviors than did the normative sample. Test–retest reliability, interitem correlations, cross-validation, and correlations with abuse characteristics were also reported. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparisons of rating scales of child psychopathology in clinic and nonclinic samples.

Mothers of 45 control and 35 clinic children (mean ages 7.6 and 7.5 yrs, respectively) completed 2 factor-analytically derived rating scales of child psychopathology, the Behavior Problem Checklist and the Parent Questionnaire. Intercorrelations among factors indicated some factor overlap and some differences between apparently similar factors. Conduct problem ratings on the Behavior Problem Checklist covaried with ratings of conduct problems, hyperactivity, and learning problems on the Parent Questionnaire. Patterns of correlations suggested that mothers of nonreferred children rated pathology per se, whereas mothers of referred children rated behaviors that fell into internalizing and externalizing clusters. Teachers asked to rate 22 referred and 22 control males (mean ages 8.3 and 8.5 yrs, respectively) on the Behavior Problem Checklist and the Teacher Rating Scale showed more consistency in the behaviors rated. It is concluded that, although similar factor labels are used from scale to scale, they reflect somewhat different behaviors and are influenced by the child's clinical status, the rater's past experience with children, and specific scale characteristics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of domestic violence on children's behavior problems and depression.

The Children's Depression Inventory, Child Behavior Checklist, and Youth Self-Report were completed by mothers, fathers, and their 8–12 yr old children to assess the effects of various types of domestic violence on children's behavior problems and depression. 110 Israeli children from lower-class families were identified through social service records. 33 of the children had been physically abused by their parents within the last 6 mo, 16 had witnessed spouse abuse, 30 had been both victims and witnesses of domestic violence, and 31 had experienced no known domestic violence. Overall, domestic violence had effects on child development that varied in magnitude and nature depending on the type of domestic violence and who reported the information about the child's adjustment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Course of psychological symptoms in sexually abused young children.

Assessed 8 sexually abused (SA) children (aged 3–7 yrs) repeatedly with the Child Behavior Checklist during a 10–18 mo period to explore the course of psychological symptoms that emerged in response to the abuse. Their individual courses were linked to whether treatment was provided and pathology in the parents. In some Ss, symptoms reflected a similar pattern of resolution. Symptomatology included depression and somatic complaints, aggressiveness, and the emergence of sexualized behavior. Parent–child interactions and the impact of therapy are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intellectual stability in children with unilateral brain lesions

Developmental differences in behavior and self-perception were examined in a group of 44 preschool and school-age children referred for evaluation of sexual abuse and 41 comparison children with no history of sexual abuse, matched on age and gender, and from a similar socioeconomic background. Children suspected of having been sexually abused were rated by their parents as having more internalizing and externalizing problems than comparison children. When children rated their self-competence and social acceptance, there were no group differences between children based on their abuse status; however, there was significant within-group variation among the children suspected of having been sexually abused. Preschool children had elevated scores of perceived competence and social acceptance, and school-age children had depressed scores. There were no age differences among the children in the comparison group. The results suggest that among children suspected of abuse, not only does their self-perception vary by their developmental level, but preschool children may respond with elevated perceptions of themselves. Focusing on individual differences in children's response to suspicions of sexual abuse enables us to identify risk and protective factors that contribute to the psychological outcomes of child sexual abuse.     

Pediatric acquired immunodeficiency syndrome. Barriers to recognizing the role of child sexual abuse

The only reportable exposure categories for human immunodeficiency virus (HIV) infection of children are vertical transmission from an HIV-infected mother or receipt of infected blood or blood products. Although sexual transmission of HIV among adults is the subject of intense concern, sexual transmission of HIV to children during child sexual abuse has received almost no investigative attention. This review discusses factors contributing to the exclusion of sexual transmission of HIV to children from studies of the epidemiology of HIV infection. Difficulties occur in screening and confirming abuse in nonselected populations of children, perceived and real barriers exist to the evaluation for HIV of sexually abused children, and problems occur in the assessment for child sexual abuse of HIV-infected children. Impediments to the understanding of the relationship between sexual abuse and HIV infection in sexually abused, HIV-infected children are considered, and measures that can allow these barriers to be overcome are discussed.     

Review of Children draw and tell: An introduction to the projective uses of children's human figure drawings.

Reviews the book, Children Draw and Tell: An Introduction to the Projective Uses of Children's Human Figure Drawings by Marvin Klepsch and Laura Logie (1982). Children Draw and Tell provides child care workers, teachers, and other allied health professionals involved with children and their families with an informative, useful, and concise introduction to the projective uses of children's human figure drawings. It is evident throughout this well-organized book that the authors have carefully avoided the use of technical jargon, making it refreshingly readable so that it is likely to appeal to a broad audience. Moreover, given the authors' observations that recent trends indicate that many psychology programs have been de-emphasizing training in projective assessment techniques in favour of behavioural assessment strategies, then this text may also serve as a valuable introductory resource to those professional psychologists lacking formal training in this area but still maintaining an interest in this widely used clinical assessment technique. The authors have written a short and valuable book which will make worthwhile reading for those interested in an introduction to the uses of children's projective drawings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological testing in evaluation of child sexual abuse

In order to assess the utility of psychological testing in evaluating allegations of child sexual abuse, the empirical literature is reviewed in an attempt to answer two questions. First, are there systematic and significant differences on psychological tests between sexually abused and nonabused children? Second, are these differences on psychological testing a direct result of sexual abuse, or are they a result of other coexisting factors that might cause psychological distress? Cognitive measures, personality inventories, symptomatology checklists, and projective tests with sexually abused children are reviewed. While a variety of standardized instruments have been administered to sexually abused children, relatively few have been utilized in empirical studies. Findings have been mixed, with stronger differences between sexually abused and nonabused children generally found on measures completed by parents than on measures administered directly to children. Sexually abused children often fall between nonabused and psychiatric groups. Use of measures specific to sexual abuse is advocated. While psychological tests may currently have limited use in validating suspected sexual abuse, they may be extremely useful in the clinical treatment of the child.     

Screening, management, and appropriate referral for pediatric behavior problems

Pediatric behavior problems are common but often go undiagnosed. This article addresses assessment of these problems in the primary care setting, including interview of parent and child, history, physical assessment, direct observation of parent-child interaction, and the use of behavior rating scales (the Preschool Children's Behavior Checklist, the Pediatric Symptom Checklist, and the Eyberg Child Behavior Inventory). Comorbidity of behavior problems with psychological disorders is discussed and a distinction is made between mild and severe behavioral difficulties. Positive parenting and healthy discipline skills are expounded, including catching children being good, active listening, conveying positive regard, ignoring minor transgressions, giving good directions, use of praise, and time-out. Criteria for consultation and referral are provided and the role of the health care provider is emphasized.     

Factors associated with sexual behavior problems in young sexually abused children

OBJECTIVE: To identify variables associated with the presence of sexual behavior problems in young sexually abused children. METHOD: Data were gathered from the clinical records of 100 sexually abused boys and girls ages 3-7 years enrolled in two treatment programs. Information was coded systematically on approximately 350 areas related to the child and family's history and functioning, the sexual abuse experience, and treatment outcome. The children were grouped and compared according to their presenting sexual behavior into three categories: (1) developmentally "expected"; (2) "sexualized/self-focused"; and (3) problematic "interpersonal" sexual behavior. RESULTS: Bivariate and multivariate analyses highlighted five variables which were predictive of sexual behavior problems among sexually abused children. Sexual arousal of the child during his/her sexual abuse, the perpetrator's use of sadism, and a history of physical and emotional abuse differentiated between those children with and without "interpersonal" sexual behavior problems. Who the child blamed for his/her sexual abuse further contributed to the distinction between children whose sexual behavior was exclusively "self-focused" (sexualized) versus "interpersonal." CONCLUSIONS: The five major predictor variables, as well as other variables identified in this study, have potential utility in assessing child risk for negative outcomes and determining referral priorities for sexual abuse treatment. Given that sexual arousal and who the child blames for the abuse are prominent variables associated with sexual problems and self-blame, clinicians will need to ensure that sexually abused children and their caregivers are given specific opportunities to deal with these areas in the supportive context of treatment. Children with sexual behavior problems differ not only in the type and level of sexual behavior they exhibit but in most other areas as well, suggesting a need for differential assessment and individualized treatment approaches.     

The impact of child sexual abuse on the children of survivors. Implications for forensic nursing

1. Assuming that dysfunctional familial patterns arise from child sexual abuse experiences and that they are learned by the victims' children, there is a potential risk conferred to the children of becoming victims of child sexual abuse. 2. Certain physical manifestations, psychosocial behaviors, and relational patterns typify the personae of adults who experienced sexual abuse as children. 3. Roles of the nurse that might be used to meet the needs of this risk group are varied and target the victims, their children, and the community at large.     

Disclosure of Child Sexual Abuse: What Does the Research Tell Us About the Ways That Children Tell?

The empirical basis for the child sexual abuse accommodation syndrome (CSAAS), a theoretical model that posits that sexually abused children frequently display secrecy, tentative disclosures, and retractions of abuse statements was reviewed. Two data sources were evaluated: retrospective studies of adults' reports of having been abused as children and concurrent or chart-review studies of children undergoing evaluation or treatment for sexual abuse. The evidence indicates that the majority of abused children do not reveal abuse during childhood. However, the evidence fails to support the notion that denials, tentative disclosures, and recantations characterize the disclosure patterns of children with validated histories of sexual abuse. These results are discussed in terms of their implications governing the admissibility of expert testimony on CSAAS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Kinetic analysis of transcytosis of epidermal growth factor in Madin-Darby canine kidney epithelial cells

OBJECTIVE: Treatment outcome in sexually abused preschool children was evaluated 6 and 12 months after treatment. METHOD: Forty-three sexually abused preschool children and their parents were evaluated 6 and 12 months after completion of either Cognitive-Behavioral Therapy for Sexually Abused Preschoolers (CBT-SAP) or nondirective supportive therapy (NST). Parents completed the Child Behavior Checklist, Child Sexual Behavior inventory, and Weekly Behavior Report to measure a variety of symptoms in their children. RESULTS: Repeated-measures analyses indicated that there were significant group by time interactions on several outcome measures from the beginning of the study to the end of the 12-month follow-up period, with the CBT-SAP group exhibiting significantly more improvement over time than the NST group. Clinical findings also indicated the superior effectiveness of CBT-SAP over NST in reducing sexually inappropriate behavior. CONCLUSIONS: Findings support the superior efficacy of CBT-SAP over NST in maintaining symptom reduction in the year after treatment completion. The importance of using cognitive-behavioral interventions for sexually inappropriate behaviors and including nonoffending parents in the treatment of sexually abused preschool children is discussed.     

Sexually abused girls' verbalizations in counseling: An application of the client behavior system.

The Client Behavior System was used to evaluate the therapeutic process with 27 sexually abused 7–17-yr-old girls enrolled in psychoeducationally based individual counseling. Based on ratings collected for the session in which the topic of sexual abuse was formally introduced, it was found that girls were more likely to provide abuse-related answers in response to questions pertaining to child sexual abuse, regardless of whether they were treated by a male or female counselor. These findings provide reason to reconsider previous recommendations that sexually abused girls are best treated by female counselors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)