Evaluation of Charges of Sexual Abuse in the Context of Custody and Divorce

Gloria Burk, Ricardo Hofer, Katherine MacVicar, Morton Neril, & Robert Schreiber^*

ABSTRACT: Sexual abuse allegations arising in the divorce and custody context present extremely difficult problems for the evaluator  The allegation damages the family system and highlights dysfunctions within individual members and the family system itself.  The allegation, whether true or not) is a symptom of significant family pathology.  Therefore, the evaluator should consider the developmental, dynamic, and family context and obtain information from all possible relevant parties.  The evaluator should also attempt to minimize the trauma that results from a sexual abuse investigation and evaluation.  A case study is presented to illustrate this approach.
  

In the last few years we have encountered an increasing number of allegations of sexual abuse of children in the course of doing child psychotherapy or when conducting formal evaluations, usually at the request of a court.  In the latter category; there has been a marked increase in the number of cases referred to us where the allegations were in the context of a bitter custody battle.

Even a casual perusal of the popular press and the research and clinical literature indicates an exponential increase in the reports of sexual abuse (Muram, Dorko, Brown, & Tolley, 1991), especially in custody disputes.  The proliferation of work in this area has led the American Psychological Association to start publishing a separate set of abstracts dealing with just this topic, and several professional journals have devoted entire issues to it (e.g., the Fall, 1991 issue of the Journal of Psychohistory devoted to historical and anthropological data on child sexual abuse, and the 1991 issue of Child and Youth Services devoted to the problem of false allegations of abuse).

Due to the emotional nature of the subject, as well as to the inherent difficulties in ascertaining the facts when working with young children, the great increase of these reports has led to a host of worrisome questions for mental health professionals.  How can we reliably ascertain the incidence and prevalence of sexual abuse of young children?  Are we going through an historic period in which the incidence and prevalence of such abuse is actually higher than in the past or are we witnessing a lifting of long-repressed injunctions against the recognition and reporting of very disturbing and destructive attitudes and behaviors towards children? (DeMauss, 1991, Kahr, 1991).  Is the current epidemic of reports of child sexual abuse encouraging some disturbed adults to believe they were abused as children or to search for evidence of sexual abuse in others when it doesn't exist?

We believe that these factors contribute to the great increase of sexual abuse reports in legal battles, and especially in custody disputes.  As sexual abuse allegations move into the legal arena, with its formalized and specific set of rules, the opportunities for distortion and manipulation, whether conscious or unconscious, grow exponentially (Awad & McDonough, 1991; Pogge & Stone, 1990; Saunders, 1988; White & Quinn, 1988).

In response to this, professionals from a wide variety of disciplines, experience, and training, have become involved in the investigation, evaluation and treatment of child sexual abuse (e.g., Coleman, 1990; Kendall-Tackett, 1992; Kendall-Tackett & Watson, 1991; Korner, 1990; Muram, 1991; Paradise, 1989; Realmuto & Wescoe, 1992; Strickland, 1989; Trute, Adkins & McDonald, 1992).  These include members of police departments, child protective services, prosecutorial staffs, pediatricians, and every kind of mental health professional.  Some mental health professionals have specialized in sexual abuse evaluations and some centers have been created solely for that purpose.  As the result of this proliferation, a network of vested interests, and even a bureaucracy, has developed that in its mixture of crusading zeal and cottage industry often adds confusion to the assessment of child sexual abuse.  All of us have seen cases in which the investigation of sexual abuse turned out to be as traumatic as the alleged abuse itself (e.g., Hunter, Yuille & Harvey, 1990;'Goodman et al., 1988; Kelley, 1990; Ordway, 1983; Schetkey & Benedek, 1989; Summit, 1983).

Mental health professionals must therefore consider all that has been learned about the developmental, dynamic and family context of child sexual abuse.  In this paper we summarize our understanding of these factors and how they impinge on the evaluation and treatment of child sexual abuse.

The very fact that the allegation is sexual in nature instantaneously confers a highly emotional charge to the situation and to all the participants, including the professionals.  No one is neutral about sexuality, and most certainly not when it involves sexuality between adults and children.  In addition, an allegation of improper and unacceptable sexual behavior occurring in the family, the main socializer and regulator of sexual activities and the supposed provider of a safe and protective environment for the young, adds intensity to the entire situation.  An allegation of sexual abuse within the family severely damages the entire system of alliances within it, disrupting established roles, unraveling bonds of trust, and highlighting dysfunctions within individual members and the family system itself

It is important to emphasize that these effects are present whether or not the abuse has occurred.  They will take place as a result of a report being made.  The children become psychological pawns for the adults involved: if the charge is true, pawns of the perpetrator; if false, pawns of the accuser.  In either case, harm ensues.  The same is true for the relationship between the adults following such a report.  The very existence of an allegation means there is serious family pathology.  This is likely to evoke strong feelings in the professionals entrusted with the family's investigation and treatment.
  

The Setting

Mandatory reporting laws are in effect in most states.  The practical consequence of these laws is that the judicial system becomes involved in sexual abuse cases early and intimately.  While we think it is appropriate to view this matter to be of such gravity to require the involvement of the judiciary, it is important to bear in mind the difference in goal and method used by the judiciary and mental health professionals (Indest, 1989; Pogge & Stone, 1990; San Diego County Grand Jury Report, 1992; Saunders, 1988; Watson, 1988; white & Quinn, 1988).

The main goal of the judicial system is to determine if the charge is true.  The goal of finding out "what happened" unifies all the stages of the judicial proceeding, from the questioning by the police, through investigation, prosecution, defense, and final adjudication.  This goal informs the methods used at every stage.

While mental health professionals are interested in whether or not the allegations are true (the reality principle), the core of the professional's work and its main goal is the understanding of the meaning that a given event, act, feeling or thought may have had for those involved.  This addresses a complex set of theoretical and clinical tenets regarding personality theory and development.  This emphasis on the meaning of an act and its function in the person's life dictates the methods that the mental health professional will use in trying to discern those meanings: very detailed attention to the manner of delivery and content of speech or other forms of communication (e.g., play, in children); great interest in historical and developmental issues to aid in the understanding and interpretation of current situations; the search for coherent themes in the person's productions; a detailed exploration of the circumstances of the family because of the role that intrafamilial relationships play in the theory of personality functioning and development.

Different goals can result in serious problems when the judicial and mental health systems collide.  Seen from such different perspectives, the same set of "facts" may be interpreted very differently.  Mental health professionals may see the workings of the judicial system as further traumatizing the child and compromising an already seriously weakened functioning of the family.  Members of the judicial system sometimes see the mental health professionals as fuzzy thinkers who do not respect the rules of evidence and who hide behind impenetrable jargon.  This is an unfortunate state of affairs.  It is obvious that this is one area where it is imperative that there be clear communication between the two systems if there is going to be any hope of bringing about some resolution to the suffering families.

This situation has not been improved by the blurring of methodologies found in the segment of the mental health community which we have called the sexual abuse evaluation "industry."  Under the guise of psychological interviews, relentless and intrusive questioning of children occurs without any regard for the most elementary principles of interviewing.  The "facts" are pursued without consideration of their meaning to the child or for the effects of the process itself upon the child.

In addition to the difficulties found in the intersection of the judicial system and the mental health professional, it is important to be mindful of the trying circumstances in which the latter is placed when conducting a sexual abuse evaluation.  While mental health professionals are trained to systematically monitor countertransference reactions, accusations of sexual abuse in children, particularly if incestuous, tend to evoke very strong feelings associated with the deepest layers of the evaluator's personality.  The frequent disintegration of the family attendant on sexual abuse allegations, the high emotional pitch of all the participants, the heavy pressure that the protagonists and society place on the mental health professional to "solve" the situation (again the "did it happen or not" question), all converge to put a heavy burden on the emotional equanimity of the evaluator.  The fact that so much is at stake for parents increases the risk of being sued for malpractice or of being reported to a licensing board.  An evaluator's work is more exposed to monitoring and review by mental health and other professionals than it is for the traditional therapist.  Mental health training programs rarely, if ever, prepare trainees for hostile cross examination by an attorney.  It is little wonder that many professionals enter these cases reluctantly, limit the number of such cases, and almost universally report emotional exhaustion at the end.
  

Evaluation of a Case of Suspected Child Abuse

We have chosen an actual case that presents many of the theoretical, technical, and practical aspects of this complicated question, and lends itself to a comprehensive discussion of child sexual abuse as it arises in the context of families in a disputed custody evaluation.  As we follow the evolution of the case and its evaluation, we will comment about the larger issues involved and suggest guidelines for improving the management of these cases, as well as point to areas for further study.  Names and some details have been altered to provide anonymity.
  

Background of the Incident

William and Sheila were married after living together for a few months.  There were always problems, including heavy use of cocaine and alcohol, an abortion, financial difficulties, and antagonism between the two sets of grandparents.  Sarah was born after the first year of the marriage.  The parents separated before the child reached age one, and were divorced six months later.

For the first two days after the separation Sarah remained with father, but then lived with mother for two years, until she was 3.  According to father, at that time mother more or less insisted that he take the child because mother was moving, was having difficulty with her boyfriend, and had no money.  It was supposed to be a temporary arrangement (3 months), but father continued keeping Sarah because he felt she would be moved around too much.  "Sarah was visiting her mother regularly every other weekend without problems, except that in retrospect father thought Sarah was ecstatic to see him and "unhappy" after being with mother, which suggested to him a vague sense of emotional neglect by mother.  There had been no reason to suspect any physical or sexual abuse.
  

The Incident

Sarah had been living primarily with father for approximately four months.  She was visiting her mother every other weekend.  Mother picked up her daughter for a routine weekend visit on a Friday evening.  She returned her Sunday evening about 9 P.M., as usual, with no comment.  According to father Sarah appeared "O.K.," except that she seemed "tired."  When he put on Sarah's diaper before bed, he noticed an "inflamed, puffed out" sore, shaped like a "U" or a "W" between her vagina and anus.  It looked like "a cat took its sharpest nail and welted your arm."  Father never did call mother; as he said, "Sheila never asked about her ... and so what would make her have any concern that I found a little mark?"

Two days later, after her return from day care, Sarah complained that it hurt to go to the bathroom.  The following Sunday or Monday father asked, "How did this happen?"  Sarah said, 'Mommy bit me and licked me."  Father said he did not pursue it, not wanting to make something of it, but did tell his girlfriend, Ann, who stayed occasionally during the week and over weekends.  Ann said Sarah told her that, "Mommy licked me and bit me and hit me with a spoon but it was an accident."  At some point (presumably two days later), Sarah came at Ann, "and for no reason, started kissing and licking" her legs.  Ann tried to get her to stop, and said, "She was heading for the genital area."

The way the report was made is not unusual, particularly with separated or divorced parents.  It illustrates the problem of troubled communication within the family.  Often, as is true here, divorced parents have not talked directly to each other for long periods of time.  This exacerbates the children's feeling of being caught in the middle, leading them to do or say things that are uncannily attuned to the parents' emotional needs.

Children typically cast what they say in a context and manner that reflects their specific developmental stage and concern.  This adds to the dangers inherent in a situation in which a parent is drawing conclusions exclusively on the basis of the child's statements or behaviors.  We are all aware of how easily information conveyed in this highly charged situation can be distorted, inaccurate, or misleading, and what havoc this distortion can create in the lives of all the participants.  The only remedy is to get the parents to talk to each other.  The implication for the evaluator is the absolute requirement to meet and talk with the accused parent and the advisability of meeting with both parents jointly, even when they are angry and hostile towards each other.

It will be recalled that Sarah first reported the alleged abuse to her father and his girlfriend.

The person to whom the child made the original statement is important in terms of assessing the veracity of the report as well as in understanding the possible function of the abuse or of the report.  Although the initial context and the content of the interaction in which sexual abuse is first raised is not known, such initial reports most often take place within the family.  If this initial report is enmeshed in the family context, the psychological meanings will get increasingly obscured and confused as the child is subjected to more and more interviews, first with other members of the family (themselves quite polarized), and then with people further and further removed from the family.  While mental health professionals can rarely control the initial stages of the investigation, it is necessary to give a great deal of thought and consideration to the history of the case before beginning the evaluation.

A friend of Sarah's father who lived next door happened to be a nurse at a local children's hospital.  She told them to call the advice nurse there, which resulted in their bringing Sarah to the hospital the following morning.  Although the medical findings were equivocal, "... could be caused by manual, oral [after the doctor was told the story], or chemical," the social worker concluded that Sarah had been sexually abused.  At this point many people became involved, including doctors, nurses, social workers, and policemen.

The authorities who are most likely to first hear a report of sexual abuse — the police, family doctors, ministers, or teachers — vary greatly in levels of skill, experience, and character structure.  This is also true of those who follow the initial report, such as child protective services workers, hospital emergency room personnel, and mental health professionals of all disciplines.  It is desirable to involve properly trained people as early as possible and to videotape the initial interviews, both to protect the child from intrusive duplication, and to protect the "evidence" from further distortion or dilution.

Those who first deal with the abuse report often fail to achieve a common perspective because of a lack of psychological training, the demands of an overburdened system, and the different perspectives of the various professions that become involved.  Thus, police tend to be concerned with evidence for a "crime," pediatricians to be looking for physical signs, child protective service workers to be concerned with the immediate decision of whether to leave the child at risk in the home, and mental health professionals to be concerned with the emotional impact.

This absence of common perspective occurred in Sarah's case.  There was an early presumption that abuse had, in fact, happened.  From that point on, the effort was to find evidence that would confirm that presumption.  The focus was so narrow that two crucial factors in the proper evaluation of sexual abuse were neglected — the dynamics of the family functioning, and Sarah's current developmental stage.
  

Family Dynamics Considerations in the Evaluation of Sexual Abuse

Viewing the allegation of sexual abuse as a family symptom is central to understanding its meaning and function.  The alleged victim, the accuser (if different), and the accused have to be seen as part of the fabric of the family structure.  The evaluation should center on the family unit and its functioning.  Just as Winnicott states, "without maternal care there could be no infant," without a troubled family there could be no incest.

In any family there will be continually shifting patterns of alliances that interlock with one another.  Healthier families will have flexible, adaptive relationships that are able to cope with a variety of stresses over time.  The more differentiated and mature the adults in the family, the more likely they are to accept responsibility for their lives, and the less invested they are in having others, particularly the children, provide fulfillment of unmet emotional needs, as well as supplying an ongoing sense of well being.

There are many kinds of mutual adaptation that two people make when they form a couple.  These patterns of mutual adaptation are the result of the individual psychologies each person brings into the relationship, as well as the sociohistorical conditions in which the couple lives.  And just as there is much variation in the degree of psychopathology in the individual and in the sociohistorical conditions, there is much variation in the degree of adjustment, stability, and pathology in the functioning of couples.  This is particularly true as it pertains to the mutual fulfillment of basic human needs.

It is into this matrix that children, so peculiarly powerless and helpless but nonetheless so powerfully significant, are placed and grow.  Because children so deeply touch their parents' emotional lives, they unavoidably have a strong effect on the entire network of relationships.  Thus, a child's presence can lead to a redistribution of conflict and tension in the family structure, resulting in substantial realignments in it.  The child may side with one parent and enter into conflict with the other, leading to profound changes in the couple's functioning.  Or the child may become the recipient, through projection, of the couple's chronic tension, taking on the role of identified patient through the development of symptoms.  Often, actual symptoms are less crucial than the elucidation of the maladaptive patterns of interaction which lead to the development of symptoms.

The evaluator will be continually exposed to the network of forces in the family unit pressuring him or her to be swept up in it.  But because of the strong emotions created by the allegation of sexual abuse, the evaluator must maintain a firm separateness and independence without losing the necessary empathy to carry out the evaluation.  Remaining independent of the family system is made more difficult by the various other professionals who become involved through the course of the evaluation, all pressing for an answer to the question, "Did it happen, or didn't it happen?"

The mother was not contacted initially.  The evaluation and subsequent investigation were carried on without her.  By the time she was brought into the picture the conclusion had been reached that sexual abuse had occurred and she was considered the prime suspect.

The exclusion of the accused parent from the initial steps of the investigation is unfortunately more the norm than the exception in our experience.  At the onset the accuser has already defined the roles of the family members and the field of investigation.  There is a victim and a perpetrator.  What is required and expected is an investigation to determine whether or not the "crime" has occurred.

Although the final goal is usually stated in terms of the protection of the child, the accusing parent often has the goal of punishing the other parent.  The evaluator must redefine the field to include all family members and carefully assess the family unit, its areas of conflict and difficulty, and the network of alliances.  The final goal must be to improve the emotional functioning of the family members, regardless of the ultimate configuration of the family.

The allegation of sexual abuse must be understood in the context of the family's shared history.  What is the specific meaning of the accusation of incest to this family, and what particular function does it serve?

The estranged father's accusation may allow him to express his rage at mother for having forced the role of major caregiver onto him after their breakup.  What was to be a temporary arrangement became permanent, presumably because father worried about the mother moving around too much.  Previous history of this couple indicates that their relationship was problematic from the onset, with heavy drug use, a previous abortion, and financial problems.  Thus, by "protecting" Sarah from her "bad" mother, father may be trying to repair what is to him a painful time in his life while at the same time projecting all the "badness" of this period onto his former partner.

The evaluator's task consists of discovering the family's established patterns of functioning that were in place prior to the new rules that appeared in reaction to the accusation, and of determining the changes in interlocking relationships that made it possible for the child or parent to make the accusation of sexual abuse public.  It is often useful to understand why the particular family member is coming forward, in this particular way at this particular time.

Father appeared to have established a new life following his divorce from Sarah's mother.  His new girlfriend was very much involved from the beginning of the investigation of the alleged abuse.  No information is provided about the girlfriend's role in the "discovery" of the abuse and the questioning of Sarah about it, or about the even more important issue of the quality of Sarah's attachment to her.  In addition, it appears that a psychologically naive assumption was posited: that the girlfriend was a neutral objective observer, as if her relationship with the father did not count, or as if she would not have feelings about his firmer wife.

It is essential in this kind of evaluation to assess the marital couple dyad both at the time of the alleged events and at the time of disclosure, especially its level of maturity and how successful it has been at maintaining a clear separation of generational roles.  Has it been able to provide a secure, safe setting for its children that encourages growth, independence, and self-expression, as well as ensuring a stable sense of belonging?  How have sexual and aggressive impulses been controlled as well as acknowledged and expressed?  Is there any evidence of aggressive and/or sexual symptoms within the nuclear family or the parents' families of origin?

As mentioned previously mother and father had a stormy marriage, with frequent and problematic involvement of both sets of grandparents.  There was evidence of poor control of impulses on the part of both parents, as shown by heavy drug use.  No information about their sexual life was available, a glaring error of omission.  The only information given about the quality of parenting Sarah received from either parent is that at the time they separated mother was having trouble coping with her own life and gave Sarah to father to care for temporarily.  Nothing was noted about the consistency and appropriateness of the parenting Sarah had been receiving before the separation, or even who the primary caregiver was.  Without this information it is impossible to fully understand the impact on Sarah of her fathers' assumption of the role of primary caregiver or of the loss of her mother.  Data regarding the role of Sarah's grandparents in her life was not provided either.  Thus, the investigation proceeded with no effort made to ascertain the quality of attachment and mothering that the child received throughout her life, and from whom.

Frequently, there is a delay between the time an alleged event takes place, the time the alleged victim reports it, and the time any action is taken in response to the report.  To understand this sequence of events and its impact on all the participants, it is necessary to explore the family's characteristic patterns of communication.  How much do the family members tell each other?  What is told?  What is denied or covered up?  Who is included and who is excluded?  Who stands to gain or lose?

No information seems to have been elicited regarding the ongoing quality of relationship and kind of communication between father and mother, Sarah and each parent, and Sarah and her father's girlfriend, nor is there any information about this in regard to Sarah and her grandparents.  It is also not clear what patterns of relating were altered either when the accusation was made public or as the evaluation proceeded.  In summary, a potentially illuminating set of data was completely ignored.

In conducting an evaluation of sexual abuse it often becomes necessary to enlarge the scope of the inquiry beyond the original family in which the alleged event took place.  These may include step-parents, new girlfriends or boyfriends of the parents, grandparents, nannies and teachers.

Sarah's maternal grandparents turned out to be central figures in this family.  The mother had continued to be dependent on them, both financially and emotionally.  They were constants for Sarah as well; while both parents came and went in Sarah's life, the grandparents stayed.  It is likely that Sarah spent more time with the grandparents than with either parent, so that the abrupt and cavalier separation from them was bound to have a large impact.  Their conspicuous absence from the evaluation process not only resulted in the loss of important historians, but it also resulted in Sarah's loss of important caregiving and attachment figures.
  

Developmental Considerations

The level which a child has reached on all of the developmental lines will determine in large part how she perceives, copes with and communicates her experience of a traumatic event.  Here we discuss only those areas which are most central in the evaluation of suspected sexual abuse.
  

Cognition

The child's cognitive level tells us about the basic building blocks which she uses to understand trauma.  The child in the preconceptual stage (age 2-4) does not yet have basic fixed concepts to understand what has happened; instead the processing of experiences occurs in terms of developmental needs and desires.  Syncretism and condensation of images are common, as would be expected from the preeminence of primary process thinking in this stage of development.  Thus, a child at this age may tell the examiner that a man bit her, but this seemingly simple and straightforward report may be a condensation of her painful experience with the man and past experiences of being bitten, as well as still-current wishes to bite.

The intuitive stage child (age 4-7) has conceptual structures, but these are based on perceptions, rather than on more realistic and stable ideas.  The child often processes perceptions in terms of his or her own egocentric ideas and fantasies.  For instance, a boy may tell the examiner that he has been secretly changed into a girl because his castration complex determines how he interprets what happened.  A girl may insist that she is pregnant as a result of fondling even when she "knows" intellectually that this is impossible.  Thus, normative castration fantasies are intensified and come to feel frighteningly real in cases of sexual abuse.

The child at the stage of concrete operations (age 7-11) has taken a tremendous step in realistic thinking and now has concepts to organize and understand what happens to him or her.  The potential is present for making logical sense of the experience, as long as regression, narcissistic vulnerability, or the intolerance of affect do not grossly distort perceptions.  At this stage, thinking is limited to the experience at hand with limited ability to generalize from it.  Suggestibility may also distort reporting of events, especially when adults pressure the child to come forth with particular data.

Before the child has entered the stage of concrete operations one cannot take what is said as the literal truth.  What the child is expressing is "her/his truth."  This is very important from the therapeutic perspective, but does not always translate directly into secondary process data for the purpose of legal evidence.

The cognitive function of memory has a pivotal role in these cases, since almost all allegations occur in the context of a report of a remembered event.  Young children frequently remember events through perceptive or enactive memory, thus their expression in play and action.  Whether these memories can later be recovered in verbal memory depends on whether or not, or to what extent, they have become unconscious.  Terr (1988) suggests that many children, even those as young as 28 to 36 months, do retain verbal memories of traumatic events.  It is possible that as the child becomes more verbal, the memory will emerge.  Conversely, Ceci and Bruck (1993) have demonstrated that children's memories can be created by adult suggestion.  Unconscious memories are outside the sphere of the coherent ego and are therefore not recallable in words until some resonating affective state leads to a cognitive and affective linkage.  However difficult it may be, it is necessary to make the distinction between the emergence of "true" memory from that generated by contagion or manipulative suggestion.
  

Verbal Primacy vs. Earlier Modes of Communication

There is wide variation in the age at which children are able to communicate primarily in words — some can be extremely verbal by the age of 4, and others not until 8 years or older.  In younger patients we expect that the experience will be communicated largely in play and that the verbal productions which accompany it will be appropriate to the cognitive level of the child.  For instance, a young child who is being evaluated for suspected sexual abuse plays out a game which she calls "water tap," thus condensing the image of the tap which is familiar, and the penis which is supposed to be unfamiliar.

Children in the preconceptual and intuitive phases who we suspect may have been abused often engage in traumatic play, which gives them an opportunity to repetitively experience in an active mode what was most traumatic about the event.  However, what detail is expressed over and over in play may not be what is obviously traumatic to an adult's mind.  Instead, the expression in the abuser's eyes or the child being held down may make the biggest impression.  What alerts us to the repetitive play's traumatic origins may not necessarily be its content, but rather its frantic and driven quality.  The content of the play may be obviously sexual, but it can just as likely be aggressive, depending on how the child has experienced and interpreted the events.  Children in the latency years are more able to talk directly about their experience, or at least to struggle to put it in words.
  

Dependence-Independence

Children have an intense need to maintain the tie to their parents, however defective the latter may be.  Young children sometimes talk in all innocence about sexual events, only to find themselves abruptly separated from parents, placed in foster homes, and encouraged to think of the parents as bad people.  The more dependent a child is on the parents the harder it will be for him or her to sustain an accusation of "badness" against them.  Since self and object representations cannot really be fully separate until adolescence, to think of a parent as bad is to think of oneself that way also.  To ward off the consequent catastrophic loss of self-esteem, the experience must be denied both to the external world and to the self.  Thus, most children will often either refuse to talk further to adults about the events or will recant.  But the need to blot out such an important aspect of reality can distort the child's ego in far-reaching ways, such as learning and thinking difficulties, or weakness of the synthetic function of the ego.
  

Libidinal Phase Anxieties

Each libidinal phase has its typical impulses, wishes, anxieties, and conflicts which color the effect traumatic events are likely to have.  In general, the closer the external event to the prevailing fantasies and conflicts at that time, the more traumatic it is likely to be.  Because of the intensity of developmentally determined fantasies the events may be seen as the fantasy come true.  For instance, the child at the height of his oedipal wishes and his castration complex, who has a painful sexual experience, may well believe that all his fantasies of punishment have been realized.  Or the sadomasochistically-tinged fantasies of a latency-aged child will be intensified when the traumatic experience has a large admixture of aggression.  For children under the age of 4, fear of loss of the mother or her love is the major anxiety, while children in the oedipal period and in latency also experience internalized guilt.

It is not infrequent that the children we are asked to investigate have been traumatized in many ways, including the child in our case report.  It then becomes difficult to determine which responses relate to which traumas.  Thus, it is important to remember that states of helplessness and flooding of the ego due to any developmental trauma may become sexualized, tinged with aggression, or both.
  

Defensive Organization

An evaluator experiences first hand the child's defensive maneuvers to avoid experiencing the unpleasant, and potentially disorganizing, affect associated with a traumatic experience.  Children easily experience traumatic states of being flooded with painful, guilt-inducing affects, and they try desperately to ward these off.  The youngest children sometimes refuse to talk or cover their ears as an avoidance or negation of the experience, as though they believe that if they do not acknowledge an event they can wish it away.  Somewhat older children recant an accusation in order to deny it to themselves, or they misremember details which tend to fade in and out depending on how comfortable the child is.  Even latency children under-report the frequency of sexual events, usually telling an evaluator that they happened "only once."  Children frequently turn passive into active in play and action to master traumatic events.  These driven reenactments provide important clues about the reality and nature of the events.  Compliance with the evaluator's wish that the child talk about the events may lead the child to rush rapidly through a superficial account of what happened in order to please the therapist but avoid the affects.  Sometimes children repress the memory of events in response to being told they must keep them a secret; nonetheless the derivatives of the repressed memory often find expression in some other, indirect ways.
  

Superego and Ego Ideal Development

Before the superego has become an internal structure, children rely on the parents' superego for the regulation of their impulses.  Thus, in very young children, (less than 4 years of age), one may initially see very little anxiety, guilt, or embarrassment about sexual events, especially if the encounter was pleasurable.  It is not until later, when the parents convey their intense discomfort to the child, that negative feelings develop.  In older children, in whom the superego is forming, or has recently formed, there develops intense and largely irrational guilt feelings following sexual abuse.

Even when children have little actual intent to take part in a sexual event, they may feel that they are responsible.  A child's superego is largely concerned with results rather than intentions, so to children bad results mean bad motivations.  In addition, the persisting egocentricity of children make them feel that they can control events.  Since the gradual relinquishment of the early omnipotent wishes toward the parents leads to the progressive establishment of the ego ideal, early trauma frequently causes problems with this relinquishment, and hence with the maturation of this function.  This is especially true when the perpetrator goes unpunished for his acts, and important adults are seen as impotent or corruptible.
  

Omnipotence of Self and Object vs. Deidealized, Realistic Appraisal

The feeling that the parents, and by extension most adults, are bestowed with considerable omnipotence is not given up until adolescence.  This makes the child feel that he is no match for the adult, and makes it less likely that the child prior to adolescence will accuse an adult of "badness" without there being some foundation to it.  It also renders the child quite suggestible during an evaluation.  That is the reason it is so important to be careful not to provide hints to children about the "correct" answer, or to lead them to answers by asking very specific questions (see Ceci & Bruck, 1993).  Because children believe that a court always discovers the truth, they can be devastated when it is implied that they are lying or when the defendant is acquitted in the case of actual abuse.  With latency a somewhat more deidealized view of adults and authority comes into play, and the child is better able to cope with an evaluation or a court appearance.
  

Truth, Lies, and Collusion with a Parent

The developmental lines for this particular function tend to be very complex.  The capacity to tell a lie, even a "No, I didn't take the cookie" type of lie, can only develop after there is some sense of feeling separate from the mother, usually around 3 years of age.  More complicated lies, in which another child is blamed for one's own misdemeanors, become possible at a later age; however, lies in which adults are falsely accused are rare before adolescence.

The most confusing possibility for evaluators and therapists alike occurs in the presence of collusion with a parent who is lying or believes something that is untrue — a collusion rooted in the wish to maintain the bond with the parent.  When oedipal and older children are involved collusively with a parent, it is often possible to see the child's play centering around "lies and secrets."  The youngest children find it very hard to keep a secret and it frequently emerges in the play themes.  A sensitive evaluation of the parent-child interaction is very important when collusion is a possibility.
  

Fantasy and Reality

Sometimes it is said that children make accusations of sexual impropriety against adults because of overactive imaginations.  While it is true that children distort reality because they cannot fully integrate it when their egos are immature, they tend to distort it in the direction of "regressive" perceptions.  Thus, the child's theory of sexuality, even in the latency years, tends to be one of oral and anal sexual activities, which would be followed by "oral," "anal," or "umbilical" birth.  Since the child's fantasies do not usually emphasize genital activity, any recital about such activity is all the more remarkable.

On the other hand, the child's clinging to pregenital sexual theories makes it hard to evaluate events which are reported as centering around oral or anal interactions.  Are these distortions of genital sexual interactions, a part of the interaction in actual sexual abuse, or nonsexual interactions blended together with normative oral and anal fantasies?  This is a complex issue, and only a careful look at all the features of the alleged events will enlighten us.
  

Character Formation

We cannot properly discuss character until adolescence when the process of relinquishing the ties to the parents makes possible a more constant and stable repertoire of character traits.  What we see in younger children are tendencies to deal with instinctual wishes in ways which become more habitual, gratifying some derivatives and warding off others.  In highly overstimulated or molested children the upsurge of sexual wishes often cannot be defended against, or modified.  This results in frequent periods of overexcitement, tantrums, and self-destructive behavior.  These may be merely "breakthroughs" or may become modified so that they are then a part of the defensive repertoire against other threatening impulses.  For instance, we well know the impulse-ridden teenager who uses sexuality to ward off preoedipal longings, or sadistic fantasies.
  

Sarah's Development

As we try to apply the foregoing considerations to Sarah, the most salient fact is that this 3-year-old lost her mother as a "mother," because of a recent major change in their relationship.  She went from constant, daily involvement with her, to every other weekend visits.  This loss was unavoidably coupled with a greatly increased proximity to her father, who in turn was in a new relationship with a woman.  It is highly likely that this new set of facts led to an early onset of an intensified oedipal stage, and if so, we would also expect some early superego development.  As these issues are explored, it should not be forgotten that Sarah did not have a secure pre-oedipal period.  Each new developmental stage for Sarah was greatly complicated by the external world.  Whether Sarah was sexually abused or not, she had gone through many potentially traumatic events in her short life.  Another important contemporary loss for Sarah was that of her maternal grandparents, who had played a central role in her raising since a very early age.

How did Sarah feel about her situation?  How did she understand it, what "theories" did she construct to account for it?  What defenses did she employ to prevent anxiety from fragmenting her ego?  These were questions the evaluator did not consider.

We also learn, as reported by the maternal grandparents (who were not interviewed by the evaluator), that Sarah was a "biter."  Does this fact suggest that she had been "bitten" by her mother in the past, and was therefore playing out an earlier trauma, or was she an orally aggressive child because of her own, internal reasons?  In the latter case, licking and biting would be her "action and emotion language," and we might understand Sarah's report about her mother as a projection of her own aggressive impulses, an expression of the complicated feelings of loss, rivalry, anger, and guilt that she felt toward her mother.

Course of the Evaluation

Mother was never notified that Sarah's statement was reported to the Child Protective Services by the social worker at the local hospital.  In addition, Sarah was to see her mother for a total of 40 minutes over the next two months following the report.  The therapist who worked with father and his woman friend recommended an inexperienced therapist for Sarah.  Sarah's therapist apparently took a hard line from the outset and interpreted Sarah's intensity as proof of abuse.  The absence of suggestive play or comment about what mother might have done was taken as proof that the child was avoiding difficult material.  The mother's hostility towards the evaluator was taken as proof of mother's craziness.  And the fact that the mother had neither admitted abuse nor sought treatment for her "problem" was taken as farther proof of abuse.  The therapist's method of treatment of the child is not known.

During this time, mother and her parents found a lawyer, who consulted a child psychiatrist for his opinion regarding mother's potential for being "abusive."  His initial impression was that mother was basically normal."  The attorney then informed the psychiatrist that the testing done by a court-appointed psychologist indicated that the mother was "'borderline' or worse."  The psychiatrist then referred the mother to a highly respected psychologist for farther independent testing to evaluate her mental status and potential for abuse.  The psychiatrist did not share his diagnostic impression with the psychologist at the time of the referral.  This testing confirmed the psychiatrist's impression, so he sent the original report written by the court-appointed psychologist to the second psychologist.  That psychologist's analysis of this report revealed that it was generated by a computer program, with some additional material written by an assistant; in his opinion this report was totally inadequate, misleading, and wrong.

The mother also took a polygraph test at the suggestion of her attorney.  Its results supported her story completely.  The court-appointed evaluator succeeded in having these results ignored by making the statement that false negatives in polygraph tests could be the result of psychosis, serious drug abuse, or pathological lying.  This statement was made in a very general way, in disregard of any evidence that any of these conditions obtained in this case.

A review of the taped interviews that the evaluator conducted with Sarah demonstrated many of the flaws possible when interviewing a child, particularly one as young as this one.  There were many utterances of this 3-year-old that were "oracular," i.e., even after many replays they remained open to widely different interpretations of their context, their point of reference, or their relevance.  In contrast to the uncertainty about Sarah's statements, there could be no doubt about the degree of conviction of the interviewer.  At one point in the session the interviewer is seen stripping a fedora and a three-piece gray suit from a life-sized doll, revealing fleshy breasts and fishnet stockings.  "This is your mother!" she said, completely ignoring Sarah who stubbornly kept muttering: "That is not my mother! That is not my mother!"

Later in the session, when she was observed to be hitting this scary creature with a stick, it was interpreted as "evidence" of her hostility toward her mother.  The evaluator did not hesitate to use psychologically oppressive means to obtain responses which, because of the manner and context in which they were obtained, have to be seen as suspect, e.g. "just answer two more questions, and then you can go to the bathroom!"  The evaluator seemed unempathic, only concerned with her own agenda.  For instance, she never acknowledged or explored with Sarah the effect of the earlier loss of her mother.

Significantly, mother's parents, intimately involved with the early raising of Sarah, were never interviewed by the evaluator, and their valuable developmental experiences and insights were never included in the court report.  Another important source of information was ignored by the evaluator — the mother by that time had a steady relationship with a new man (whom she has since married, and with whom she has had a subsequent child).  He appeared to be an intelligent, reasonable, and sensitive individual who was present with mother and daughter the entire time of the weekend in question, and who confirmed mother's story that Sarah had slipped on the top of a jungle gym while straddling the top bar.  He reported that Sarah "cried briefly but never complained afterwards."

Despite the testimony of the child psychiatrist who presented much of the above information, and the mother's able legal representation, the judge ruled that abuse occurred, and consequently ordered supervised visitation.  This arrangement eventually failed because the mother could not afford to pay for supervision indefinitely, and the mother-daughter relationship deteriorated because of the artificial nature of the contact and the severe limitation of time.

The child psychiatrist made several attempts, both in person and in writing, to present the additional information to the court-appointed evaluator in the hope of persuading her to change her recommendations, to no avail.  He was eventually joined by the visit supervisor, who also felt from observing mother and daughter that abuse had not occurred, also to no avail.  The mother and her family attempted to sue the psychologist whose testing seemed to have sent the court-appointed evaluator off in the wrong direction initially, but found out that such testing is protected from such action. M other eventually gave up, had a second child in her new relationship, and has not seen Sarah in three years as of this writing.
  

Case Discussion

Discerning the meaning of what a child says or does is a complex area of investigation that severely tests the clinician's skills.  Therapy affords a long time to collect data and elucidate meanings, but in evaluations a great deal is often made of only a few communications, usually in the absence of a therapeutic alliance.  A particularly troublesome quandary, often faced in an evaluation, is the determination of whether a child's report is an accurate representation of a reality, or whether it is more a reflection of the child's internal state.  All too frequently evaluators go by the principle that "the child never lies about abuse" and simply assume that a real event did occur whenever it is reported.  Although this may be an easier position for the clinician to take, it ignores the complexities inherent in the situation.

In the case presented here we have a 3-year, 2-month-old girl who had been separated from her mother and maternal grandparents (who were probably her primary caregivers) for the previous four months, after returning from a visit with mother.  This case has two striking and unusual features: first, the mother was accused of the sexual abuse, and second, the child had gone through the traumas of her parents' stormy marriage, difficult divorce, and loss of her mother.

Sarah had essentially been given over by her mother to her father at 2 years, 9 months, so that during the rapprochement phase she had suffered a disruption in the relationship with her most important object.  Since that time she had seen her mother only every other week for weekend visits.  In a child of under 3 this amount of contact is quite unlikely to be enough to maintain an intrapsychic image of a good object, or, since object constancy has probably not been achieved, a good self-object.  One way she responded was by remaining a hitter and a biter, a persistence of oral-stage conflicts which she had exhibited earlier in life and with which her maternal grandparents had tried to help her.  She was still not toilet trained, despite being past 3 years of age.  The structuralization of her ego was lagging, as doubtlessly the inconsistencies and losses of parental care would lead us to expect.

In this case the possibility that mother did not molest her child was not adequately considered.  (This is a common problem with allegations of sexual abuse.)  It is unusual for a mother to be accused of molesting a daughter.  It is unusual to find women who sexually abuse children of either sex, who are not social isolates, have not had abusive childhoods themselves, or are not severely emotionally disturbed (Wakefield & Underwager, 1991).  The only negative evidence concerning the mother's emotional stability was a superficial computerized psychological report suggesting that she was "borderline," a diagnosis contradicted by a subsequent, more thorough, psychological evaluation.

One alternative interpretation of her statements is that Sarah combined the pain of the perineal injury she sustained (and possibly the pain of being hit with a spoon as a punishment) with the pain of separation and her own "biting" wishes.  When making her report to her father, it is clear that Sarah knew that there are different kinds of actions, those for which one is responsible and "accidents" for which one is not responsible.  This distinction points to her having superego precursors that are beginning to determine her actions, even if not yet fully effective.  Sarah might have been projecting her own "bad" wishes onto her mother or, since she is not intrapsychically separate from mother, she could experience her own "bad wishes" as mother's "bad wishes."  She could have been painfully uncertain about who is bad, her mother for leaving her or she herself for wanting to bite mother in retaliation.  Is it possible that the outside pain (as from biting), is condensed with the inner pain of longing and anger from the separation?  If this were the case, what she might "really" be saying to the adults is that she feels her mother left her because of her hitting and biting wishes, and that this is very painful to her.

There may well have been difficulties in the relationship between mother and daughter before the weekend in question, but there was no opportunity to explore this because the two were never seen together during the evaluation.  And by the time the visitation supervisor provided her positive opinions about the relationship, the evaluator and the court were no longer interested.

Fortunately, we do not have to rely solely on what the child says in this kind of situation.  The child's symptoms are also available.  Although very young children often do not find sexual events anxiety-producing since the superego is not yet internalized, any painful stimuli usually renders it traumatic, and the sexual events become organized in the child's mind around the pain.  In this case, it is hard to imagine that a child would not find an oral sexual experience, complete with biting, painful and traumatic.  If the experience was painful and traumatic, then we would expect to see various signs of both anxiety and overstimulation.  But Sarah did not display any apparent post-traumatic symptoms, with the possible exception of the biting and licking of her father's fiancée.  The reason that this exception has a low level of plausibility is that there were indications that these behaviors had never been given up (the more that could be learned about this the better).  The lack of any subsequent symptoms or reports of post-traumatic play at home or in her therapy are telling evidence against the alleged abuse having occurred.

In interviewing this child we would expect that themes of loss, denial of loss, and attempts to restitute the good object would dominate the picture.  Attempts to pressure the child for disclosure of sexual material, for further evidence of "badness" on her part or her mother's, would not be in the best interest of this child, whose ego already has been quite battered.  If one pushes and prods the child there is no way of telling if the material given by her constitutes a submission to the powerful and aggressive evaluator or therapist, a way to please the interviewer, or the truth.  Chances are that a long period of therapy working first on the loss of mother would be necessary before any reliable material relating to the alleged sexual trauma could be obtained.
  

General Discussion

Charges of sexual abuse in the context of custody are extremely serious, disruptive, and difficult to verify.  What is learned from this case, and from so many others, is that the process of evaluation can itself contribute to a lasting morass of personal and family chaos.

This paper has dealt with the conduct and effect of professional intervention.  However, an implicit and crucial question has been to consider just what constitutes a successful outcome of this intervention.  It is not simply a matter of verifying or disproving an accusation. whether or not abuse actually occurred, and whether or not that can be determined, children must come out of the evaluative experience feeling protected.  Despite the obvious threats to themselves and to the persons most responsible for their care, children must feel that a protective umbrella has been formed to restore or build a safe environment.  The evaluator cannot do this directly, but should endeavor to facilitate this by strengthening and supporting healthy elements among the adults in the family.  Guiding the child and others into therapy may provide the best opportunity for this to happen.

This is especially true in cases where the facts remain uncertain.  Long-term, patient, and non-judgmental therapy may allow for eventual clarification.  Even when this is not possible, it may allow children to understand and work through their inevitable sense of responsibility and loss.  Children, at their own pace, should be allowed to play or talk about whatever they wish.  If they have been traumatized, this will surface in time.  The quality rather than the content of the play may give a better sense of whether or not a child has been abused.  The therapist should honor the child's defenses rather than roughly bypass them to obtain the "truth."  If the evaluation or the therapy is experienced as an inquisition, it can lead to the formation of pathological defenses in the child.  Confusion, conflict, and the intensification of intra-and interpersonal disturbance are all too frequently the result.

The potentially traumatic effect of the evaluation can not be minimized.  It can be harmful even if nothing has happened.  The child may already have been terrified by the initial interventions of family members, police, or hospital staff, and may experience the evaluation as a further assault.

It is our contention that an accusation of abuse usually signals a significant disorder in the family.  The evaluator must widen the field of inquiry and perspective to allow an understanding of what abuse means to everyone in the family, and to comprehend the forces that generate a real or false charge.

How do we really understand the phenomenon that many accusers turn out to have been abused themselves?  Are they simply more sensitive to a common problem that society has been denying?  Are they unconsciously choosing abusive mates, or unconsciously provoking abusive behavior in their families, projecting and replaying their own experience through unsuspecting family members?

We certainly have to think long and hard about better ways for various agencies and systems to cooperate.  Differences in orientation, philosophy, training, purpose, and experience of the various agencies inevitably lead to serious problems.  These can include errors in judgment, repetitions, false paths followed, inter-agency hostilities and competitions, which all add to or create trauma for family members caught up in this nightmare.

More attention must be paid to the emotional health of the evaluator.  At the very least this unfortunate person will soon come to feel exactly what the child does in the eye of the investigative and psychological storm.  Though this can be helpful as a diagnostic tool, it is a painful one, and adds considerably to the already high level of stress.  If the evaluator is not unbalanced already, these cases have the potential for disturbing the sanest or calmest among us.  In addition to unconscious projections, which are inevitably focused on the evaluator, there are pressures to protect the child, to please the court with a decision, to manage the evaluator's own troubling internal reactions to abuse, and to defend against contentious and passionate adults who may include members of the family, attorneys, or other professionals who disagree.  The result is either rapid burn out or a tendency to adopt zealous positions regarding the topic of sexual abuse, which offer protection from the pain of uncertainty.  Consultation with colleagues seems even more necessary in this area than in others.

We need to resolve the basic polarity between the pressure to rush to judgment, often from the judicial system, and the importance of patience, so that the child is able to deal with many powerful forces, and so that the family dynamics may unfold.  At times the evaluator must act swiftly and decisively too, but usually the therapeutic skills of waiting, neutral observation, and a thoughtful search for a larger perspective are far more beneficial.  Closer contact and consultation among all disciplines, including regular meetings to discuss cases, may be useful.

And there are other polarities besetting people in this field.  Many individuals, therapeutic camps, and agencies, divide into warring factions of "believers" and "skeptics."  While there is no doubt about the increase in accusations of sexual abuse in the context of custody disputes, it still remains to be determined what percentage of these are false.  Similarly, it is unclear whether there are more cases now than before, or just a greater willingness to recognize what has always been going on.  We are learning that recovered memories are not always true.  There is a question whether we can distinguish reliably between true and false memories.  These are matters that require persistent and careful thought and discussion.  It is easier, as in this paper, to point out what has and could go wrong, but very difficult to find solid, positive ground.

Despite the many unknowns, we remain firm in our conviction that there is no substitute for sophisticated clinical experience and judgment to reach an integrated picture of the functioning of children — to assess such issues as memory, truth-telling, suggestibility, compliance, and unconscious forces, in a developmental framework.  This in turn must be folded into the context of family dynamics, and the motivation and function of particular adults.
  

References Cited

Awad, G. A., & McDonough, H. (1991). Therapeutic management of sexual abuse allegations in custody and visitation disputes. American Journal of Psychotherapy, 45, 113-123.

Ceci, S. J., & Bruck, M. (1993). Suggestibility of the child witness: A historical review and synthesis. Psychological Bulletin, 113, 403-439.

Coleman, L. (1990). False accusations of sexual abuse: Psychiatry's latest reign of error. Journal of Mind and Behavior, 11, 545-556.

DeMauss, L. (1991). The universality of incest. Journal of Psychohistory, 19, 123-164.

Goodman, G. S., Jones, D., Pyle, E., Prado-Estrada, L., Port, L., England, P., Mason, R., & Rudy, L. (1988). The emotional effects of criminal court testimony on child sexual assault victims: A preliminary report. In J. Shapland & J. Drinkwater (Eds.), Issues in Criminological and Legal Psychology (Vol. 13), pp. 46-54. The British Psychology Society.

Hunter, R., Yuille, J., & Harvey, W. (1990). A coordinated approach to interviewing in child sexual abuse investigations. Canada's Mental Health, 38, 14-18.

Indest, G. (1989). Medico-legal issues in detecting and proving the sexual abuse of children. Journal of Sex and Marital Therapy, 15, 141-160.

Kahr, B. (1991). The sexual molestation of children: Historical perspectives. Journal of Psychohistory, 19, 191-214.

Kelley, S. J. (1990). Responsibility and management strategies in child sexual abuse: A comparison of child protective workers and police officers. Child Welfare, 69, 43-51.

Kendall-Tacket, K. A. (1992). Professionals' standards of "normal" behavior with anatomical dolls and factors that influence the standards. Child Abuse & Neglect, 16, 727-733.

Kendall-Tacket, K. A., & Watson, M. W. (1991). Factors that influence professionals' perceptions of behavioral indicators of child sexual abuse. Journal of Interpersonal Violence, 6, 385-395.

Korner, 5. (1990). Evaluating child abuse: Who is the client? Psychotherapy in Private Practice, 8, 1-11.

Muram, D. (1991). Interpretations of colposcopic photographs: Evidence for competence in assessing sexual abuse. Child Abuse & Neglect, 15, 69-75.

Muram, D., Dorko, B., Brown, J. C, & Tolley, E. A. (1991). Child sexual abuse in Shelby County, Tennessee: A new epidemic? Child Abuse & Neglect, 15, 719-725.

Ordway, D. P. (1983). Reforming judicial procedures for handling parent child incest. Child Welfare, 62, 68-75.

Paradise, J. E. (1989). Predictive accuracy and the diagnosis of sexual abuse: A big issue about a little tissue. Child Abuse & Neglect, 13, 169-176.

Pogge, D. L., & Stone, K (1990). Conflicts and issues in the treatment of child sexual abuse. Professional Psychological Research and Practice, 21, 354-361.

Realmuto, G. M., & Wescoe, S. (1992). Agreement among professionals about a child's sexual abuse status. Child  Abuse & Neglect, 16, 727-733.

San Diego County 1991-1992 Grand Jury Report Number 8. Child sexual abuse, assault, and molest issues.

Saunders, E. J. (1988). A comparative study of attitudes toward child sexual abuse among social work and judicial system professionals. Child Abuse & Neglect, 12, 83-90.

Schetky, D. H., & Benedek, E. P. (1989). The sexual abuse victims in the courts. Psychiatric Clinics of North America, 12, 471-481.

Strickland, S. (1989). Sexual abuse assessment. Pediatric Annals, 18, 495-500.

Summit, R. C. (1983). The child sexual abuse accommodation syndrome. Child Abuse & Neglect, 7, 177-193.

Terr, L. (1988). What happens to early memory of trauma? A study of twenty children under age five at the time of documented traumatic events. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 96-104.

Trute, B., Adkins, E., & McDonald, G. (1992). Professional attitudes regarding the sexual abuse of children: Comparing police, child welfare and community mental health. Child Abuse and Neglect, 16, 359-368.

Wakefield, H., & Underwager, R. (1991). Female child sexual abusers: A critical review of the literature. American Journal of Forensic Psychology, 9, 43-69.

Watson, A. S. (1988). Some psychological aspects of the trial judge's decision making. Mercer Law Review, 39, 937-960.

White, S., & Quinn, K. (1988). Investigating independence in child sexual abuse evaluations: Conceptual considerations. Bulletin American Psychiatry and the Law, 16, 260-278.
  

Other References

Benedek, E., & Schetky, D. (1988). Problems in validating allegations of sexual abuse: 1. Factors affecting perception and recall of events. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 912-915.

Criville, A. (1990). Child physical and sexual abuse: The role of sadism and sexuality. Child Abuse & Neglect, 14, 121-127.

Daldin, H. (1988). The fate of the sexually abused child. Clinical Social Work Journal, 16, 22-32.

Fundudis, T. (1989). Children's memory and the assessment of possible child sexual abuse. Journal Child Psychology & Psychiatry, 30, 337-346.

Furniss, T. (1985). Conflict-avoiding and conflict-regulating patterns in incest and child sexual abuse. Acta Paedopsychiatrica, 50, 299-313.

Gaddini, R. (1983). Incest as a developmental failure. Child Abuse & Neglect, 7, 357-358.

Goodwin, J. (1988). Post-traumatic symptoms in abused children. Journal of Trauma and Stress, 1, 475-488.

Muchlinski, E., Boonstra, C., & Johnson, J. (1989). Planning and implementing pediatric sexual assault evidentiary examination program. Journal of Emergency Nursing, 15, 249-255.

Paradise, J. E., & Emaus, F. J. (1990). Substantiation of sexual abuse charges when parents dispute custody or visitation. Pediatrics, 488-490.

Quinn, K. (1988). The credibility of children's allegations of sexual abuse. Behavioral Sciences and the Law, 6, 181-199.

Rowan, E. L, Rowan, J. B., & Langelier, P. (1990). Women who molest children. Bulletin of the American Academy of Psychiatry and the Law, 18, 77-83.

Sherkow, S. P. (1990). Evaluation and diagnosis of sexual abuse of little girls. Journal of the American Psychoanalytic Association, 38, 347-369.

Stanley, S. (1989). Child sexual abuse: Recognition and nursing intervention. Orthopaedic Nursing, 8, 33-40.

Sugar, M. (1983). Sexual abuse of children and adolescents. Adolescent Psychiatry, 11, 199-211.

Walker, L. E. (1990). Psychological assessment of sexually abused children for legal evaluations and expert witness testimony. Professional Psychology: Research and Practice, 21, 344-353.

Watkins, S. A. (1990). The double victim: The sexually abused child and the judicial system. Child and Adolescent Social Work Journal, 7, 29-42.

Will, D. (1983). Approaching the incestuous and sexually abusive family. Journal of Adolescence, 6, 229-246.

Yates, A., & Musty, T. (1988). Preschool children's erroneous allegations of sexual molestation. American Journal of Psychiatry, 145, 988-992.

Yates, A., & Terr, L. (1988). Anatomically correct dolls: Should they be used as the basis of expert testimony. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 254-257.

Zueler, M. B., & Reposa, IL E. (1983). Mothers in incestuous families. International Journal of Family Therapy, 5, 98-110.