Psychological Assessment of Alleged Child Sexual Abuse Victims

Psychological Assessment is different from therapy. A psychologist must know which is being requested and when one stops and the next begins. Likewise, clinical goals are different from forensic goals. Clinical goals in assessment relate to identifying problems in functioning with the plan of remediation or intervention. Forensic goals in assessment pertain to addressing questions of interest to a legal and/or court procedure.

Psychological reports may contain any or all of these issues, but psychologists should be clear as to what they are pursuing and why, especially when dealing with cases of Child Sexual Abuse (CSA). In addition, non-psychologist mental health professionals have many important roles in the assessment process of CSA cases as well..

This section will primarily limit comments to issues pertaining to the assessment processes utilized by psychologists which are usually different from assessment issues concerning other mental health professionals and forensic examiners. Naturally, psychologists sometimes find themselves in the roles that forensic interviewers and/or mental health professionals occupy, but it is not always necessary to have the training and credentials of a psychologist to fill some of these other roles.

Specific Guidelines for non-psychologist assessments of alleged abuse can be obtained partially through other sections mentioned on this web site. Further information and/or specialized training will be needed and can be pursued through the following organizations:

American Professional Society on the Abuse of Children:
www.apsac.org

Family Violence and Sexual Assault Institute:
www.fvsai.org

The National Association of Counsel for Children:
www.naccchildlaw.org

Georgia Council on Child Abuse:
www.gcca.org

National Children's Advocacy Center:
www.ncac-hsv.org

Southern Regional Child Advocacy Center:
www.ncac.org/srcac/index.htm

Office of Juvenile Justice and Delinquency Prevention:
www.ojjdp.ncjrs.org

American Academy of Child & Adolescent Psychiatry:
www.aacap.org/clinical/index.htm

American Academy of Pediatrics:
www.aap.org/practice/childprotection.html

National Association of Social Workers: www.naswdc.org/practice/standards/child.htm

The International Society for the Study of Dissociation:
www.issd.org/

Information and training to specifically assist Georgia psychologists in psychological assessments can be further explored through the following organizations:

Georgia Psychological Association:
www.gapsych.org

American Psychological Association:
www.apa.org

The American Psychological Association has a number of linked web sites that psychologists will find invaluable in refining skills and broadening understanding of special issues in dealing with CSA cases. Perhaps the place to start with APA web site links is to review the ethical principles for psychologists concerning psychological assessments of CSA cases.

For a web site review, please consider paying special attention to the following categories: "Boundaries of Competence, Maintaining Expertise, Avoiding Harm, Multiple Relationships", the entire section of "Evaluation, Assessment, or Intervention", the entire section of "Privacy and Confidentiality", and the entire section on "Forensic Activities". These sections can all be found in the Table of Contents of the web site:
www.apa.org/ethics/code.html

To refine the issues further, it is suggested that psychologists review other APA web site links pertaining to psychological testing, including the following:

www.apa.org/science/testing.html

www.apa.org/science/standards.html

www.apa.org/science/disclosure.html

www.apa.org/science/faq-findtests.html

www.apa.org/science/ttrr.html

www.apa.org/science/testclearinghs.html

However, many psychologists will find that the most specifically applicable set of web site guidelines that APA lists for psychological assessments of suspected child sexual abuse victims are the "Guidelines for Psychological Evaluations in Child Protection Matters". These highly useful guidelines can be located at:
www.apa.org/practice/childprotection.html

It is from these APA guidelines, as well as from the author's practice experience, that the issues enumerated below are taken. They may be helpful to psychologists who find themselves in roles related to psychological assessment of children suspected (or confirmed) to have had experiences of sexual abuse.

General Guidelines for psychological assessments can start with a list of questions psychologists frequently are asked to address in the assessment of CSA cases:

• How seriously has the child's well being been affected by the abuse?
• What therapeutic interventions would be recommended to assist the child?
• Can the parent(s) be successfully treated to prevent harm to the child in the future?
• Do other psychological problems exist separately from abuse issues?
• What would be the psychological effect on the child if returned to the parent(s)?
• What would be the psychological effect on the child if separated from the parents, or if parental rights are terminated? ("Guidelines for Psychological Evaluations in Child Protection Matters", P.3, 1998)

Attempting to answer these questions through psychological assessments can be very challenging and even stressful to psychologists. It is important for psychologists who choose to accept the task of assessment in CSA cases to be adequately trained and prepared for the complex issues involved. However, the guidelines suggested on this web site and by the APA are not meant to be mandatory, with penalties attached to non-compliance. In fact, practice guidelines continue to be updated and are in the process of flux and change. Guidelines suggested here are meant to be aspirational and not mandatory.

Assessment: Nuts and Bolts

First Tool: Relationship Building: develop rapport; be therapeutic, not traumatic to the child.

Guidelines:

1. Interview the child alone if at all possible. If parents or siblings are in the room, the information from the child could be biased. This may definitely be questioned in court.
2. Keep hands off the child. Even touch meant to be encouraging or reassuring may be associated in the child's mind with past abuse.
3. Explain your role to the child in developmentally appropriate language. Include the child, at a developmentally appropriate level, in the process of "informed consent". Informed consent will also be necessary, with the legal guardian giving permission for the assessment.
4. The orientation of the psychologist in an assessment is to objectively explore the best needs of the child and to avoid bias due to alliances with family/agencies etc.
5. Psychologists should avoid multiple relationships that could potentially bias or place at risk the objectivity of their primary role.

Hints:

1. Although psychological evaluators differ with each other in their opinions, many psychologists prefer to get family information and special details regarding the allegations before meeting with the child. The issue at stake is a trade-off between basing conclusions on the most comprehensive information possible vs. maintaining maximum objectivity through avoiding influence from other persons' biases.
2. Get on the child's level. Use toys, drawings, toy phones, puppets, etc. to interact with child (see web site section by Ethel Amacher for detailed description of child-friendly forms of communication and information gathering approaches).

Second Tool: Fact Finding

Guidelines:

Determination of the events of the alleged sexual abuse (Fact Finding) and relationship building are also activities and goals pertinent to forensic interviewers who may have professional backgrounds besides psychology. For a thorough review of these issues, please refer to web site materials written by Ethel Amacher, Ann Graffam Walker, and also by Connie Carnes. For the sake of clarifying the boundaries of roles, these issues will not be discussed in detail in the present section about psychological assessments, but would include such issues as:

1. Using child's language level
2. Using forensically defensible questions
3. Seeking information to explain a progression of events
4. Receiving the child's feedback in an emotionally appropriate manner
5. Exploring alternative hypotheses
6. Comparing statements with test data findings
7. Recognizing and recording "Behavioral Reenactment" of abuse behaviors during the interview, etc.

Third Tool: Assessment Measures

Guidelines:

1. Obtain an estimate of cognitive/language functioning. This doesn't have to be a long-form IQ test, but could include a brief indicator of the child's ability to understand and respond to questions. The child's cognitive and language functioning has clinical significance (e.g. school placement issues) as well as forensic relevance (proof that the child is competent to understand and answer interview questions). Some examples of cognitive level or language development tests include:
• Kaufman Brief Intelligence Test (K-BIT) (Kaufman, 1990)
• Kaufman Infant and Preschool Scale (Kaufman, 1979)
• Boehm Test of Basic Concepts (Boehm, 1984)
• Cognitive Abilities Test, Form 5 (Thorndike & Hagen, 1995)
• Cognitive Diagnostic Battery (Kay, 1982)
• McCarthy Screening Test (McCarthy, 1978)
• Peabody Picture Vocabulary Test-III (Dunn, 1997)
2. Assess degree of psychological impact. Useful are depression inventories, trauma inventories, dissociation inventories, behavioral rating scales, and personality inventories. (Warning: be aware of professional licenses required to interpret many of these measures). Projective tests are useful in assessing clinical issues related to treatment needs, but are the most vulnerable to forensic challenge in court. Although not an inclusive list, the following are some of the tests and inventories used by many psychologists in abuse assessments:
• The Child Behavior Checklist (Achenbach, 1992)
• AAMR Adaptive Behavior Scale-School, Second Edition (Nihira, Leland, & Lambert, 1993)
• Behavior Assessment System for Children (Reynolds & Kamphaus, 1992)
• Burks' Behavior Rating Scales (Burks, 1977)
• Behavior Rating Profile: Second Edition (Brown & Hammill, 1990)
• The Child Sexual Behavior Inventory (Friedrich, 1997)
• The Trauma Symptom Checklist for Children (Briere, 1996)
• The Child Depression Inventory (Kovacs, 1992)
• Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1989)
• The Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) (Hathaway & McKinley, 1992)
• Children's Impact of Traumatic Events Scale-Revised (CITES-R) (Wolf et. al., 1987)
• Children's Apperception Test (CAT) (Bellack, 1993)
• Roberts Apperception Test for Children (RATC) (McArthur and Roberts, 1990)
• The Picture Story Telling Test (Caruso, 1988)
3. Other issues in Assessment:
1. Assess child's understanding of truth/lie
2. Use of forensic drawings
3. Use of anatomically detailed dolls (psychological and/or other evaluators should first carefully examine guidelines from: www.apsac.org)

Hints:

1. Research shows sexually abused children are 6-8 times more likely to include genitalia in drawings.
2. Dolls can be ordered from several sources, such as WPS: 1-800-648-8857

Contacting Psychological Test Publishers On-Line

• American Guidance Service: www.agsnet.com
• APA FAQ/Finding Information About Psychological Tests:
  www.apa.org/science/faq-findtests.html#locatepub
• Buros Institute of Mental Measurements: www.unl.edu/buros
• Consulting Psychologists Press: www.cpp-db.com
• MHS: www.mhs.com
• NCS Pearson: www.ncs.com
• Pro-ed: www.proedinc.com
• Psychological Assessment Resources: www.parinc.com
• The Psychological Corporation:www.psychcorp.com
• Riverside Publishing: www.riverpub.com
• Western Psychological Services: www.wpspublish.com

Fourth Tool: Evaluating the Credibility of Abuse Allegations

Assessing for co-morbid clinical conditions

Since a psychological assessment may have both clinical and forensic purposes, another function may be to identify additional problems beyond those related to the impact of alleged sexual abuse. Psychological testing may be especially valuable in identifying and exploring such conditions as:

• Neurological Dysfunction
• Learning Disabilities
• Mental Retardation
• Attention Deficit Hyperactivity Disorder
• Affective Dysregulation
• Personality Disorders

Final Thoughts

• Be aware of the mandated reporting law in your state. Psychologists must report abuse if they have a suspicion of abuse.
• Make sure all releases are signed to be clear about where written reports will be sent.
• Get as much specialized training and supervision as possible. Document any supervision (even peer supervision) in the child's chart.
• Psychological evaluators of children with abuse allegations must be trained in:
• assessment techniques
• child development
• child interviewing
• forensic psychology
• child memory issues
• play therapy / art therapy
• cultural issues

Information Included in an Abuse Specific Psychological Report

There are many different formats for psychological reports. However, it may be helpful to review the sample report that follows (with identifying information removed for purposes of confidentiality):

BACKGROUND INFORMATION:

I received background information on _______from her caseworker in Kansas, Ms._______________, and her local caseworker, Ms.______________. I also interviewed _________ foster mother,______________. Ms. _________sent me written documents on_______. I was asked to evaluate ________ and provide treatment recommendations.

I asked Ms. _________to complete the Achenbach Child Behavior Checklist on_______. Results indicate that she sees ________as having problems in academic areas and in sexual behavior. Her clinical scales are all within normal limits, although the withdrawn scale and the attention problem scale are elevated. I also received an Achenbach Teacher Report Form on ______from her current teacher. Her teacher states that she does not know ______ well enough yet to comment on problems. Her clinical scales are all within normal limits, with the highest scales being the anxious/depressed scale, the attention problems scale, and the delinquent behavior scale.

I spoke with Ms. _____________on 9-01-00 to obtain information about ________. Ms. ____________ said ______has talked to her about her brother who died. She reportedly slept with this brother, but _____ had denied anything inappropriate occurred with him. Ms. ___________ said Ms. ________ had complied with every request the agency had made.

I spoke with Ms. ________ on 9-10-00. We discussed the testing needed by her agency. She was concerned about ________ sexual behaviors, since ______ has been out of her biological home for 2 years, and neither placement since then reported any sexual behaviors, until now.

CLINICAL INTERVIEWS AND TEST RESULTS:

I first met with _____ on 9-02-00. Before meeting with her, I spent an hour with her foster mother in order to understand how _____ is currently functioning in her home. Ms. _________ indicated that she and her husband hope to adopt______. ________'s birth mother is a second cousin of her husband. _______'s older brother, ______, killed himself last April, reportedly as a consequence of alcohol and drug use. ______ has lived with the ________'s for 9 months. Ms. ________ thought _______ was happy with them and fit in well. She had some problems at school with not doing her work and talking too much.

_______ has had a number of behavior problems in the________ 's home. This includes crying, hitting, kicking, and refusing to go to time out. They have gone to ________ Mental Health for counseling since January 2000. _____ 's therapist there referred ____ here because of sexual acting out by____. Specifically, when lying on Ms.______ 's bed watching television, ______ rubbed her private part on Ms.______ 's bottom. _____ also was accused of looking at a 3-year-old boy's penis and kissing and sucking it, then telling him not to tell. _____ has reportedly tried to touch Ms.______ 's breasts, and one time tried to touch Mr._____ 's private part. Ms. _______ has also observed _____ with both hands in her pants while grunting. Ms. _______ said _____ told her she used to watch her mother having sex with her boyfriends.

______ attends _________ Elementary School, and is repeating 2nd grade. Her school counselor originally referred her to therapy because _____ would bark like a dog or use baby talk when asked questions. She demonstrated regressive behavior. She begs to sleep with Ms. _______ at night, but this is not allowed.

My first interview with ______ was on 9-02-00. She was cooperative and told me her age. She said she lives with ______ and _________, who will be her real parents. She talked about her birth mom, ______, and her birth dad, ________. Then she said he wasn't her birth dad, he was her "fake Dad". She said her birth dad was smoking and drinking and she had to go to different foster homes. She discussed all her moves. She was very positive in talking about her current home.

My second appointment with _____ was on 9-17-00. She talked about her recent birthday. She completed projective drawings during this appointment. During her free drawing, she took a long time and interacted with me frequently. This drawing was a rainbow. When I asked her to draw a house, she asked me if she could draw a cloud with her brother who died. She included this in her picture, and told me he was in his 20's and died from smoking. ______ talked about______, her counselor. She did not know why she sees her, but said it is fun.

The house and tree _____ drew were both from her current environment, indicating good attachment to her current family. Even more so, she drew (foster mother) for her "person" drawing. She said ________ was trying to find her in the woods. Her nurturing needs are evident, and she seeks this from her current mother. For her drawing of her family, she drew herself, then ________and ____(current parents). She said they were in the water at a water park. The picture was very positive in emotional tone.

My next appointment with ____ was on 9-24-00. During this appointment, I asked ____to draw the worst thing that had happened to her. She immediately said that her brother died. However, her picture was of her birth mom, and she said she lived on the streets with this mom. She drew her mother smoking, and said they were living on the street and in the same room in a hotel. _____ then talked about how she is not "_______" anymore, she is "______", because her parents signed adoption papers. I asked _____to draw the best thing that had happened to her. She drew herself, her current dad and mom, and said the best thing was them adopting her. She said she has called them "mom" and "dad" since she came, but she used to call them "aunt" and "uncle".

I showed ____forensic drawings of an elementary school aged child, front and back views (female). I asked her to label all body parts, which she did. However, she did not want to label the breasts or genitals, and covered the vaginal area with her hand. She finally labeled the breasts as "nipples" and the vagina and buttocks as "private". I then asked _____to color in any part that had ever been touched when she did not want it to be touched. She immediately said "none".

She then colored in the vaginal area, and said ______ touched it, but did not know what he touched it with, but she thought it was his hand. She said this happened in Kansas, in a hotel. She said they had the bed with blankets and she slept on the floor on a mattress. She said ______slept on the floor without anything. She said ______was______ 's boyfriend, and ______ was in the hotel room when this happened, but she was taking a shower. She said she had her clothes on and was sitting on the floor on her mattress. She said _______was with her but her mother never knew about it. _____ thought she was 5-years-old at the time. She said her other brother was not there; he was at a different house. _____ said she got moved away from ______when she was 6. She denied that either of her brothers ever touched her private part, and she also denied that her mother had done that. She said the only person who did that was her mother's boyfriend, and he is still her boyfriend.

I administered the Peabody Picture Vocabulary Test III on this date. This is a test of intelligence as measured by receptive language._____ 's scores are as follows:

These scores are much lower than what would be expected from her past scores and her current school performance. Therefore, I administered the following tests to get a more detailed description of her abilities:

On 9-25-00, I administered the Wechsler Intelligence Scale for Children-Third Edition (WISC III). This is an intelligence test which is divided into two main areas: verbal and performance. Scaled scores can range from a low of 1 to a high of 19. Ten is considered an average score._____ 's scores are as follows:

_____ 's scores on this test indicate average ability in both verbal and performance areas of intelligence. She has some scatter among subtests, but most scores fall within the average range, except for Object Assembly and Mazes. She may have difficulty with planning ahead in nonverbal activities.

_____ also completed the Wide Range Achievement Test-3 on 10-17-00. This test examines her ability in three main subject areas. ____'s scores are as follows:

_____ 's achievement in these three areas is compatible with her intelligence. She is in the average range in all three subject areas.

The final test administered to _____was the Incomplete Sentences Blank, given on 10-17-00. This test indicated that _____is very concerned about her brother and thinks about his death frequently. This issue needs to continue to be explored in therapy. She is very positive about her current home environment and her current parents. She has many aggressive feelings, and wants to hurt people when they boss her around. She also complains about nightmares.

SUMMARY AND RECOMMENDATIONS:

__________________ is an 8-year-old white female who is currently being evaluated prior to being adopted by the family she is currently living with. Mr. and Mrs. ______ are related to______ 's biological mother, and they are very interested in adopting ____. They seem to be very committed to _____'s well being and have followed through with every suggestion their caseworkers have made. They have been taking _____to counseling at the Mental Health Center, but she was referred here for further evaluation because of sexual acting out by_____.

______ is having obsessive thoughts about her brother and his death. She talks about this and thinks about it much of the time. She also is quite angry about her biological mother and the life she led with her. She describes sleeping on the floor in motel rooms while her mother and her mother's boyfriends slept in beds with blankets. She denied inappropriate touching by her brothers, but disclosed sexual abuse by one of her mother's boyfriends, _________. She believes her mother is still with this man.

______ has several behavior problems, including sexual acting out, nightmares, temper tantrums, regressive behavior, and some inattention in school. However, she is of average intelligence and average achievement levels in three main academic areas, suggesting no evidence of a Learning Disability. Her low score on the PPVT III may be explained by her lack of exposure to vocabulary in her past. This type of deficit can frequently be made up in a stimulating educational environment.

I strongly recommend _____ remain in her current placement and be adopted as soon as possible. The permanence will help _____ to feel secure and continue to make progress. She is doing well in school and gets good support from her foster parents. She needs to continue in therapy on a regular basis, in order to work on grief and loss issues, past abuse, and anger.

I hope these suggestions are helpful in the planning of ______'s future. Feel free to contact me if further information is needed.

Nancy A. McGarrah, Ph.D.
Licensed Psychologist

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Wood, J. et al., (1993) "Suggestions for Improving Interviews in Child Protection Agencies," Child Maltreatment, Vol. 1, No. 3.