Elsevier

Child Abuse & Neglect

Volume 25, Issue 4, April 2001, Pages 489-503
Child Abuse & Neglect

The diagnostic utility of sexual behavior problems in diagnosing sexual abuse in a forensic child abuse evaluation clinic

https://doi.org/10.1016/S0145-2134(01)00222-8Get rights and content

Abstract

Objective: This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample.

Method: A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores.

Results: The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children.

Conclusions: This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse.

Résumé

Objectif: Cette étude examine l’utilité de considérer les problèmes de comportement sexuel en tant qu’indicateurs pour le diagnostic d’abus sexuels. On a fait l’hypothèse que, les problèmes de comportement sexuel ayant des déterminants multiples, ils sont en relation variable avec les abus sexuels dans un échantillon clinique.

Méthode: On a examiné un échantillon de 247 enfants évalués pour abus sexuels dans une clinique où l’on pratique des expertises multidisciplinaires. Les résultats du “Child Behavior Checklist” (CBCL) et du “Child Sexual Behavior Inventory” (CSBI) ont été analysés et comparés à ceux d’une évaluation stucturée indépendante de ces scores.

Résultats: L’évaluation de l’équipe d’experts a mis en évidence des abus sexuels dans 25% des cas et n’en a pas mis en évidence dans 61%. Les enfants de cet échantillon ont affiché un haut niveau de problèmes à la fois d’ordre sexuel et d’ordre non-sexuel. Toutefois on a noté une variabilité considérable dans les scores concernant les problèmes d’ordre sexuel. De cette façon, dans cette étude, un score élevé, ou un score bas n’avait pas de relation avec un diagnostic d’abus sexuel. En fait, des enfants non-violentés sexuellement pouvaient tout autant présenter un score CSBI élevé que des enfants ayant subi une violence sexuelle.

Conclusions: Cette étude n’a pas trouvé de relation significative entre un diagnostic d’abus sexuel et la présence ou l’absence de problèmes de comportement sexuel dans un échantillon d’enfants référés pour une évaluation d’abus sexuels. Les résultats suggèrent que les professionnels en milieu communautaire devraient considérer les problèmes de comportement sexuel comme indicateurs d’abus sexuels avec beaucoup de précautions.

Resumen

Objetivo: El estudio examinó la utilidad de los problemas de conducta sexual como un indicador diagnóstico del abuso sexual. La hipótesis era que los problemas de conducta sexual eran multiply causados y consecuentemente estaban variablemente relacionados con el abuso sexual en una muestra clı́nica.

Método: Se incluyó una muestra de 247 niños evaluados por abuso sexual en una clı́nica forense multidisciplinaria de evaluación para el abuso en los niños. Se analizaron los resultados del Child Behavior Checklist (CBCL) y el Child Sexual Behavior Inventory (CSBI) y se compararon con los resultados de una evaluación de abuso estructurada, realizada de manera independiente de estos puntajes.

Resultados: La evaluación del equipo forense encontró evidencia de abuso sexual en el 25% de los casos y no encontró evidencias en el 61%. Los niños en esta muestra exhibieron un elevado nivel tanto de problemas de conducta sexuales como problemas de conducta no sexuales. Sin embargo, se observó considerable variabilidad en los puntajes de problema de conducta sexual. Por lo tanto, en este estudio un puntaje alto o un puntaje bajo no tenı́a relación con el diagnóstico de abuso sexual. Ciertamente, los niños que no habı́an sido sexualmente abusados tenı́an la misma posibilidad de tener puntajes altos en el CSBI como los niños sexualmente abusados.

Conclusiones: Este estudio no encontró una relación significativa entre un diagnóstico de abuso sexual y la presencia o ausencia de problemas de conducta sexual en una muestra de niños referidos para una evaluación de abuso sexual. El resultado sugiere que la comunidad de profesionales deben ser precavidos al confiar en los problemas de conducta sexual como un indicador diagnóstico del abuso.

Introduction

The desire for a reliable indicator of sexual abuse has led clinicians to look at sexual behavior problems as both a screening and as a diagnostic tool. Although sexually abused children as a group exhibit more sexual behavior problems than nonabused children Adams et al 1995, Cosentino et al 1995, Dubowitz et al 1993, Friedrich 1993b, Friedrich et al 1992, Friedrich et al 1986, Gale et al 1988, Goldston et al 1989, Hibbard and Hartman 1992, McClellan et al 1997, Mian et al 1996, Wells et al 1997, Wells et al 1995, White et al 1988, the utility of behavioral measures in a diagnostic assessment remains in question. In a research review, Kendall-Tackett, Williams, and Finkelhor (1993) found that sexual behavior problems and post-traumatic stress disorder could differentiate sexually abused children from nonabused children. However, they also found that a third of sexually abused children exhibit no such symptoms. This asymptomatic group of sexually abused children thus limits the utility of such behavioral tools because of the risk of increasing the false negative rate of diagnosis.

Another potential problem for these tools is the false positive rate. How good a discriminator for sexual abuse is the presence of sexual behavior problems? Are there other determinants of sexual behavior problems apart from sexual abuse? The various studies that have indicated an association between sexual behavior problems and sexual abuse raise four methodological questions. What methods were used to measure sexual behavior problems and how reliable are these methods? How was the diagnosis of sexual abuse made and, importantly, were sexual behavior problems used in the diagnostic assessment?

Early studies of the relationship between sexual behavior problems and sexual abuse relied primarily on the Child Behavior Checklist (CBCL) (Achenbach, 1991) to measure sexual behavior problems. The CBCL is a questionnaire that asks caretakers to rate the frequency of a variety of behaviors over the previous 6 months. The CBCL divides behavior problems into internalizing and externalizing problems. Internalizing problems include withdrawal, somatic concerns, depression, and anxiety. Externalizing problems include aggression, delinquency, and conduct problems. Six items of the CBCL comprise the sex problem scale (Friedrich et al., 1986). These items are: behaves like the opposite sex, plays with own sex parts too much, has sexual problems, thinks about sex too much, wishes to be the opposite sex, and plays with own sex parts in public. The sex problem scale is scored for only a limited number of age groups.

Studies using the CBCL’s sex problem scale found that sexually abused children have higher scores than nonabused children Dubowitz et al 1993, Friedrich et al 1987, Hibbard and Hartman 1992. Using three items of the sex problem scale, Dykman et al. (1997) found that sexually abused boys exhibited significantly more sexual behavior problems than sexually abused girls. However, a limitation of the scale is that the handful of items on the CBCL sex problem scale do not adequately sample the range of sexual behaviors generally exhibited by children Achenbach 1991, Friedrich et al 1992.

The Structured Interview for Symptoms Associated with Sexual Abuse (SASA) was developed as a screening tool for sexual abuse in children (Wells, McCann, Adams, Voris, & Dahl, 1997). The interview inquires about 26 symptoms, five of which pertain to sexual behavior. Sexually abused boys were found to be more likely to demonstrate curiosity about sex and to be sexually aggressive. As with the CBCL, sexual behaviors were only a small subset of a range of behavior problems identified by the instrument.

Faced with the limitations of the CBCL sex problem scale, Friedrich (1997) developed a comprehensive measure of sexual behavior problems, the Child Sexual Behavior Inventory (CSBI). After the development of three preliminary unpublished versions of the instrument—the CSBI (Friedrich et al., 1992), the CSBI-R (Friedrich, 1993b), and the CSBI-3 (Friedrich, 1995)—the CSBI was formally published in 1997 by Psychological Assessment Resources (Friedrich, 1997). All versions of the instrument measure sexual behavior problems based on the numerical frequency of sexual behaviors over the 6 month period prior to assessment. All three use the child’s primary female caretaker as the informant. The published CSBI includes a total of 38 sexual behavior items.

Versions of the CSBI have been administered to samples of nonabused children in an attempt to identify the overall frequency of sexual behaviors in children Friedrich et al 1998, Friedrich et al 1991. These studies indicate that nonabused children ages 2 to 12 years exhibit a variety of sexual behaviors, the most frequent being self-stimulating behaviors, exhibitionism, and problems with personal boundaries. Intrusive sexual behaviors were reported infrequently in these samples. An inverse relationship between sexual behaviors and age was also identified, with older children demonstrating less sexual behavior. These findings are consistent with other reports that some sexual behaviors, particularly self-stimulatory behaviors, curiosity about sexuality, and exposure of genitals to other children, are normal childhood behaviors, at least in certain age groups Cavanagh Johnson 1993, Lindblad et al 1995.

The utility of the CSBI in distinguishing sexually abused from nonabused children was described in two studies that used two of the earlier unpublished versions of the CSBI Friedrich 1993b, Friedrich et al 1992. Two recent studies also found differences between sexually abused children and nonabused children when utilizing versions of the CSBI Cosentino et al 1995, Mian et al 1996.

Studies of nonabused children also identified a number of additional variables related to sexual behavior problems, such as maternal education, family nudity, life stress, hours spent in daycare, and the presence of domestic violence Friedrich et al 1991, Friedrich et al 1998. Gray, Busconi, Houchens and Pithers (1997) also found a direct relationship between domestic violence and sexual behavior problems in a population of sexually aggressive children. Several studies found an association between scores on the CBCL and the CSBI Cosentino et al 1995, Friedrich et al 1991, Friedrich et al 1998, indicating that sexual behavior problems exist concurrently with, and are not necessarily independent of, other behavior problems. It thus appears that sexual behavior problems have multiple etiologies.

How the diagnosis of sexual abuse is arrived at in the studies that look at behavioral indicators is central to the utility of these indicators. If behavioral indicators are used in the diagnostic assessment, then the conclusion that they are useful becomes a self-fulfilling prediction.

In many studies, the method used to classify children as sexually abused was not clearly described. A few studies applied reasonably stringent, although infrequently found, criteria such as perpetrator confession (e.g., Wells et al., 1995). Several studies relied primarily on substantiation of abuse as determined by child protective services or law enforcement Adams et al 1995, Friedrich et al 1992, Gray et al 1997, McClellan et al 1997, Mian et al 1996, Wells et al 1995. Others used children identified as abused in specialized sex abuse diagnostic clinics Cosentino et al 1995, Dubowitz et al 1993. However, the diagnostic system utilized in these clinics was not clearly described. Some studies provided no clear description of the criteria used in classifying children as sexually abused Dykman et al 1997, White et al 1988.

Professionals assigned the task of investigating sexual abuse may be influenced by the presence of sexual behavior problems when making a diagnosis of abuse. For example, Kendall-Tackett and Watson (1991) found that professionals were more likely to believe that sexual abuse had occurred when children under the age of 6 were exhibiting advanced knowledge about sex. Thus, it is possible that, in the studies cited above, some children are included in abuse samples whose diagnosis of abuse was influenced by the presence of sexual behavior problems. Such confounding of variables would constitute a methodological weakness in any conclusion that sexual abuse is associated with sexual behavior problems.

This methodological weakness led us to analyze the diagnostic utility of sexual behavior problems in a sample of children assessed for sexual abuse in a forensic child abuse program where behavioral indicators are not used in the diagnostic process. Thus, this sample of children offers an opportunity to examine the relationship between sexual abuse diagnosis and sexual behavior problems in a setting where diagnosis and behavior are independent measures.

Section snippets

Methods

The sample of 247 children constitute all children evaluated at the Spurwink Child Abuse Program (CAP) for sexual abuse allegations between September 1, 1997, and March 31, 1999, for whom results from the Child Sexual Behavior Inventory (CSBI) are available. Because the CSBI is normed for children age 2 to 12 years in age, children evaluated who were younger than 2 years or older than 12 years were excluded from the sample. The two largest sources of referrals for these children were medical

Results

The diagnostic results are summarized in Table 3. The team found evidence of sexual abuse (Strong or Moderate) in 24% of the cases, while no evidence of abuse was found in 61%. The remaining 15% were classified as Don’t Know.

Descriptive statistics for the five behavioral variables are presented in Table 4. The children on average obtained high scores on the five behavioral variables. Because all five variables are expressed as T-scores, the expected sample mean would be 50 and the standard

Discussion

This study found no significant relationship between sexual abuse diagnosis and sexual behavior problems as measured by the Child Sexual Behavior Inventory among children assessed for sexual abuse in a multidisciplinary forensic evaluation setting. Similarly, the study found no significant relationship between sexual abuse diagnosis and behavior problems as measured by the Child Behavior Checklist. There was a high level of correlation between the sexual behavior problem scores and the other

Conclusions

The study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in children referred for a forensic sexual abuse evaluation. Although some sexually abused children exhibit serious sexual behavior problems, this study indicates that community professionals should use caution when using sexual behavior problems as a diagnostic indicator of abuse. Indeed, such use runs the risk of increasing the false positive rate if a child

Acknowledgements

The authors would like to thank William Friedrich and David Finkelhor, for their review of preliminary manuscripts, and Robert I. Kabacoff for his statistical consultation.

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