ChiMAbuse& Neglect,Vol. 16, pp. 755-762, 1992
0145-2134/92 $5.00 + .00 Copyright © 1992 Pergamon Press Ltd.
Printed in the U.S.A. All fights reserved.
BEHAVIORAL P R O B L E M S IN A L L E G E D S E X U A L A B U S E VICTIMS ROBERTA A. HIBBARD AND GEORGIA L. HARTMAN Department of Pediatrics, Indiana University Medical Center, Indianapolis, IN
AbstractmThis study was conducted to compare the parental assessments of problem behaviors, using the Achenbach Child Behavior Checklist, among alleged sexual abuse victims (n = 81) and an age, race, and gender matched group of nonabused comparison subjects (n = 90). Alleged sexual abuse victims demonstrated significantly higher mean total behavior problem, internalizing and externalizing scores than the comparison sample. Subscale profiles were all in the direction consistent with withdrawal, impairment in social interaction, and sexual problems. Item comparison indicated that sexual abuse victims were more likely to be assessed as having some problem behaviors that have been reported as being indicative of sexual abuse. A significant difference was not obtained on several behaviors that have been previously reported as indicative of sexual abuse. These findings support concerns that sexual abuse victims do exhibit more problem behaviors, but caution must be exercised when interpreting individual behaviors because of their frequency in a nonabused sample.
Key Words--Sexual abuse, Behavior.
INTRODUCTION BEHAVIORAL INDICATORS OF sexual abuse are signs and symptoms that may result from abusive experiences. They are not, however, specific to sexual abuse, as many of these behaviors are nonspecific signs of distress. Some professionals place considerable importance on the presence of an indicator as suggesting sexual abuse. Little attention is paid to the frequency of such behaviors among the population of children at large. Reported behavioral indicators of sexual abuse have included sleeping and eating disturbances, fear and phobias, depression, guilt, shame, anger, aggression, poor school work, running away, withdrawal, antisocial behavior, sexual behavior problems, anxiety, somatic complaints, and low self-esteem (Briere, 1988; Browne & Finkelhor, 1986; Friedrich, Urquiza, & Beilke, 1986; Gelinas, 1983; Gomes-Schwartz, Harowitz, & Sauzier, 1985; Kohan, Pothier, & Norbeck, 1987; Kolko & Maser, 1988; Mannarino & Cohen, 1986; Morrison, 1989). The aforementioned indicators are frequently reported among sexually abused children, however, concurrent comparisons are rarely made. Many researchers studying the effects of sexual abuse on behavior have compared their data from a sexually abused sample with preestablished norms for the instrument in question rather than collecting data from a matched comparison group of nonabused children in a similar situation (Friedrich et at., 1986; Gomes-Schwartz et al., 1985; Mannarino & Cohen, 1986). An exception to this was a study by Friedrich et at., (1986) in which they compared sexually abused subjects with a clinical sample and a nonabused comparison sample using the Child Behavior Checklist. They did not, however, look at the individual items. Many of the individual items on the tool Received for publication May 10, 1991; final revision received October 9, 1991; accepted October 16, 1991. Requests for reprints may be sent to Roberta A. Hibbard, M.D., Department of Pediatrics, Indiana University Medical Center, Riley Hospital, 702 Barnhill Drive, Indianapolis, IN 46202. 755
756
R. A. Hibbardand G. L. Hartman
have been touted as indicators of sexual abuse ( e.g., run away, trouble sleeping). In practice, professionals often use the behavioral indicators in their determination of alleged sexual abuse. Therefore, a comparison of behaviors between an abused and normative sample could have great clinical significance. The purpose of this study was to examine frequencies of and differences in reported individual behaviors and behavior profiles in alleged sexual abuse victims and an age, gender, and race matched group of nonabused children receiving routine medical care in a pediatric clinic.
METHOD
Sample Subjects were alleged sexual abuse victims (ASAV), ages 4 to 8 years, and a sample of nonabused comparison children matched by group for age, gender, and race. Alleged sexual abuse victims were recruited from a child sexual abuse clinic where they were receiving medical evaluations or an expressive therapies program where they were receiving mental health evaluations because of suspicions of child sexual abuse. These children were all referred by Child Protective Services or law enforcement as part of the routine evaluation of such victims. Administration of the study instruments became a routine part of the clinic procedures during the period of data collection. Waiver of informed consent for this sample was granted by the Indiana University Institutional Review Board. Nonabused comparison subjects were recruited from children receiving routine well child care in the general pediatric clinics. They were selected to provide a sample whose group demographic characteristics matched those of the alleged sexual abuse sample. A nonabused child was one who had no history of alleged sexual abuse. This presumes no abuse but cannot assure that the sample was not contaminated by unidentified sexual abuse victims. In an attempt to prevent such contamination, the primary physician and parent were asked if there had ever been any concerns about the child having been sexually abused. The identification of such concerns or a specific history of sexual abuse evaluated in the past eliminated the child from the study. Written informed consent from the parents was obtain ed~
Instruments & Procedure As part of a larger project examining child rearing practices, drawings, and allegations of sexual abuse (Hibbard & Hartman, 1990), parents were asked to complete the Achenbach Child Behavior Checklist (CBCL) on their child. The CBCL was administered to the parents prior to an interview to avoid contamination effects from the interview. The CBCL has been found to be a reliable tool in the assessment of child behavior problems. It provides a quantitative index of child behavior problems. Test-retest, interparent, interinterviewer, and longterm reliability have been established (Achenbach, 1979; Achenbach & Edelbrock, 1981). The CBCL is a list of 118 items that reflects the parent's view of the child's behavior at that time or in the preceding 6 months. Parents indicate if an item is "not true," "somewhat true," or "very true" for the child in question. Two broad factors, internalizing and externalizing, have been identified. The child behavior profile is a set of subscales calculated by adding different item scores from the CBCL. The items making up a particular subscale (e,g., aggression) vary depending upon the age and gender of the child, and not every subscale is calculated for each age/gender group (4-5 and 6-11 year-old females, 4-5 and 6-11 year-old males). Friedrich et al. (1986) created a 'Sexual Behavior Scale' calculated by adding the score on six items from the checklist dealing with sexual behavior (#5--Behaves like opposite sex, #59--Plays with
757
Behavior problems in ASAVS Table 1. Demographics
Mean age in years (SD) Race (% white) Gender (% female) SES (% Medicaid)
Alleged Sexual Abuse Victims (n = 81)
Comparison Children (n = 90)
5.59 (1.26) 81% 78% 30%
5.34 (1.17) 79% 73% 22%
own sex parts in public, #60--Plays with own sex parts too much, #73--Sexual problems, #96--Thinks about sex too much, #110-- Wishes to be of opposite sex). The individual items on the CBCL were compared by groups using the Mann-Whitney test. Behavior Problem t scores, subscale t scores and Sexual Behavior Scale scores were compared between groups using analysis of variance. Due to the necessity for multiple comparisons a p value of .01 was used in tests for significance.
RESULTS Eighty-one alleged child sexual abuse victims and 90 comparison children completed this part of the study. The mean age of this sample was 5.46 years (SD -- 1.2 years), 75% were female, 80% were white, 20% were black, and 25% were receiving medicaid. No significant demographic differences by group were identified (Table 1). Not all eligible children were enrolled in the study. This was because some children were unwilling to complete other parts of the study (i.e., draw human figure drawings), or the accompanying adult was unwilling to participate or not knowledgeable about the child's background (i.e., foster parent). In some cases the time available for data collection was limited. No demographic information was available on comparison children who did not participate because there was no consent. The alleged sexual abuse victims enrolled in the study (including 3-year-olds, later dropped because of insufficient subgroup size) during the last 6 months represented 60% of those eligible. Those not enrolled had a mean age of 5.1 years (range 3 to 8.5 years); 70% were white, and 84% female. Thus the alleged sexual abuse victims not enrolled did not significantly differ demographically from those enrolled. Among the alleged sexual abuse victims, 42% experienced repeated abusive episodes, 20% exhibitionism, and 74% gential fondling. Information on 75 alleged perpetrators was available; 87% were male, 84% white, 32% were fathers or stepfathers, and 46% were other family members. The mean age of alleged perpetrators (n -- 49) was 25.8 years (SD -- 11.4 years). Mean behavior problem, internalizing, and externalizing t scores by group are presented in Table 2. In each case, the alleged sexual abuse victims scored significantly higher than the nonabused comparison subjects. No interactions of group, gender, and age were identified. Alleged sexual abuse victims' and comparison subjects' individual item scores were compared. The percent of the parents who indicated the behavioral item was "not true" for their
Table 2. CBCL Scores by Group
Mean total t (SD) Mean internalizing t (SD) Mean externalizing t (SD)
Alleged Sexual Abuse Victims
Comparison Children
F
p
60.63 (11.70) 59.11 (10.71) 59.45 (11.24)
55.64 (9.57) 54.37 (10.42) 54.01 (9.00)
9.99 8.77 14.22
.002 .004
0145-2134/92 $5.00 + .00 Copyright © 1992 Pergamon Press Ltd.
Printed in the U.S.A. All fights reserved.
BEHAVIORAL P R O B L E M S IN A L L E G E D S E X U A L A B U S E VICTIMS ROBERTA A. HIBBARD AND GEORGIA L. HARTMAN Department of Pediatrics, Indiana University Medical Center, Indianapolis, IN
AbstractmThis study was conducted to compare the parental assessments of problem behaviors, using the Achenbach Child Behavior Checklist, among alleged sexual abuse victims (n = 81) and an age, race, and gender matched group of nonabused comparison subjects (n = 90). Alleged sexual abuse victims demonstrated significantly higher mean total behavior problem, internalizing and externalizing scores than the comparison sample. Subscale profiles were all in the direction consistent with withdrawal, impairment in social interaction, and sexual problems. Item comparison indicated that sexual abuse victims were more likely to be assessed as having some problem behaviors that have been reported as being indicative of sexual abuse. A significant difference was not obtained on several behaviors that have been previously reported as indicative of sexual abuse. These findings support concerns that sexual abuse victims do exhibit more problem behaviors, but caution must be exercised when interpreting individual behaviors because of their frequency in a nonabused sample.
Key Words--Sexual abuse, Behavior.
INTRODUCTION BEHAVIORAL INDICATORS OF sexual abuse are signs and symptoms that may result from abusive experiences. They are not, however, specific to sexual abuse, as many of these behaviors are nonspecific signs of distress. Some professionals place considerable importance on the presence of an indicator as suggesting sexual abuse. Little attention is paid to the frequency of such behaviors among the population of children at large. Reported behavioral indicators of sexual abuse have included sleeping and eating disturbances, fear and phobias, depression, guilt, shame, anger, aggression, poor school work, running away, withdrawal, antisocial behavior, sexual behavior problems, anxiety, somatic complaints, and low self-esteem (Briere, 1988; Browne & Finkelhor, 1986; Friedrich, Urquiza, & Beilke, 1986; Gelinas, 1983; Gomes-Schwartz, Harowitz, & Sauzier, 1985; Kohan, Pothier, & Norbeck, 1987; Kolko & Maser, 1988; Mannarino & Cohen, 1986; Morrison, 1989). The aforementioned indicators are frequently reported among sexually abused children, however, concurrent comparisons are rarely made. Many researchers studying the effects of sexual abuse on behavior have compared their data from a sexually abused sample with preestablished norms for the instrument in question rather than collecting data from a matched comparison group of nonabused children in a similar situation (Friedrich et at., 1986; Gomes-Schwartz et al., 1985; Mannarino & Cohen, 1986). An exception to this was a study by Friedrich et at., (1986) in which they compared sexually abused subjects with a clinical sample and a nonabused comparison sample using the Child Behavior Checklist. They did not, however, look at the individual items. Many of the individual items on the tool Received for publication May 10, 1991; final revision received October 9, 1991; accepted October 16, 1991. Requests for reprints may be sent to Roberta A. Hibbard, M.D., Department of Pediatrics, Indiana University Medical Center, Riley Hospital, 702 Barnhill Drive, Indianapolis, IN 46202. 755
756
R. A. Hibbardand G. L. Hartman
have been touted as indicators of sexual abuse ( e.g., run away, trouble sleeping). In practice, professionals often use the behavioral indicators in their determination of alleged sexual abuse. Therefore, a comparison of behaviors between an abused and normative sample could have great clinical significance. The purpose of this study was to examine frequencies of and differences in reported individual behaviors and behavior profiles in alleged sexual abuse victims and an age, gender, and race matched group of nonabused children receiving routine medical care in a pediatric clinic.
METHOD
Sample Subjects were alleged sexual abuse victims (ASAV), ages 4 to 8 years, and a sample of nonabused comparison children matched by group for age, gender, and race. Alleged sexual abuse victims were recruited from a child sexual abuse clinic where they were receiving medical evaluations or an expressive therapies program where they were receiving mental health evaluations because of suspicions of child sexual abuse. These children were all referred by Child Protective Services or law enforcement as part of the routine evaluation of such victims. Administration of the study instruments became a routine part of the clinic procedures during the period of data collection. Waiver of informed consent for this sample was granted by the Indiana University Institutional Review Board. Nonabused comparison subjects were recruited from children receiving routine well child care in the general pediatric clinics. They were selected to provide a sample whose group demographic characteristics matched those of the alleged sexual abuse sample. A nonabused child was one who had no history of alleged sexual abuse. This presumes no abuse but cannot assure that the sample was not contaminated by unidentified sexual abuse victims. In an attempt to prevent such contamination, the primary physician and parent were asked if there had ever been any concerns about the child having been sexually abused. The identification of such concerns or a specific history of sexual abuse evaluated in the past eliminated the child from the study. Written informed consent from the parents was obtain ed~
Instruments & Procedure As part of a larger project examining child rearing practices, drawings, and allegations of sexual abuse (Hibbard & Hartman, 1990), parents were asked to complete the Achenbach Child Behavior Checklist (CBCL) on their child. The CBCL was administered to the parents prior to an interview to avoid contamination effects from the interview. The CBCL has been found to be a reliable tool in the assessment of child behavior problems. It provides a quantitative index of child behavior problems. Test-retest, interparent, interinterviewer, and longterm reliability have been established (Achenbach, 1979; Achenbach & Edelbrock, 1981). The CBCL is a list of 118 items that reflects the parent's view of the child's behavior at that time or in the preceding 6 months. Parents indicate if an item is "not true," "somewhat true," or "very true" for the child in question. Two broad factors, internalizing and externalizing, have been identified. The child behavior profile is a set of subscales calculated by adding different item scores from the CBCL. The items making up a particular subscale (e,g., aggression) vary depending upon the age and gender of the child, and not every subscale is calculated for each age/gender group (4-5 and 6-11 year-old females, 4-5 and 6-11 year-old males). Friedrich et al. (1986) created a 'Sexual Behavior Scale' calculated by adding the score on six items from the checklist dealing with sexual behavior (#5--Behaves like opposite sex, #59--Plays with
757
Behavior problems in ASAVS Table 1. Demographics
Mean age in years (SD) Race (% white) Gender (% female) SES (% Medicaid)
Alleged Sexual Abuse Victims (n = 81)
Comparison Children (n = 90)
5.59 (1.26) 81% 78% 30%
5.34 (1.17) 79% 73% 22%
own sex parts in public, #60--Plays with own sex parts too much, #73--Sexual problems, #96--Thinks about sex too much, #110-- Wishes to be of opposite sex). The individual items on the CBCL were compared by groups using the Mann-Whitney test. Behavior Problem t scores, subscale t scores and Sexual Behavior Scale scores were compared between groups using analysis of variance. Due to the necessity for multiple comparisons a p value of .01 was used in tests for significance.
RESULTS Eighty-one alleged child sexual abuse victims and 90 comparison children completed this part of the study. The mean age of this sample was 5.46 years (SD -- 1.2 years), 75% were female, 80% were white, 20% were black, and 25% were receiving medicaid. No significant demographic differences by group were identified (Table 1). Not all eligible children were enrolled in the study. This was because some children were unwilling to complete other parts of the study (i.e., draw human figure drawings), or the accompanying adult was unwilling to participate or not knowledgeable about the child's background (i.e., foster parent). In some cases the time available for data collection was limited. No demographic information was available on comparison children who did not participate because there was no consent. The alleged sexual abuse victims enrolled in the study (including 3-year-olds, later dropped because of insufficient subgroup size) during the last 6 months represented 60% of those eligible. Those not enrolled had a mean age of 5.1 years (range 3 to 8.5 years); 70% were white, and 84% female. Thus the alleged sexual abuse victims not enrolled did not significantly differ demographically from those enrolled. Among the alleged sexual abuse victims, 42% experienced repeated abusive episodes, 20% exhibitionism, and 74% gential fondling. Information on 75 alleged perpetrators was available; 87% were male, 84% white, 32% were fathers or stepfathers, and 46% were other family members. The mean age of alleged perpetrators (n -- 49) was 25.8 years (SD -- 11.4 years). Mean behavior problem, internalizing, and externalizing t scores by group are presented in Table 2. In each case, the alleged sexual abuse victims scored significantly higher than the nonabused comparison subjects. No interactions of group, gender, and age were identified. Alleged sexual abuse victims' and comparison subjects' individual item scores were compared. The percent of the parents who indicated the behavioral item was "not true" for their
Table 2. CBCL Scores by Group
Mean total t (SD) Mean internalizing t (SD) Mean externalizing t (SD)
Alleged Sexual Abuse Victims
Comparison Children
F
p
60.63 (11.70) 59.11 (10.71) 59.45 (11.24)
55.64 (9.57) 54.37 (10.42) 54.01 (9.00)
9.99 8.77 14.22
.002 .004
