Use of the CSBI and TSCC in Screening for CSA & Evaluating Sexually Abused Children

Use of the CSBI and TSCC in Screening for CSA & Evaluating Sexually Abused Children L. Dennison Reed, Psy.D.

Typical Steps in Screening for CSA • Meet with concerned caregiver: • Discuss the limits of confidentiality • Have caregiver complete CSBI if suspected victim is 2-12 • Determine caregiver’s basis for concern: • Child’s abuse-related statements & manner in which they came forth • Child’s concerning (sexual) behavior, if any [review CSBI with caregiver]

Typical Steps in Screening for CSA • If case is ‘ambiguous’ after meeting with caregiver, meet with the child ‘if’ this is within your area of competence; otherwise, ‘refer out,’ e.g., preschoolers, ongoing litigation): • Conduct forensic interview(s). Oftentimes, more than one interview will be necessary • For kids 8-16 consider, having them complete Trauma Symptom Checklist for Children (TSCC).

The TSCC and CSBI can also be used when evaluating confirmed victims of CSA

Child Sexual Behavior Inventory (CSBI) To be completed by caregiver of children ages 2-12

CSBI Answer Sheet

Three Types of Scores on the CSBI • “Total” score • “Sex Abuse Specific Items” (SASI), e.g., puts mouth on another’s sex parts • “Developmentally-related Sexual Behavior” (DRSB), e.g., 3-year-old touches sex parts in public places

CSBI Measures that are most suggestive of CSA • Clinically elevated CSBI ‘Total’ score (≥ T65) is suggestive of sexual abuse…. • Especially if ‘Sexual Abuse Specific Items’ (SASI) score is also clinically elevated (≥ T65) [e.g., puts mouth on another child’s sex parts]

Possible explanations for clinical elevations on CSBI ‘Total’ score & SASI score • Sexual abuse • Vicarious exposure to sexuality (e.g., observing caregivers or others engaging in sexual behavior) • Conduct disorder, Oppositional-defiant disorder or general aggressiveness • Family nudity • Physical Abuse and/or Neglect • Deliberate exaggeration of child’s sexual behaviors on CSBI by the child’s caregiver (Total ‘raw’ score > 45 is likely to be invalid)

Significance of Developmentally Related Sexual Behaviors (DRSB) on CSBI • Exp. 3-year-old ‘touches sex parts in public; 12-year-old is ‘very interested in opposite sex’ • DRSB scores are often elevated along with other sexual behavior problems, but often relate to factors other than sexual abuse, e.g., vicarious exposure to family nudity and sexuality, family stress • When the majority of the CSBI Total score elevation is based on DRSB items (rather than SASI), these are often—but not always—younger, non-sexually abused children in the midst of some life transition, e.g., parental divorce

--CASE EXAMPLES— Using the CSBI as part of a CSA Screening Protocol

The Case of AA (CSBI only; too young for TSCC) • 7-year-old boy referred by his family physician who thought AA may have been sexually abused by his mother’s former boyfriend • AA’s mother reported that her ex-boyfriend had been physically abusive to AA, which is what prompted their separation. She also said AA had witnessed her having intercourse with her ex-boyfriend, probably more than once. The ex-boyfriend also frequently touched her in a sexual fashion in AA’s presence, e.g., lifting up her blouse or skirt and putting his hand inside her pants. She and her son had lived in 16 different homes since the AA’s birth.

AA’s CSBI (by mother) Total T-score 73; SASI T-score 71 • Touches or tries to touch (mother’s) breasts; touches (mother’s) sex parts, e.g., he grabbed her crotch when she was wearing a swimming suit; talks about sexual acts; wants to watch TV or movies that show nudity; is very interested in the opposite sex (i.e. , his mother)

Information provided by AA’s grandmother and teacher • AA’s grandmother, who baby-sits AA 60 hrs. a week, completed the CSBI. This resulted in scores in the ‘normal’ range on Total score and SASI. She denied that AA had ever touched her breasts or grabbed her sexually (as he had done to his mother), or that he self-stimulated • AA’s (female) teacher’s description of AA’s behavior was quite similar to the grandmother’s description. She denied having seen AA engage in any sexual behavior in the classroom.

Findings re. AA • AA denied that his mother’s ex-boyfriend or anyone else had molested him; but he acknowledged seeing mother’s ex-boyfriend engage in sexual behavior with his mother • Although AA obtained SASI and Total scores in the clinical range on the CSBI completed by his mother, his sexual behavior was restricted to acting out with his mother and there was no indication that he engaged in self-stimulating behavior, or sexual activity with himself, or with any adults or with his peers • it was concluded that his sexual behavior was most likely primarily the result of his exposure to sexuality between mother and her ex-boyfriend rather than being attributable to contact sexual abuse

The case of EE (CSBI only) • 10-year-old boy referred for screening by after two unrelated boys in EE’s neighborhood complained that EE had ‘anally penetrated’ them with an object. • EE was living with his mother and two siblings at the time of the screening. EE’s mother did not believe EE had been molested; however, her oldest child had been molested by a maternal uncle when the mother was in treatment for substance abuse more than one year earlier. The uncle had been sentenced to outpatient therapy after pleading guilty to molesting one of his nieces.

EE’s CSBI Total & SASI T-scores >110 (Total raw score 30 = not exaggerating); DRSB T-score 45: • Touches sex parts at home and in public places; masturbates with object (blanket, pillow, plastic toy); French kisses; pretends dolls are having sex; talks about sex acts; touches mother’s breasts; touches other children’s sex parts; tries to have intercourse with other children; touches animal’s sex parts

Findings re. EE • A pediatric exam found evidence of anal scarring that could be consistent with anal penetration; however, EE had a history of encopresis, which could explain the scarring • EE admitted that his maternal uncle had molested EE for more than two years, and the most recent incident had occurred 3 months earlier (while the uncle was in outpatient therapy for molesting EE’s sister). EE’s molestation included fondling, sodomy and fellatio • EE’s uncle was subsequently convicted for molesting EE

Trauma Symptom Checklist for Children TSCC) To be completed by children ages 8-16

When to administer the TSCC • During your initial session with the child (age 8-16) he/she can complete the TSCC • Willingness to endorse sexual concerns/distress on the TSCC is associated with willingness to disclose CSA during the ensuing forensic interview • It may be helpful to have the child complete the TSCC after some rapport building to encourage more willingness to disclose symptoms relating to sexual concerns/distress.

Sexual Concerns-Distress (SC-D) Subscale on TSCCis associated with CSA • Includes items relating to sexual conflicts, fears, and other unwanted sexual responses: • Getting upset when people talk about sex • Not trusting people because they might want sex • Thinking about sex when I don’t want to • Clinical elevations on the SC-D scale are associated with CSA history and with children’s willingness to disclose CSA during subsequent forensic interview

Sexually Abused Children Who Are In Denial Sometimes Obtain Unusually Low TSCC Sexual Concerns-Distress (SC-D) Subscale Score • Sexually abused children who score unusually low on the TSCC SC-D subscale are likely to deny their abuse during forensic interview

Significance of Elevations on both the CSBI ‘Total’ score and the TSCC ‘Sexual Concerns-Distress’ Subscale • Although no tests by themselves “prove” that a child was sexually abused, significant elevations on both of these scales are particularly noteworthy • Friedrich (2002) found that high scores on both of these scales among children for whom there was “at most” a suspicion of sexual abuse are often illuminating of prior sexual maltreatment. Follow-up interviews with children in an inpatient setting who had elevations on both of these scales and had not previously disclosed sexual abuse led to disclosures of sexual abuse in roughly half of these children

--CASE EXAMPLES— Using the TSCC when screening for CSA and when Evaluating Sexually Abused Children

R.D.-12 y/o Asian female reporting extensive PA from age 7 by mother & SA from age 9 by older brother Valid profile; Clinical elevations on SC, SC-P and SC-D; ANX, DEP, PTS and DIS-F Common profile for chronic abuse; extensive treatment probably necessary

SH-10 y/o White F. forcibly raped on way home from school. Genital trauma consistent with forced sex. No other trauma history Valid profile; Clinically elevated SC-D only. Common profile for acute (not chronic) sexual victimization. Future elevations on PTS and/or DEP are possible

A.F. 9 y/o White M in treatment for school probs. Denies SA, but step-brother admitted anally raping A.F. for years. Also, medical evidence of chronic anal penetration Invalid profile (UND = 76T) & no clinical scale elevations. Common among abused children denying abuse

--CASE EXAMPLE— Using the TSCC and CSBI as part of a CSA Screening Protocol

The case of DD (TSCC & CSBI) • 9 year-old girl referred for evaluation because of an upsurge in night terrors, difficulty sleeping alone, problems separating from mother, withdrawal from/avoidance of father, and recent onset masturbation. DD also began insisting on wearing baggy T-shirts and jeans. Although DD was several years away from menarche, her mother found tampon containers in DD’s clothes and bed sheets and DD admitted she had put them “in” herself, but she denied she had been molested or that anyone told her how to use tampons. DD’s behavioral problems began about 3 months ago. • DD’s mother completed the CSBI. DD underwent an initial rapport building session and completed the TSCC

DD obtained CSBI Total score of 68 and SASI score of 54 based on: • Stands too close to people • Talks about wanting to be the opposite sex • Masturbates with hand • Touches sex parts when at home • Puts objects in vagina • Gets upset when adults are kissing • Is very interested in opposite sex

DD’s TSCC (& CSBI) results • Clinically significant elevations on three TSCC scales: • Sexual Concerns-Distress (SC-D) Subscale • PTSD subscale • Anxiety subscale • DD displayed a pattern often seen in sexually abused children: Clinically elevated CSBI ‘Total’ score + clinically elevated TSCC SC-D score

Findings re. DD • During the 2nd interview of DD, she reported she had been fondled on 4 occasions while at summer camp by a 15-year-old boy who also attended the camp. DD stated, “He ordered me to meet him at midnight by the canoes or he would kill me.” She further stated that he rubbed her “chest” and “down there” indicating her vagina. She had told no one about the abuse and explained that as soon as she returned from camp (three months ago), she switched to wearing only baggy T-shirts and jeans “so boys don’t like me.”

TEST FINDINGS MOST CLOSELY ASSOCIATED WITH CSA • CSBI clinical elevations on: • ‘Total’ score • Sex Abuse Specific Items (SASI) • TSCC clinical elevations on: • Sexual Concerns-Distress (SC-D) subscale • When all of the above are clinically elevated, this is a more powerful indicator of likelihood of: (1) CSA and (2) disclosure of CSA

Use of the CSBI and TSCC in Screening for CSA & Evaluating Sexually Abused Children