Child sexual abuse is a multifactorial societal problem affecting all socioeconomic groups, with research demonstrating it as an underreported event, especially in children less than age six (London et al., 2008). Investigations of the impact of sexual abuse disclosure and intervention have shown that in most cases, the perpetrator was known to the patient, i.e. a parent or an adult in charge of supervising the child (Ullman, 2007; Berliner & Conte, 1995; Sorensen & Snow, 1991). Higher rates of post-traumatic stress disorder among college age students has been measured in those students who had a history of abuse by a family member and who also delayed disclosure of the abuse (Ullman, 2007). Allegations involving patients reporting abuse from a family member are particularly difficult since the outcome may involve a parent who is truly loved by the child being sentenced by law to several years in prison. Abuse investigations become impeded when children ultimately deny the occurrence of substantiated abuse (Paine & Hansen, 2002), or in the case of clear forensic evidence, they recant a prior disclosure. A review of the literature on how children report sexual abuse to others by London, Bruck, Wright, and Ceci (2008) found that relatively low rates of recantation are found in studies that were not based on a history of ritualistic abuse. Recantation rates as high as 23% were found in younger children from family situations where the perpetrator was a parent or step-parent, and the non-offending parent was not supportive (Malloy, London, & Quas, 2007).
Forensic nurses are obligated to apply the ethical principle of veracity when working with school age children who have been sexually abused by a family member. Veracity in health care situations is defined as the “comprehensive, accurate and objective transmission of information as well as to the way the professional fosters the patient or subject's understanding” (Beauchamp & Childress, 2001, p. 284). This includes accurately reporting what the child/patient said, what the forensic examination revealed, and additionally, communicating information to the child/patient while answering questions with age-appropriate honesty. The focus of the nurse cannot be on the ultimate outcome for the perpetrator, rather on the best possible emotional experience for a child undergoing the forensic examination. For example, does answering questions honestly from the child regarding possible outcomes for familial perpetrators of molestation compromise potential therapeutic benefits that the certified sexual assault nurse examiner (SANE) is able to provide as part of the comprehensive care of the child victim? Should the forensic nurse withhold this information during the health history assessment and exam to minimize further emotional trauma to the young child who may be incapable of understanding these implications? How does veracity apply given that a child may ultimately recant this difficult disclosure? As the nurse is not assuming the role of a therapist, the nursing priority focus is to first “do no harm” followed by the forensic component of his or her role.
The purpose of this paper is to explore nurses' ethical and professional responsibilities to the child subjects of familial sexual abuse, despite the potential for the child to recant the disclosure. Fact-based scenarios will be explored that the forensic nurse may encounter with the younger school-age child, demonstrating the challenges and the importance of applying veracity. Second, in this article we will briefly explore the moral, cognitive, and psychosocial development of school-age children, and how these factors impact and contribute to their ability to process events occurring in the family.
Review of literature
This literature review is divided into two sections. An examination of literature pertaining to child sexual abuse and disclosure will comprise the first section of the review. The second part of the review provides an overview of developmental theories that are used to understand children's perceptions and ultimate decision-making capabilities.
Child sexual abuse and disclosure
Disclosure of familial sexual abuse is without a doubt difficult and stressful for children. Less than five percent of all confirmed cases of child sexual abuse will have any physical findings on exam (Sapp & Vandeven, 2005; Anderst, Kellogg, & Jung, 2009; Girardet et al., 2011). Alexander (2011) states that physical findings may be present in “as much as 10% of girls who have been sexually abused, but very rarely in boys” (p. 482). In pre-pubertal females the abuse may not have caused an injury, any minor injuries have since healed, and/or any significant injury has healed due to the length of time, possibly years, between the abuse occurrence and the ultimate disclosure. Therefore, the most reliable indicator of sexual abuse is the history given by the child (Sapp & Vandeven, 2005; Hornor, 2010). Physical exams completed by a thoroughly educated SANE can minimize further trauma and anxiety for the child, and most children do not report having increased anxiety following the ano-genital exam (Hornor, Scribano, Curran, Stevens, & Roda, 2009).
The nurse needs to have an understanding of several variables in order to best utilize the ethical principle of veracity with the younger school-age child. The issues surrounding child sexual abuse and the resulting aftermath of child disclosure and potential recantation can be found in the literature. According to London et al. (2005), several studies completed between 1991 and 2001 have shown that recantation of disclosure amongst children does occur, with rates ranging from 6.5% to 27%. Numerous variables occurring within the home can contribute to recantation, which ultimately could result in placing the child back into the abusive situation with the perpetrator. Various factors include pressure from the non-offending parent who may not believe the child (Lovett, 2004; Malloy & Lyon, 2006), and pressure from the offender to recant along with withdrawal of parental affection are often present. Some children may also experience overwhelming feelings of guilt and self-blame for the abuse and the choice to disclose. Placement outside of the home into a foster care situation may also influence a child's decision to recant (Sorenson & Snow, 1991; Rieser, 1991; London et al., 2008). Due to the known risk of recantation, Marx (1996) proposed development of a tool to assess the risk of recantation, as well as interventions to reduce this risk by addressing the individual needs of the child and the non-offending family member. Recommendations included psychological therapy for the child and frequent ongoing contact with the interdisciplinary support team. When discussing the importance of the team approach, Alexander's definition of interdisciplinary care (2011)“professionals also work together to jointly assess the situation” (p. 485) is particularly relevant. Minimizing the time delay between abuse and disclosure, aiming for rapid resolution of the criminal trial, and involving the child in the court system by giving clear, age-appropriate explanations of the courtroom environment can all factor into best outcomes for the child, while providing the child some level of emotional security. Forensic evidence when obtained within 72 hours of the assault (Hornor, 2011) can provide corroboration of the disclosure even in cases where the child may later recant due to familial pressure. Involvement of the nurse in a supportive role, while creating a relationship based upon veracity with a child, is not necessarily to reduce the risk of recantation, but it is to gain trust so the disclosure can be corroborated within the legal system, in order to avoid the placement of the child back into the abusive home.
In a small interpretive phenomenological study, sexually abused children's experiences with the legal system were explored (Back, Gustafsson, Larsson, & Bertero, 2011). Child participants between the ages of nine and fifteen years expressed the desire to receive support from one professional who was well informed about child sexual abuse and the legal process involved with it, as opposed to being required to talk to several different professionals, including law enforcement, and then feeling as though their credibility was being questioned. The researchers reported that they felt confusion and distrust in expressing what had happened to them when they saw how well the attorneys, judges, and police treated the perpetrator.
Carefully assessing for possible evidence of abuse is secondary to obtaining an accurate history, assessing the health of the child, and is not a medical forensic interview (Alexander, 2011). Although the SANE does not assume the role of a professional victim's advocate, nor is the SANE a legal position, the nurse has knowledge, education, and expertise in acquiring a health history, providing emotional support, managing forensic evidence, and providing testimony when required (International Association of Forensic Nursing, 2006).
Establishing a positive health care provider/patient relationship between the SANE nurse and the child is important. A study by Hatlevig (2006) determined that the many events that occur in a child's life following a disclosure of sexual abuse confirms the need for nurses to not only have a better understanding of the future implications on the child victim but also to assist in advocating for resources for these patients. Application of the ethical principle of veracity when caring for children who have been abused can be a key factor in whether or not they follow through on the recommended mental health services that can improve their psychological outcomes. In short, the SANE has an important role in working with children who have been abused, and who often present in the Emergency Department, a less than ideal setting (Palusci, Cox, Shatz, & Schultze, 2006; Bechtel, Ryan, & Gallagher, 2008).
Developmental theories contributing to children's cognition
Numerous theories of moral development exist in the literature, perhaps the most well-known being the early research done by Lawrence Kohlberg (1969) in which children are proposed to be passing through moral stages in a specific order, following a predicable sequence. Younger school-age children are typically considered to be in the premoral or preconventional stage, where the focus is on avoidance of punishment, and rules are meant to be obeyed if established by more powerful individuals (Kohlberg, 1969; Kohlberg, 2008; Walker, 1982). Parenting style is another consideration in the perceived moral development of children, suggesting that loving parents who teach their children to consider multiple perspectives have children with the ability to maturely reason about moral situations (Berkowitz, 1991).
Piaget (1951) developed an influential theory of childhood cognitive development demonstrating the relationship between assimilation and accommodation ultimately resulting in learning. Children typically enter the concrete operational stage at approximately age five years, at which time they only begin to be able to think and reason with logic. Abstract concepts are difficult for them to understand until closer to eleven years of age although children in this stage are able to understand the concept of time. Ultimately the child develops reasoning and thinking skills, is able to think through actions, and anticipate consequences (Piaget, 1961).
Industry versus inferiority is characterized by Erikson (1963) as the typical stage of psychosocial development experienced by school children ages six to eleven years. During this time period, the child's relationships with peers and with those outside of the home become increasingly important. During this time, the child develops a sense of self-worth when achieving success and competence in the acquisition of new skills. Inferiority occurs with repeated task failure or lack of support or trust from those adults who are important in the child's life. Erikson's theory regarding children in this stage was tested in a study by Kowaz and Marcia (1991), that confirmed his initial postulates and validated the concept of industry. Application of Erikson's industry versus inferiority stage was further analyzed by Alkhatib and Barrett (2007) within the context of children exposed to the stress of war and terrorism, undoubtedly extremely stressful events. They found frequent incidence of regression among these children, along with symptoms common with post traumatic stress disorder; somatic symptoms, inability to concentrate in school, and defiant behaviors.
Theories of stress and coping in children abound in the literature. Coping is a process that includes a child's attempts to change a perceived threat themselves, or to change how they feel about the threat. Children use coping to solve problems and regulate how they feel about them by either changing their environment, or by how they consider the stressful event (Rutter, 1998). Theoretically, coping methods in children could explain why some children adamantly deny abuse or recant prior disclosure even in the presence of clear and convincing evidence. A study of resilience in children subjected to extreme stress from abuse suggested that there are several factors present within the child that contribute to better outcomes for the child. School involvement, social ability with other children, average to above average intelligence, and a positive relationship with an adult caregiver were all considered to be protective for the child following maltreatment. Positive self-esteem was correlated with higher levels of resiliency in school-age children who had a history of abuse, either physical, sexual, emotional or a combination of these (Cicchetti & Rogosch, 2009). In discussing the impact of childhood stressful events, Garmezy and Rutter (1983) refer to the many studies that conclude that such life events can result in psychiatric disorders beginning in childhood, and the relevance of the associated physiological changes associated with chronic stress that should be considered and addressed.
The discussion of the clinical scenarios that follows is based upon actual cases completed by a board certified adult and pediatric sexual assault nurse examiner (SANE-A, SANE-P), who is the nursing director of a medium-sized Midwest sexual assault and treatment facility.
Consider the case of Theresa (pseudonym), who was nine years old and age-appropriate developmentally, when an adult friend of the family came across several videos in the cabinet near the television in Theresa's home that had been filmed of her father's penis penetrating Theresa's labia majora. This video was delivered to law enforcement. When law enforcement came to the home, Theresa disclosed that “Daddy has been having sex with me.” The inexperienced law officer allowed the mother and the older brother to remain present in the room for this discussion. The brother questioned her as to why she was lying about their father. The mother did not intervene, nor did she provide any support or reassurance to the child at the time. Theresa was left in the room with her brother while the mother was interviewed in a separate area. She was brought to the treatment center the same day. A medical history and forensic exam was completed by the SANE. Following the health history, the nurse explained her role and assured the child she was all right, and the purpose of the exam was to make sure her body was okay. When asked if the child understood why she was at the treatment center, she denied knowing the reason. The nurse assured her that she was not in any trouble, and that she was going to ask Theresa some questions about her body and what she calls specific body parts. She actively participated in the conversation at this point. The nurse questioned if there were places in her body that no one should touch, at which point she named her “private” and her “butt” and pointed to her labia majora area. When asked if anyone had ever touched her “private” or her “butt,” her demeanor changed drastically. Her head hung low as she stared into her lap, and quietly replied “no.” Attempting to establish typical growth and developmental parameters and level of age-appropriate understanding, the nurse asked Theresa if it was okay for a doctor or a nurse to look down there, at which point Theresa replied “yes.” The nurse reaffirmed that Theresa was correct, and also discussed that there should never be secrets about touching the “private” area on anyone. When asking Theresa if it was okay for someone to take pictures or video of anyone's “privates,” she told the nurse that is was not. When asked if anyone had ever taken pictures or videos of her “privates,” she replied “no,” at which point the nurse ended the questions for the health history component and began the physical assessment. During the actual physical exam including vital signs and a nursing assessment, the child's demeanor returned to being interactive and talkative. The exam ended with reassurance from the nurse that Theresa's body looked completely normal. Due to a time frame of greater than two weeks, no forensic evidence was collected. No genital or anal injury was noted during the exam. Theresa never acknowledged these sexual acts happened and never disclosed. Solely upon the video evidence the father was eventually convicted of child molesting and sentenced to 100 years in prison.
Another case, Layla (pseudonym), an eight-year-old girl who, when her mother came to pick her up following a weekend visitation with her father, described a sexual assault involving her father. Law enforcement was able to collect printed photos from the father's home depicting him in sexual acts with Layla including digital and penile female sex organ penetration. She was immediately brought in for a forensic exam, during which positive DNA evidence was obtained, corroborating her story. She reported that this was the only time her father had ever done anything like this to her. While the nurse was taking forensic photos of her genitalia, Layla asked if the nurse could see her father's fingerprints on her “bottom,” since this was where he had touched her. No anal or genital injury was noted during the exam. Layla verbalized that she loved her father. The nurse explained to Layla that this was not her fault, and that it was all right to love him, and that he loved her. Layla's mother told her that it would be her fault if “Daddy went away.” Layla questioned what would happen to her father, and the nurse truthfully explained that what happened was not up to either of them, but that he needed to get some help. Ultimately, Layla testified and in corroboration with the DNA evidence, her father was convicted and sent to prison for 20 years.
Annie (pseudonym) was a six-year-old girl who disclosed to the babysitter that it hurt to urinate following a visit to her father's house, which was approximately two weeks prior. During the health history of the medical exam by the SANE, Annie disclosed that “daddy put his pee-pee in my pee-pee,” and could articulate that “it felt good.” When asked about urination, Annie reported “It stinged me.” She also added that she saw “red dots” in her underwear. She repeatedly asked the nurse, “Did Daddy mean to hurt me?,” and the nurse proceeded to answer her by stating “I don't know, and I’m sorry Annie. I want you to know that I talk to a lot of kids and this isn't your fault,” prior to explaining the basic steps of how she would be looking at Annie's “pee-pee” and bottom. The nurse also provided reassurance that she was going to check Annie's entire body to be sure everything was all right with her body. Following the completion of the physical assessment, the nurse reassured the child that her entire body including her “pee-pee,” was normal. The nurse assured Annie that she made a good decision when she told her babysitter about what had happened to her. During the week following the disclosure and subsequent exam by the SANE, and during a follow-up visit with the Department of Child Services caseworker, Annie told the caseworker that her paternal grandmother spent time with her, talking about how wonderful her Daddy is and that she must be confused about what really happened during the visit with him. During the follow-up interview with the Department of Child Services, Annie recanted her disclosure, completely denying anything had ever happened. Law enforcement ultimately closed the case, and Annie stayed in the home with her mother.
Children may become a target for sexual abuse from the very adults they rely on for protection and safety. Sexual molestation during childhood occurs at a high rate amongst this age group of younger school-age children (Trickett & Putnam, 1993) although Colangelo & Keefe-Cooperman (2012) report that Child Sexual Abuse (CSA) prevalence rates are difficult to establish. Women reporting sexual abuse during childhood or adolescence ranged from 28% to 30% (Roland, 2002) whereas Freyd et al. (2005) reports rates closer to 20% of women worldwide. As a result of molestation, it is common to see child patients vacillate between extreme shyness and overt aggressive behaviors. Often they also do not experience restful sleep, as their awareness of the environment around them is heightened (The National Child Traumatic Stress Network, 2011), which could lead to other physiological and psychological problems.
The nurse's role in communicating with the child patient who has been sexually abused is that of patient advocacy. Difficulties may arise when the nurse feels uncomfortable or unsure of the optimal way to communicate with a child, based on the child's age or developmental and emotional maturity level. It is imperative that the SANE understand and be able to apply knowledge of the cognitive and psychosocial level where these young school age children are typically expected to be. These children may also be experiencing comorbid stressors such as failure in school. This can perpetuate a sense of inferiority, furthering low self-worth, commonly a characteristic in children who are being abused. One could speculate that when considering developmental theories, that the younger school-age child would also typically comply with the known abuser if the abuser were perceived as being a more powerful individual, and by complying, the child is avoiding potential punishment. If the nurse does not understand the implications of the stages of child development, particularly that of the younger school-age child, how can the nurse best communicate and be truthful at a level that shows the most respect for children, while at the same time provide them with the reassurance that they are believed?
Based on the scenarios presented, when caring for Theresa is it necessary that the nurse convince her that these events actually happened, given the reality of Theresa totally denying the occurrences? Undoubtedly, many factors are involved in her denial, including the length of time Theresa had been enduring the sexual abuse. Considering stress and coping theories, the nurse should recognize that it can be common in this age group to use denial as a means of coping. Children in this age group may also fear the shame, possible jealousy, and fear of the family breaking apart (American Academy of Child and Adolescent Psychiatry, 2010). Based on her chronological and developmental age, Theresa was only beginning to develop abstract thinking, and this may have been a contributory factor to her likelihood for self-blame in the situation. Can one speculate that her concrete thinking, typical of this age, may contribute to her believing that participating in these acts of abuse is her fault, or somehow even her idea? Theresa may have been capable of perceiving or recognizing the weakness and likely non-support of her mother, who actually denied any knowledge of this happening, and even later supported the father, likely furthering Theresa's reluctance to disclose. Additionally, the persistence and pressure from the older brother who accused her of lying could theoretically have contributed to Theresa's lack of disclosure.
Layla presented a different challenge, in that she clearly was thinking very concretely when asking the nurse if the nurse could see her father's fingerprints on her “bottom.” The nurse may have to consider issues of regression in her development, possibly due to the abusive event itself or simply that she is only in the beginning stages of developing abstract understanding. She may have felt that she needed reassurance from the nurse that there was some proof present, prior to making any further decisions, in case she was not believed. She questioned whether or not she could still love her father, so was clearly conflicted in the area of rule-following, common to this cognitive stage of development, so by answering her question directly that she could still love her father but suggesting that he needed help, the nurse was being truthful at Layla's developmental level of capable understanding. When considering her conceptualization of rules, it makes sense that she would agree to testify, since in her psychological developmental stage, she may have been able to recognize that her father had broken a rule by doing this with her. She also had the support and reassurance from her mother that she was believed.
Implications for clinical forensic nursing
Optimal nursing care for child patients who have been sexually abused (and the perpetrator is a family member) can be extremely emotional for the SANE to deal with. Providing care in a nonjudgmental way, while also appropriately addressing the young child's growth and development, and being truthful to the child can be challenging. Therapeutic and professional nursing care must be given during the exam in order to guarantee the best possible emotional and psychological outcomes for the child, thereby contributing to decreasing the possibility of later recantation of the abuse disclosure. The SANE must be able to communicate with children truthfully and effectively in a calm and compassionate manner. Understanding of the moral, cognitive, and psychosocial stages of development of the younger school age child allows the nurse to best address the child's emotional needs, utilizing veracity. An ethical dilemma presents when a particularly mature young child asks a direct question of the SANE regarding a possible outcome for the perpetrator, and the nurse must decide how to best handle the question. This child may have been in a deceitful situation for years with the perpetrator of the abuse. Even when evidence appears overwhelming, the role of the nurse is not to speculate with child patients, but to reinforce that they were brave and made the right choice by telling someone, because what happened to their body was wrong. Providing reassurance that they are not responsible for what ultimately happens to the perpetrator is extremely important. Children of any age must feel supported, understood, and believed. The nurse needs to recognize that without this support the child patient may revert to using defensive mechanisms put into place to help cope with the abuse, ultimately interfering with the child's safety and development.
The SANE needs to clearly understand the differentiated role of the forensic interviewer. This role includes specialized training in establishing rapport and asking open-ended questions of the child (Teoh & Lamb, 2010) that become admissible in court. The goal of the forensic interview is to obtain accurate information with the focus on finding facts for the investigation (The Center on Child Abuse and Neglect, 2000).The National Children's Advocacy Center (2012) offers courses in forensic interviewing and describes this skill as “the cornerstone of investigations into child sexual abuse.” The role of the SANE in the child exam is solely for the medical history interview due to its direct connection to diagnosis and treatment for the child. Offering the child small reinforcements, such as candy or stickers, may be used to increase cooperation during the clinical exam by the SANE but “must be avoided in forensic interviews” due to the possible influence on the young child's answers to the interviewer (Silovsky, 2000, p. 6).
SANEs must separate their emotion and desire to see the perpetrators of abuse convicted against their professional duty to provide the best possible care to the young patients who have been sexually abused. There are no easy or simple answers that will apply to every case involving young children, but an understanding of their developmental level and how to best approach them, utilizing the ethical concept of veracity in nursing care is extremely important in this field. Best outcomes for the child include directing them to the most appropriate mental health services in order to begin healing the many psychological wounds that accompany this crime. Being factual is an essential part of veracity, but it is also of utmost importance that the nurse does not lead the child to any particular disclosure because this may compromise emotional benefit to the child, as well as the legal case.
Areas for further research and exploration include the minimal level of education and preparation in childhood development that the pediatric sexual assault nurse examiner (SANE-P) should have in order to best handle the complexity of these situations dealing with young children who have been sexually abused by a perpetrator who is a family member. Does the nurse have the childhood development and background necessary to fully understand the child's level of comprehension of why they are being examined and questioned, and how to best address this individual developmental level? Does the nurse have an adequate background in understanding typical childhood reactions to stress, or the coping mechanisms common to this age group? Can the nurse ethically and morally apply the principle of veracity appropriately to these young children without bringing further harm? What is the necessary level of understanding for the nurse of how these young school-age children conceptualize events in their lives, and what is the optimal way for the nurse to deal emotionally and personally with these complex situations?
The goal of the nurse when working in this area of professional nursing is to be truthful and ethical with child sexual abuse patients. The nurse needs to understand enough about child development to communicate accurately with children. The nurse needs adequate background in understanding coping mechanisms to be supportive to each individual child. Finally, the nurse needs strategies to deal with personal emotional stress caused by professional responsibilities.
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