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J. he need for specialized services for adolescents who are alleged sexual abusers has received relatively little attention in the practice of pediatrics. Most physicians, nurses, and other health professionals are not specifically trained to identify or respond to situations of sexual abuse involving the adolescent as a victim much less as the offender. Maladaptive sexual behavior of adolescents is often confused or mistaken for normal sexual curiosity or early sexual experimentation. Based on recent studies,1'4 such behavior has assumed greater visibility as a serious problem about which all human service providers - especially pediatricians - should be more concerned.
Professionals who provide care to young children must become involved in the prevention and control of child rape, sexual victimization, and /or molestation. It is widely believed that early identification and intervention and appropriate care for potential rapists and child molesters is a significant first step in reducing the incidence and tragedy of sexual abuse of children.5 Parents and society at large have become more aware of the serious problem of unacceptable and maladaptive sexual conduct among adolescents which often leads to legal involvement and criminal charges. When pediatricians have better understanding of the magnitude of the problem and its characteristics, they are more likely to provide appropriate advice to parents and adolescents as well. Such intervention may reduce or prevent more serious criminal acts of sexual abuse or violence directed toward young children.
Sexual abuse of children involving an adolescent perpetrator poses unique and often difficult problems for pediatricians, social service providers, law enforcement personnel, and mental health professionals.2 These cases run the gamut from violent rape or forced sexual acts with children to age-inappropriate sexual behavior within the family structure.
Sexual contact - such as intercourse, fondling of the genitalia, exhibitionism, or sodomy - between an older adolescent and a young child is considered abusive. This is especially significant and harmful when the child is threatened, bribed, coerced, misled, or forced to engage in such acts.6
Such sexual abuse routinely has negative physical and psychological consequences for the younger child and, when the situation comes to the attention of the family, the parents often will turn to the pediatrician for advice, guidance and support. The pediatrician may be involved in providing health care to the child victim, another child in the home, or the adolescent offender. Parents frequently experience conflict in these situations, particularly if the adolescent is well known to the child or is a member of the family. The adolescent may have shown previous evidence of moderate to severe psychosocial maladjustment characterized by poor impulse control, aggressive behavior, negative self image, or social isolation from peers.
This article is intended to familiarize pediatricians with some of the factors and characteristics of child sexual abuse by adolescents which will assist them in communieating about adolescent sex offenders, and in the provision of appropriate intervention. Such intervention includes assessment of the problem, advice and counseling for both adolescents and parents, and referrals to appropriate mental health and law enforcement agencies. The article is based on clinical observations and findings from a specialized outpatient program designed to serve the alleged adolescent sex offender. Recommendations are based on the experiences of the multidiscip unary professional staff of the program. There is no attempt to provide detailed information on the medical management of these cases. Other sections of this issue of Pediatrie Annals will cover, more comprehensively, such factors as proolems in normal sexual development, adolescent sexuality, homosexuality, prostitution and similar topics.
JUVENILE ABUSER TREATMENT PROGRAMS
The Special Unit of the Child Protection Center (C PC/ SL.') of Children's Hospital National Medical Center has a pi -gram of specialized intervention and treatment se. ices for cases of alleged child sexual abuse or assault in which the identified abuser is a juvenile. The program is known as the Juvenile Abuser Treatment Program (J & TP) and has been in operation since October I980.7
The JATP is unique in the United States in that it is the only specialized program for alleged adolescent abusers which is a component of a child sexual abuse victim program located in a pediatrie teaching hospital. It was established as a result of the growing awareness on the part of C PC / S U staff about the magnitude of the problem of sexual abuse by adolescents: in over 1,600 cases of child sex ial victimization known to the Special Unit, 46.8% ol .he cases involved a juvenile offender, with over 32% of these involving a family member.
The ages of the victims ranged from two years to 15 ...with a mean age of six years. Twenty-six percent of ...tims were young males. All but one of the alleged ...rs were male. Their ages ranged from 12 to 18 ...ith a mean age of 14 years and two months. The ...vas usually a sibling or some other relative of the ...Siblings were the most frequent victims (36%); ... nieces, and nephews totaled about 39%."
...program for adolescent sex offenders has as its ...medical care, mental health treatment, social ...ce intervention, and advocacy for greater awareness about cases of child sexual abuse involving a juvenile perpetrator. The adolescent must be under 18 years of age at the time of entering the program and at least 12 years of age at the time of the reported incident. Each case is screened for eligibility by JATP staff.
Juvenile offenders with documented thought disorders, chronic substance abuse problems, mental retardation or who do not fit within the age range of 12 to 18 years are not eligible to participate in this outpatient program. Juveniles who fall in the ineligible category are referred to other more appropriate community facilities. They may need residential mental health care, incarceration (detention) or special detoxification programs because closer supervision, observation and greater structure of the treatment is required.
Clients receive comprehensive services including medical examinations, psychological and /or psychiatric evaluations, psychosexual assessments, counseling and liaison with law enforcement and social welfare agencies. These specialized services are provided in conjunction with, and in addition to crisis intervention and short-term mental health treatment services currently being provided for child victims of sexual abuse.
In a study of 137 convicted adult rapists and child molesters conducted by Groth et al5 almost half reported that they performed their first sexual assault between the ages of eight and 18 years. The preliminary findings of Children's Hospital's JATP indicate that this problem is multi-faceted, complex, and often misdiagnosed. In particular, physicians and other professionals frequently are inclined to dismiss the problem as simply an "adolescent adjustment reaction. "'
In looking at the families of the adolescent abuser, a number of general characteristics seem to be common, such as marital conflict, poor communications and strained relationships, or distance between father and son. Often there are problems involving minor acts of delinquency or other negative behavior on the part of the adolescent which serve as an irritant to the parents. The parents often attempt to curtail this behavior by placing more stringent restrictions on the teenager. The normal parent-child conflicts of adolescence tend to become exacerbated.
In looking at these adolescents, one may observe youngsters who are withdrawn, often very passive, and generally functioning at an immature social level. These teenagers usually relate poorly to peers and have a generally negative attitude toward almost everything. They often seem to have little knowledge or understanding of sexual behavior.8 Usually, complaints of this nature are brought to the attention of the pediatrician through a concerned parent, other family members, or perhaps the adolescent himself. It is important to listen closely to the complaint in order to see if there are early warning signs or symptoms of more specific sexual pathology. Parents and adolescents seldom make a straightforward complaint because of concerns about adverse legal consequences and social stigma.9 Yet there is often enough personal conflict and turmoil in the home when the situation of sexual abuse is disclosed that parents reach out for advice and guidance from an uninvolved, trusted professional, such as the family pediatrician.
COMMUNICATION WITH PARENTS
Once it has been determined that an adolescent is involved in inappropriate sexual behavior with younger children, the first issue relates to the responsibility of the pediatrician and how he or she should proceed. In-depth analysis of the sexual abuse incident, its underlying causes, the legal ramifications and surrounding dynamics is a job for an experienced mental health and/or child protection specialist.10 In general it is the pediatrician's role to determine the type of support and advice the family may need while the crisis is in the acute phase, which is usually shortly after disclosure. In order to make a determination about appropriate advice and treatment for both the adolescent and other family members, it is important to obtain additional information.
One of the most valuable sources of information is often the individual who brings the problem to the attention of the physician. Many of the generalized problems that characterize some families of adolescent sex abusers are not observed directly by the physician. However, bits and pieces of information may come out over a period of time during office or clinic visits. Parents may be the single most important source of information as their own anxiety, guilt, and concern about the situation become more acute."
Initially, parents should provide a better understanding about issues such as the adolescent's school performance, social interactions, significant family relationships and major personality traits. These factors are significant in that they will enhance the pediatrician's general knowledge about the adolescent and his family. The purpose of exploring these issues is to aid the pediatrician as he or she attempts to provide guidance to the parents about the prognosis for the adolescent.4 For example, if the adolescent has an extremely low intellectual level and is not adjusted well at school, he may not be able to benefit from verbal therapy. It may be very difficult for him to comprehend the consequence of his behavior. Under these circumstances, a more structured setting for treatment may be appropriate.
The adolescent's ability to relate to his peers is a good indicator regarding his ability to benefit from group treatment efforts. Of course the specific decisions about the type of mental health therapy the adolescent should receive are made after a thorough assessment and an indepth clinical evaluation, yet it is often helpful when the pediatrician provides advice and support to parents on a much broader level.
Without doubt, the adolescent needs to have a concerned, supportive family. It is important to inquire about the parents1 initial reaction to the incident and whether or not their initial feelings have changed. Questions about family strengths, ability to communicate about difficult issues, and the degree of closeness of family members will enable the physician to have a clearer view of the family dynamics and home environment which can either hinder or facilitate appropriate intervention.
If the parent and other family members have a negative attitude toward the juvenile abuser and the sexual abuse incident, this could be a major barrier to the achievement of a satisfactory resolution of the problem.2
Parents may decline voluntary treatment that is strongly recommended by the social service agencies or the court. This is especially true when there is not adjudication or court stipulation for treatment, yet the adolescent has obvious emotional difficulty with sexual issues and there is strong evidence based on the other evidence that sexual exploitation has taken place. Unfortunately, this non-supportive attitude by parents tends to increase the denial factor that the adolescent has and thus inhibits the treatment process.
In addition, if the adolescent is in therapy and positive parental support is lacking, often the total responsibility for the family turmoil is directed to the adolescent. Even if the whole family has entered into treatment, the parents may cast all responsibility for the sexual abuse upon the juvenile without examination of other possible contributive factors. They do not regard their family as having problems and such issues as poor family communication, lack of appropriate male role models, personality disorders and dysfunctions within the family system, may be contributory factors.
The possibility of an adolescent becoming "labeled" or "identified" as a sexual offender or rapist is a topic most professionals, parents and society wish to avoid. Needless to say, it is extremely anxiety-producing for everyone. The more receptive the pediatrician is, the more likely it is that parents will provide complete, accurate, and honest information. Parental reactions and their level of cooperation are major factors in projecting the degree to which the adolescent will be accessible and responsive to treatment and rehabilitation. Initially, parents usually are angry with the adolescent and want to deny the gravity of the situation. They tend to blame themselves, especially when other family problems (marital, financial, educational, etc.) are present. They often feel frustrated and demonstrate ambivalent feelings, expressing lack of interest in the outcome at one point and deep concern at another. The impact of the incident on friends, neighbors, and other family members is also a major source of concern to them.
Frequent concerns expressed by parents reflect such issues as: Is my son a homosexual? (if abuse has involved a younger male child), Will he grow up to rape aduït women? (if physical injuries are involved), or How can this abusive behavior be prevented? It is important not to provide false reassurances in areas in which no clear answers are evident. It is best for the physician to reinforce the significance of more in-depth evaluation and treatment for the adolescent, the child victim, and other family members (if intrafamily abuse is the problem).
When broaching the subject of sexuality, the pediatrician may want to inquire about the parents' knowledge regarding when their child first expressed an interest in sexual issues. It is important to determine the degree of comfort or discomfort of the parents in discussing their sexual attitudes. This will give the pediatrician a cue regarding what attitudes may have been passed on to the adolescent. This phase of the information-gathering process is usually difficult and stress-producing for both the physician and the parent. It is helpful if the physician conducts this discussion within the broader context of normal sexual development and the typical adolescent conflicts related to independence and autonomy.
Parents often fail to set limi is or recognize the impact of highly stimulating sexual environments, particularly to vulnerable teenagers. If there is a history of prior sexual victimization of the adolescent when he or she was a child, there is a greater probability that he may become abusive in his behavior to others.
In addition to gathering information about family functioning and issues related to sexuality, the physician should also ascertain some general information about the alleged sexual assault.
Important factors include:
* The age relationship between the adolescent and the child involved;
* The methods used to get the child to comply (e.g., force, bribery, threats, etc.);
* The type of act (e.g., intercourse, exhibitionism, sodomy);
* The frequency of the alleged incidents with this child victim;
* Whether other children may have been victimized by the adolescent (especially vulnerable children such as those with physical or emotional handicaps or those who are very young or small in stature);
* Whether the adolescent (alleged offender) has been sexually victimized or traumatized.'
COMMUNICATION WITH THE ADOLESCENT
Often, a problem of sexual abuse which is known to the pediatrician is not reported by the involved adolescent. Whether or not to raise the issue or just how to proceed is a delicate matter requiring careful consideration. Factors include whether or not the adolescent is aware that the physician has been told, what the previous relationship is between the adolescent and the physician, and the degree of family tension and stress which is impacting on the adolescent.
If the physician has received a full and clear history about the sexual abuse from the parent or other family member, and if the adolescent Js aware of the physician's involvement, the discussion could be initiated without great difficulty. It is important that the adolescent is allowed to state his/her point of view, provide additional information, or simply verify what is already known. Of course it is best if the parent has informed the adolescent prior to the visit that the physician has been or will be consulted for advice. Confidentiality, and other rights of the adolescent should be understood and mutually respected between the parent, the adolescent, and the physician. Before concluding the discussion with the parent, it is important to ascertain what is expected of the physician, such as counseling with the adolescent, ongoing counseling with the parent, intervention with other professionals, etc.
Once the pediatrician becomes involved directly with the adolescent, the type of questions asked and the information provided should be supportive of current case management activities. Since, initially, most juvenile offenders will deny the seriousness of the problem or refuse ?? discuss details, it is not beneficial to pressure them, particularly if the primary reason for the office visit (as understood by the adolescent) is for followup on other specific medical problems. It is significant to ascertain specifically the adolescent's knowledge regarding the purpose of the office visit.
Even if the adolescent is unaware of the physician's knowledge about the alleged abuse, the parents should have the opportunity to request some guidance or advice regarding their own communication with the adolescent. It is still very important for the physician to obtain more feedback on the adolescent's interpretation of his/her behavior. Engaging in a discussion about the alleged incident should be approached with some caution. Picking up on the moods expressed, attitudes, facial expressions, and similar observable signals offers a way to "open the door" while expressing concern. The physician might say: "Many times we find ourselves in situations which are hard to explain. I want you to know that I am available if you need some advice or someone to talk to about things which concern you." These types of statements from the physician may encourage or facilitate the discussion.
The adolescent should have an opportunity to respond to the same broad questions which were addressed to the parent: perception of the family dynamics and relationships, peer involvement, school performance, or personality traits. The response will either validate what has already been said, or it will indicate where certain problems in communication might be.
When focusing more specifically on the sexual assault incident, the physician should evaluate the adolescent's willingness to discuss the problem. If the adolescent is unable to express some remorse, guilt or shame (especially when there is clear-cut evidence of abuse) then it should be difficult for someone to truly engage in therapy since they are unable to understand their own behaviors and may show litte empathy for the victim.8
The physician should attempt to develop insight into adolescent behavior and encourage expression of more healthy sexual activities. This is best facilitated when the physician can be nonjudgmental and supportive with free and open dialogue. Questions should be no n obtrusive and noninvasive. When the adolescent is more comfortable in expressing his feelings about his family, then he may be more receptive to advice and guidance. Specific dialogue should focus on his relationship with his father (or other significant males), his satisfaction with peer relationships and the child victim. The goal is to determine whether or not the adolescent is incapable of empathizing with the child victim and thus unable to avoid such exploitative behavior in the future. Those professionals who treat sex offenders have indicated that the expression of empathy toward the victim by the offender is the single most important factor in preventing recidivism.4
The physician should attempt to direct his counseling or advice where the adolescent seems to have the greatest need. For example, does he seem anxious, depressed or frustrated about what has happened? How does he seem to be coping with the various agencies involved? The physician will be most helpful if he is able to identify any specific personal conflict areas in which the adolescent is able to verbalize about the incident. This is not the same as an expression of empathy with the child victim. Even when he admits to sexual abusive behavior, this does not necessarily mean he has assumed responsibility and is open for change.
Since the physician is not expected to provide comprehensive in-depth mental health treatment, the most effective role for the pediatrician is to encourage greater communication with the adolescent and between the adolescent and his family.
During any follow-up visits, the physician should assess the level of improvement of the family relationships, the degree of compliance with the mental health treatment plan, and the adolescent's ability to assume responsibility for his acts.
If no formal reporting has been done (to the police or child protection services) the physician must explain his or her obligation to report cases of child sexual abuse to the appropriate official agency within the jurisdiction.12 The importance of child protection and supervised treatment of the adolescent should be discussed with both parent and adolescent.
The problem of juvenile sex offenders is complex and multifaceted. It is important that the physician be supportive yet very explicit about the need for qualified mental health supervision over a period of time. Recognizing the parents' feelings, providing an atmosphere for ventilation, gathering as much specific information as possible about the incident and family unit, all enable the pediatrician to offer supportive, accurate advice about an often concealed problem.
Most families become so distraught by the emotional explosion that occurs upon disclosure that they tend to want to deny that sexual abuse has occurred. It is important for them to recognize the needs of both child victim and adolescent offender. The decision to arrest and charge juveniles who are sex offenders sometimes reduces their denial particularly since it points out the need for mental health services and for them to take responsibility for their behavior.
Child sexual abuse involving a juvenile poses special problems for social service agencies, family members, and the pediatrician who may be involved with the family. It must be recognized that the sexual abuse incidents have negative psychological and social consequences for the child victim, and all family members. Pediatricians should be knowledgeable about the problem in order to provide support and advice for both parent and adolescent.
1. Groth N, Lo red o C: Juvenile sexual offenders: Guidelines for assessment. Internaiionai Journal of Offender Therapv and Comparative Criminology 1981. voi 25, No J.
2. Rogers C: Intrafamily Child Sexual Abuse/ J u venite Abuser Treatment Program. US Department of Health. Education, and Welfare. Office of Human Development Service. National Center on Child Abuse and Neglect. 1980.
3. Finkelhor D: Sexually Victimized Children- New York. Free Press. 1979.
4. Dicsher, Wenet. et al: Adolescent sexual offense behavior: The role of the physician. J Adoiesc Health Care, to be published.
5. Groth N: Sexual trauma in the life history of rapist and child molester. Yiaimologr: An International Journal 1979; 4:10-16.
6. Thomas JN: Ys, you can help a sexually abused child. RN 1980; 43(8):23-29.
7. Thomas J. Rogers C: A treatment program for intrafami(ysexua t offenders, in Stuart I. Greer J (eds): Sexual Aggression: Current Perspectives on Treatment. New York, Van Nos t rand Reinhold Co. to be published.
8. Lo red o C: Sibling incest, in Sgroi S (ed): Handbook of Clinical Intervention in Child Sexual Abuse. Lexington. Massachusetts. Lexington Books. 1982, p 177.
9. Groth N: The adolescent sexual offender and his prey. International Journal of Offender Therapy and Comparative Criminologi 1977. vol 21, No 3.
10. Burgess A. H o im si rom L, McC ausa nd M: Divided loyalty in incest cases, in Sexual Assault of Children and Adolescents. Lexington. Massachusetts. Lexington Books, 1978.
11. Thomas J. Rogers C: Sexual abuse of children: Case finding and clinical assessment. \ursing Clinics of Sorth America 1981: 16:179-188.
12. Lloyd D: Medical-legal aspects of sexual abuse. Pediatr Ann I979;8(5):8889.