A communicate of the literature reveals that the area of forensic questioning of young children in relation to child abuse is fraught with differing opinions and controversy. The clear need for courts to have definite facts with regard to perpetration of abuse on children by adults will continue to exist as long as child abuse does. In the guidelines for the assessment of allegedly abused children, the American Psychological connection Committee on professional institution and Standards (1998) indicates that forensic data and specialist witnessing may help the court in understanding, gaining perspective, and increasing the fairness of determinations. Professionals in psychological medicine may be asked to conclude if abuse has been perpetrated, and may use the determination of Post Traumatic Stress as a proof that it has. (Regan, Johnson, Alderson, 2002). In the case of people v Stritzinger (1983), the consummate Court ruled that unavailability due to a "mental infirmity" must be considered whether by the survey refusing to testify, or on the hint of an specialist witness. While the specialist may advise the child not testify due to Ptsd, the specialist would be on shaky grounds to state that the Ptsd is proof of the abuse. While Fisher and Whiting (2001) agree that some aspects of Ptsd symptoms are consistent with a child's behavioral reactions to abuse, an unreliable pattern of abused children with Ptsd make using the determination as a proof a very flawed reasoning. They do add though, that if abuse has been founded, the determination becomes a framework to conclude level of impact on the child and as a medicine springboard. This would also then seem to be recursive, with the determination of Ptsd following a founded case to advise the question: should the child be returned to the custody of, say, a parent offender, or a non offending parent who failed to protect the child, and the child is extremely reactive to as a reminder of the abuse? Since the persistence of Ptsd symptoms are likely closely related to the intensity, volume of vital incidents, and duration of abuse, it would appear that there is no current predictive tool to ascertain how long medicine will take. This situation serves to complicate custody issues, not to mention issues of the child having visitation feel with a person who could be a perpetrator. Further, if the child's symptoms worsen following feel with their biological parent(s), is it ethical to desensitize a child to feel with their perpetrator in order for the child to return the perpetrator's care? If there is no "return home" goal, and the child will be adopted, what is the therapeutic point of chronic exposure?
There is of course, no current, valid, and trustworthy tool to predict if an personel will organize Ptsd following a trauma. (Walters, Bisson, Shepherd, 2006) Perry and Azad (1999), in a study on the incidence of Ptsd, found that 34% of a sample of children who had been identified as being sexually abused, and 58% of children identified and being both sexually and physically abused met the criteria for Ptsd. In addition, the study found that all of the children, while not fully Ptsd, had clinically vital symptoms. The children in the study that had only partial symptoms may very well continue improvement on to full Ptsd status. Thus, children diagnosed with Ptsd as a result of abuse come to be a extra concern outside of the people of children who have experienced abuse, but have not been diagnosed with Ptsd.
Though common sense informs that extra care needs to be given to children who have experienced traumatic events, the issues of their post-trauma care can come to be quite complex. Lieberman and Van Horn state that:
Responses to early trauma need to be understood as the introductory manifestation of long-term risks to the child's unfolding development. (p. 112)
Briere and Spinazzola (2005) sound that in the case of a lengthy history of house interpersonal trauma, a complexity of traumatic stress develops that negatively effects the child's attachment with the parent. Such complexity of this people of child victims gives rise to the need for specialized attention, study, and formulations of forensic and medicine approaches. In a study with regard to the "pathways" to Ptsd in abused children, Kaplow, Dodge, Jackson, and Saxe (2005) found that behavioral signs noted immediately after disclosure of abuse might constitute varied reactions that consist of avoidance, anxiety, and dissociation. In turn, these then come to be foundations for further and longer-term symptom development. Briere (2006) notes that the connection in the middle of trauma and dissociation may not be as easy as it first appears; there may be multiple components that produce the dissociation effects, together with early attachment issues, emotional neglect, and neurobiological disturbances. Briere also states the possibility that dissociation may exist before trauma and be a risk factor for victimization. Again, this points to inherent ethical questions: is any forensic questioner trained adequately to correlate what may be very subtle and internalized symptoms presenting? One might assume, due to the nature and purpose of forensic examination, the child may communicate vital incident material that was not formerly revealed. Is there any data to show that forensic questioning does no further harm? If the long term investigate reply to that examine is at last found to be true, professionals may be trapped by the terrible dichotomous question: catch the perpetrator, or heal the child?
In increasing to these complexities, the age of the child when victimization occurs becomes a factor in forensic test and treatment, along with the primary question in most witnessing, memory. Nader (2001) states that at issue in younger children are their very age: they may have "literal interpretations, animistic thinking, faulty hypotheses, and inaccurate associations." (p 281) Nader also asserts that age not only plays a role in perception, but also what details the child attends to, and how the child's state of mind at the time of the trauma affects encoding of the memory for later recall. And of course, memory of the child victim is key to child security assessments, police investigations, courtroom proceedings, and to a lesser degree, subsequent treatment.
Leiberman and Van Horn (2001) address the question of the traumatized child's behaviors in relation to memory:
Traumatized reminders tend to remain unidentified when they operate outside of the child's known awareness or when the child cannot use language to communicate what is happening. The child's behavior may be strongly influenced by stimuli that act as triggers for memories of traumatic experience. (p118)
This assessment also seems to point to the question of preverbal memories that do not facilely find verbal expression or discernment by the child or the forensic investigator. Ceci and Bruck (1995) expands on the memory issue by asserting that due to the phenomenal amount of simulation while abuse there are likely some parts of the trauma feel that were never encoded in memory, so were never 'stored'. Furthermore, they cite studies that demonstrate that errors in children's accounts are most often omission rather than commission errors. Such studies reinforce the oversimplified truth that just as in adult female rape victims, child victims do not generally lie about sexual abuse.
With such complexity, subtle nuance, and varied aspects, how victim survey facts is gained and used in child abuse cases becomes likewise a complicated and delicate matter. Group opinion, media enthusiasm, multiple court opinions and those falsely accused of maltreatment of children all attest to the struggle to get the process accurate, fair, and unbiased. Many of the criticisms of singular cases, ordinarily targeting child security agencies and workers, while made by individuals not educated in the nature of trauma or Ptsd in children, have validity and serve to press the field into doing a better job. (Wexler, 1995)
In 1990, Congress enacted the Victims of Child Abuse Act that contains a detailed description (Iv) to guide investigations, prosecutions, and corrections of the Justice Department. These guidelines are an certain revision over a ideas that appears to have had a Group credit for at least some inconsistent and even unethical forensic and clinical approaches. But a easy communicate of these guidelines reveals that a body that does not nearly understand the nuances and complexities of the problems has created them that child (Ptsd) victims suffer. There appears to be no such required guidelines for most county level child security services. Also in the mix of complications in achieving the truth and attaining justice is the variation in training and philosophical foundations in the middle of law enforcement, courts, and the field of psychology. (Wrightsman, 2005) Even a cursory communicate of questioning tactics in the middle of the disciplines yields a wide variation in styles, approaches, and objectives. Not all of these approaches may be sensitive to the victim's emotional, developmental or thinking state. In fact, a very real examine is exactly how many police departments have a specially trained staff member to examine a child victim. Clinicians may cringe at the image of a rough and tumble officer who has never questioned a child abuse victim doing their best to pick their way straight through a child's vital incident account.
Children ordinarily communicate issues of abuse by whether deliberately or easily telling someone, or they make an unintentional reference to the abuse. (Ceci, et al., p.75) While these could be done for the first time in the presence of a child security worker or police officer, they more likely are done first in the presence of a trusted adult. The time lapse in the middle of the first telling and the second forensic telling is a time frame that bears study as to the emotional impact and time impact on the child's memory. This becomes especially with regard to in child protective services that have extraordinarily large caseloads in ratio to workers, where time in the middle of description and questioning may be days, or even weeks.
In addition, such aspects as linguistic problems related with the child's developmental level and cultural environment add to the challenge of accuracy. (Ceci, et al. P. 76) One also needs to think the changeable of culture, ethnicity, and quite possibly religious background. Should the forensic analyst be less than sensitive, or just possibly ignorant of a singular culture, response of the child would quite conceivably be altered.
In cases of sexual abuse, London, Bruck, Ceci, and Shuman (2005) conducted investigate that found child sexual abuse chamber syndrome (Csaas) to be quite valid. The effects of Csaas are generally thorough as impacting the pattern of disclosure in a singular case, with gradual disclosures, not to mention recantations quite common. A very easy and unpublished experiment in a county in Pennsylvania asking five child security workers if they had ever heard of Csaas yielded a negative response in all five. If those so closely related with child security are not aware of valid supportive investigate that has been colse to for practically twenty years that so articulates child victim's experience, there categorically is much training to do.
Multiple cases presented sensationally in the media attest to the significance of questioning techniques. The use of leading questions, questions that are posed in a manner assuming a specific answer, or questions that are too complicated for the child's age are common examples of problematic methods that can cause the child to offer often expound confabulated material. (Wrightsman, 2005) Such inadequate methods that ignore the child's developmental level can produce dramatic, hysterical reactivity in the community, as in the case of people v Raymond Buckey. A amount of collected studies indicate that children do make commission errors about things they have never experienced, and can create fantastic, well-constructed, believable accounts of abuses that have never occurred to them. Especially when faced with an adult questioner who is using repeated suggestive methods and has a confirmatory bias, children's survey accuracy suffers. (Ceci, et al., 1995)
Compounding plainly bad questioning and investigative techniques, is the issue of how the symptoms of Ptsd interact with forensic questioning. The Dsm groups symptoms into three basic categories of re-experience, psychobiological alterations, with avoidance, numbing and detachment comprising the last category. Wilson, Friedman, and Lindy (2001) sound that there may be a need to add three more categories to fully sound Ptsd, together with problems in interpersonal relationships, disturbance of ego structure, and alterations to the victim's psychological makeup. Schuder and Lyons-Ruth (2004) sound the list further by describing a collection of attachment behaviors that can be seen in traumatized infants. There is some evidence that there are child specific behavioral signs of Ptsd, such as precocious improvement and behavioral regressions. (Nader, p284)
In light of what has been demonstrated thus far in the investigate on the effects of Ptsd in abused children, a diagnosed child pressed into courtroom testimony appears to be contraindicated as to hereafter medicine concerns. It would stand to imagine that due to the nature of forensic evidence and facts gathering, whether by a forensic thinking health professional, child security worker or a police detective, all of whom are focused less on medicine than on the goal of victorious litigation, hereafter medicine is a secondary concern. It would seem that the very arrival of an analyst and the nature of the questions would have the clear inherent to trigger re-experiencing, avoidance, numbing, detachment, and bodily agitation. If unenlightened questioners, or questioners not taking into inventory the child's developmental level are added to this mix, it would seem likely that triggering may occur with some reliability. This would appear to be a ripe subject for investigate and testing. Even a child who has experienced abuse and is not diagnosed with Ptsd may find the courtroom feel daunting. Wrightsman (2005) explains:
"It can be argued that for any victim of sexual abuse or rape, whether an adult or child, the feel of facing your alleged attacker in court is particularly stressful. The trauma is compounded if opposing attorneys view the children as especially susceptible to intimidation while cross examination, and judges remain oblivious to efforts to "break down the child on the survey stand." (p 285)
Though one might hope that the aforementioned description Vi of the Victims of Child Abuse Act guidelines would directly address questioning tactics by attorneys, test of the description reveals no such measures. It should be noted, though, that the description does furnish for measures that make an endeavor to be sensitive to the child's emotional state such as video taped or finished circuit video testimony with an adult supportive attendant in close presence to the child. But even these may not be adequate to mitigate all of the inherent cues and triggers to (post traumatic) stress reactivity. One wonders why these same supportive measures (perhaps with the sustain parent or therapist of the child attending) are often not provided routinely, and as mandatory in cases of repeated forensic exam per Csaas.
The legal and therapeutic aspects of child abuse cases are inextricably entwined. Without definite facts and proofs of abuse, the child may be returned to a perpetrator. The process of gaining that definite facts and proof may negatively impact the child's symptoms and progression of treatment. Crouch, Smith, and Ezzell (August 1999) cite the fact that investigate in developing valid and trustworthy tools to quantum relevant variables of outcomes is lacking. One of those variables that bear study is the determination of abuse process and the subsequent legal forensics process to ascertain if there are long chronic effects of the child captivating straight through such a gauntlet. While psychologists may use a collected battery of standardized tests and measures in the determination of a Ptsd diagnosis, these may not be sensitive adequate to pick up varied impacts and effects of the abuse on the child. The tools may even misidentify the impacts and effects as an entirely other diagnosis. (Briere, Elliott, 1997) It stands to imagine that the same measures may be inadequate to conclude if the protective process itself is causing further harm to the child. There are tailored checklists and inventories available, such as the Trauma symptom Checklist for Children and the Child Sexual Behavior inventory (Biere, Spinazzola, 2005), but these appear to have inherent limitations. The Tscc is a self description for children ages eight to sixteen, and the Csbi, while evaluating children in the middle of the ages of two to twelve, only evaluates sexual behaviors. Given the complexity of 'complex Ptsd', there may be no adequate tool to ascertain the full, unique impact of the vital incidents on a specific child. Schuder, et al. (2004) speaks about 'hidden trauma' that is an integral part of the child's relational feel and may consist of behavior sets and interaction qualities that are not noticed as problematic by even a trained observer. Even with the current state of the art questioning environments and protocols, expectations of adults for children to facilely speak with a relative stranger following what may be a traumatic and embarassing abuse episode, and that challenges the child's house loyalty is a tall order.
It is well established that the determination of Post Traumatic Stress Disorder was industrialized out of the middle of the last century's feel with combat in varied wars. The determination was not designed with abused children in mind. Marshal, Spitzer, and Liebowitz (1999) conducted longitudinal studies that used Acute Stress Disorder criteria that advise that there is a need to reevaluate the Dsm arrival to stress syndromes. This clearly is the case when inspecting the expansion of comprehension of the experiences and behaviors, and extra needs of abused children with Ptsd diagnoses. Briere and Spinazola (2005) opine that clinicians often may need to make decisions on what part of the stress complicated is most relevant, and that ever more definite tools are needed to fully understand the unique dimensionality of a survivor of trauma. Such comprehension should lead to improvements in the forensic questioning of child victim witnesses and legal interventions, as well as treatment. A valid and trustworthy progress determination tool for use at the commencement and duration of medicine would bring a wealth of facts to the process and outcome of medicine efforts.
There are some efforts attempting to organize best practices training programs in forensic interviews of abused children, among them the American Prosecutors investigate Institute's National center for Prosecution of Child Abuse, the American professional society on the Abuse of Children, and the National Children's Advocacy Center. (Siegal, 2004) The National Children's advocacy center states on their website that their training has an efficacy of gaining adequate credible factual survey facts to prosecute in 64% of their cases (www.nationalcac.org) The National center for Prosecution of Child Abuse schedule strives to get training to half of the nation by 2010. There was no current facts on the website with regard to how many States have thus far been sufficiently trained.
It would appear that Daubert case may point to more than just the 'junk science' worry; it may in fact point to the need for some vehicle to educate judges as well as front line workers in the care of abused and Ptsd diagnosed children. In May of 1996 in the consummate Court of Tennessee, a dissenting opinion from Judge Leon Burns typifies the this singular difficulty:
The Group worker's testimony discounted all the well-known facets of impeachment. First, she told the jury that recollection and memory, often and first-line assault in credibility skirmishes, was not leading with child victims and should not be considered. Secondly, she discounted the significance of detail, an additional one fertile basis for cross-examination and impeachment. Finally, and more subtly, she explained away the significance of inconsistencies in children's testimony.
Clearly, Judge Burns was not afforded adequate educational forensic facts on disclosure patterns and the many biological effects of Ptsd on a child. Had Judge Burn's opinion been in the majority, the child in examine (and possibly many children to come) may have had a very distinct outcome.
As stated thus far, there are likely many variables of outcomes from forensic test of a child who is traumatized by abuse. It possibly goes without saying that ill managed or outright botched forensic efforts leave behind children who have been further damaged by the ordeal. One might expect that if some kind of 'psychological first aid' were to be provided very soon after the child revealing, this might mitigate improvement of Ptsd symptoms, and thus make for a more definite forensic exam, but Bryant (2007) found that there was no solid validity to the claim that vital incident debriefing was sufficient in preventing subsequent Ptsd. Regardless of the preventive hope for Cid, the institution does furnish the victim with a here-and-now supportive care. A communicate of the Field Operations Guide of the National Child Traumatic Stress Network (2006) shows a extremely supportive arrival that might be typified as quite gentle, un-pressured, and decidedly 'un-questioning'. Without such debriefing support at the time of forensic questioning (and one might reasonably sound that a goodly amount of children do not receive such debriefing), the introductory forensic endeavor with its primary focus and objective on fact finding, has the great inherent to add unnecessarily to the child's stress load..
Court test is of course, forensic in nature, and due to the basic philosophy of adversarial face-to-face confrontation of one's accuser, drastically in counterpoint to Ptsd medicine in children. Wilson, et al. State that a "core medicine arrival removes obstacles so that the organism can heal on it's own." (p40). Most inexpensive adults would agree that placing a child on a survey stand, whether in front of a jury or just a judge would qualify as an intimidating 'obstacle' to the child's best interest of healing from Ptsd. Walters, Bineman, and Wright argue that hearsay testimony by professionals who have worked with the child, though clearly not the norm in a court hearing, is a clearly inexpensive alternative to risking further damage to the child. While protecting the child, this may place the clinician in a gray area where the dual role as the therapist and specialist survey may come up. Strasburger, Gutheil and Brodsky (1997) note that this can be come very ambiguous, but also may be somewhat certain when clinicians identifying themselves as specialist witnesses are unavailable due to locality and economic reasons. In addition, clinicians serving a case may be routinely asked to furnish solution in the form of instruction with regard to Ptsd in children to help judges more fully understand the issues.
As time marches on, it becomes ever more clear that specificity in medicine needs to be industrialized to address the singular idiosyncratic presentations of abused children diagnosed with Ptsd. The literature is rife with calls for even more investigate to study the efficacy of existing treatments and to organize new ones. (Lombardo and Gray, 2005) This wheel turns exceedingly slow. Nader (2004) advises that the practitioner who is going to work with Ptsd children who are victims of abuse needs to have a good working knowledge of psychotherapeutic ideas as well as a specific, experienced trauma background.
Most models of medicine for Ptsd in children are plainly derived from adult models, mirroring the earlier criticism of more specific determination criteria for children with the disorder. Most current approaches consist of multiple recounting of the vital incidents, re-attribution of erroneous responsibility, regaining a sense of safety, and helping the child procure a sense of operate in their lives. (Nader, 2004) Other well-known approaches such as cognitive-behavioral therapy, with a focus on trauma seem to be consistently cited as providing vital revision over other forms of medicine such as child-centered therapy. (Cohen, Deblinger, Mannarino, and Steer, 2004). Other therapies such as Eye Movement Desensitization and Reprocessing (Emdr) have vital chronic consider over efficacy and validity with adults, let alone children.
Lieberman and Van Horn (2004) begin to refine a more child sensitive arrival by noting that two very leading focus areas for children with Ptsd as a result of interpersonal violence are re-establishing care giving routines and certain reciprocity in the middle of the child and care giver. Gaensbauer (2004) refines this child sensitive arrival further, stating that clinicians intervening in the child's life must take care not overwhelm and allow the child's emotions to get out of operate due to history material. He also comments on "spontaneous play", but is not clear if this is in opposition to structured play therapy (p. 199) Gaensbaur goes on to note that: "probably the most leading gift we can make as therapists to the child's saving is to help parents to deal with the child's symptoms in the home environment." (p.199) This categorically would apply equally to sustain parents when a child has been removed from an abusive parent(s). Gaensbaur addresses the behavioral acting out related to Ptsd by suggesting a two pronged arrival that includes firm limit setting and demonstration of empathy for the child's expressed emotions as attached to the vital incidents. (p. 200)
This author's anecdotal experiences in the field treating abused children with Ptsd for some ten years is that there are many front line clinicians that while having adequate training and feel in psychotherapy and other multi modal techniques, have but a rudimentary comprehension of Ptsd. In addition, they generally and largely rely on behavioral approaches and techniques to address an abused child's behavioral expressions of the disorder. categorically anecdotal study of the efficacy of such singularly behavioral techniques has demonstrated that the application appears to reliably escalate the child's symptoms and move them towards extreme life and developmental altering decompensation. The question appears to be that children with Ptsd often present strong oppositional symptoms that are likely attached to their allosatatic reactivity. This may be in increasing to co morbid diagnoses. Many adults, even trained clinicians, reflexively react to a child's opposition with an growth of pressure by way of behavioral techniques. Such a shift to a behavioral pressure stance can be quite subtle, and even unconscious on the part of the adult, but no less real in result on the child. Adults, who serve as child security workers, police officers, attorneys, therapists, and judges, to a child, may begin the cuing and triggering of the child's stress just by their titles.
Conclusions and Directions
There appears to be adequate evidence to show how children who have been abused feel and demonstrate Ptsd is qualitatively distinct from adults. specific investigate into these qualities and even inherent child-specific symptoms and varied behavioral episodes need to be explored. Ascertaining if current formats of forensic questioning contribute to driving Ptsd symptoms deeper, contribute to their escalation and intensity, or are supportive of healing appears to be a fair area of concern. The improvement of ever more specific and specialized forensic and medicine approaches, as informed by valid scientific investigate on child victim's expressions of Ptsd is needed. Accurate tools to guide the process of medicine and quantum outcomes are needed. High potential farranging instruction of all professionals complicated with child victims about the nature and peculiarities of Ptsd in children would allow for more definite and sufficient litigation and movement of the child towards and straight through treatment. There is no specialized, specific, and individualized medicine modality for treating Ptsd in children who have been victims of interpersonal abuse. Though all of the mentioned therapy alternatives categorically implicitly consist of empathy and gentleness, none articulate gentleness as a key aspect of treating abused children. possibly after all of the investigate and articulation of therapeutic and legal approaches and modalities, easy gentleness may be the healing salve that is needed. Certainly pressing a child straight through a legal process does not qualify as 'gentle.' It is time for the clinical healers to move forward out of repetitions of 'the need for more research' on the improvement of more sufficient forensic and therapy approaches, and do the developing right now, in the field.