Mental Health Assessment

In addition to CPS investigations, mental health professionals in a variety of contexts have become involved in the assessment of sexual abuse allegations. The goals of these mental health assessments are several: determining the likelihood of sexual abuse, making recommendations about child safety, proposing treatment plans, predicting prognosis for response to treatment, and assisting in legal intervention. With regard to the final goal, because sexual abuse is not only a mental health problem, but also a crime, mental health professionals may assist in litigation to protect children, to criminally prosecute alleged offenders, and to exact civil damages in cases involving sexual abuse.

There are a number of models for mental health assessment of possible sexual abuse. For example, models can involve the child alone, the child and other family members, and the offender alone. The appropriate model depends on the goals of the assessment, the nature of the child - alleged offender relationship, and the age and functioning of the child. Sensitive and careful assessments assist the child and others affected by the allegation in seeing the assessment process as health promoting rather than traumatic.

Child Sexual Abuse

A somewhat unique characteristic of sexual abuse assessments for mental health professionals is the importance of determining whether an event (sexual abuse) occurred. Mental health skills need to be adapted and expanded to address this requirement. Mental health professionals must usually engage in direct inquiry about sexual abuse with the child and others, using nonleading questions. A variety of child interview questioning protocols have been developed to guide evaluators. One example is shown in Table IV.

Evaluators employing this protocol are urged to use open-ended questions (found at the top of the continuum) and only to resort to more close-ended questions when open-ended ones do not assist the child in communicating his/her experience. For example, if a

Table IV A Continuum of Questions for Assessment of Possible Sexual Abuse

Question type

Example

Open ended

1. General question

2. Focused question

A. People

B. Body parts

C. Circumstances of abuse

D. Circumstances of prior disclosure

3. Follow-up question

A. Narrative cue

B. Repeat disclosure

C. Clarification

D. Details of abuse

E. Details of context of abuse

4. Multiple choice

5. Direct question

6. Leading question

7. Coercion Close ended

More confidence

1. Why did you come to see me?

A. What kind of a guy is your dad?

B. Did you ever see a penis?

C. Tell me everything you remember about daycare?

D. Did you tell your mom something happened?

A. What happened next?

B. You said he touched you?

C. He touched you where?

D. What did that touching feel like?

E. Do you remember where this happened?

4. Did it happen before or after Christmas or both?

5. Did your daddy put his peepee inside?

6. Your mom makes you suck her breast, doesn't she?

7. You can't leave until you tell me what happened.

Less confidence child does not respond to a focused question, ''Are there things you like about your grandpa?'' the mental health evaluator might ask a multiple choice question, ''Does he ever do special things with you, buy you things, or do any other nice things you can think of?'' The more open-ended the question, the more confidence the mental health evaluator should have in the child's response and visa versa. However, both analogue studies and clinical research indicate most children require direct or focused questions to disclose sensitive material. If information is elicited using a close-ended question, the interviewer should follow this disclosure with a more open-ended question. Leading questions and coercion are inappropriate for use in an evaluation of a child for sexual abuse.

Other special features of sexual abuse assessments include the following: Mental health professions should gather information on past and current history of the abuse allegation and of the people involved. Collaboration with other professionals, for example, examining physicians, child protection caseworkers, police officers, and lawyers, is integral to such assessments. The mental health professional must be able to clearly articulate criteria he/she uses in determining the likelihood of sexual abuse. In a review of such decision-making strategies in 1995, Faller found 12 sufficiently elaborated to be discussed. The criteria shown in Table V are found in these decision-making strategies.

An interesting and somewhat surprising finding from Faller's review was the number of mental health professionals who endorsed medical findings as an important factor. This is interesting because, of course, medical evidence is not gathered by mental health professionals. Furthermore, most cases of sexual abuse have no medical findings. The other items endorsed by the majority of mental health professionals were criteria derived from child interviews, specifically details about the sexual abuse and details about the context of the abuse.

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