ابزار تشخیصی مشکلات رفتار جنسی در تشخیص سوء استفاده جنسی در یک کلینیک ارزیابی کودک آزاری پزشکی قانونی

Objective: This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample. Method: A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores. Results: The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children. Conclusions: This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse.

The desire for a reliable indicator of sexual abuse has led clinicians to look at sexual behavior problems as both a screening and as a diagnostic tool. Although sexually abused children as a group exhibit more sexual behavior problems than nonabused children Adams et al 1995, Cosentino et al 1995, Dubowitz et al 1993, Friedrich 1993b, Friedrich et al 1992, Friedrich et al 1986, Gale et al 1988, Goldston et al 1989, Hibbard and Hartman 1992, McClellan et al 1997, Mian et al 1996, Wells et al 1997, Wells et al 1995 and White et al 1988, the utility of behavioral measures in a diagnostic assessment remains in question. In a research review, Kendall-Tackett, Williams, and Finkelhor (1993) found that sexual behavior problems and post-traumatic stress disorder could differentiate sexually abused children from nonabused children. However, they also found that a third of sexually abused children exhibit no such symptoms. This asymptomatic group of sexually abused children thus limits the utility of such behavioral tools because of the risk of increasing the false negative rate of diagnosis. Another potential problem for these tools is the false positive rate. How good a discriminator for sexual abuse is the presence of sexual behavior problems? Are there other determinants of sexual behavior problems apart from sexual abuse? The various studies that have indicated an association between sexual behavior problems and sexual abuse raise four methodological questions. What methods were used to measure sexual behavior problems and how reliable are these methods? How was the diagnosis of sexual abuse made and, importantly, were sexual behavior problems used in the diagnostic assessment?

The study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in children referred for a forensic sexual abuse evaluation. Although some sexually abused children exhibit serious sexual behavior problems, this study indicates that community professionals should use caution when using sexual behavior problems as a diagnostic indicator of abuse. Indeed, such use runs the risk of increasing the false positive rate if a child demonstrates worrisome sexual behavior but was not abused. It also runs the risk of increasing the false negative rate if a child does not demonstrate such behaviors, yet was abused. Notwithstanding the lack of utility of sexual behavior problems as a diagnostic screen for sexual abuse, such behaviors still require careful evaluation using standardized measures in order to make recommendations about intervention, both to facilitate healthy sexual development in children and to protect other children from sexually intrusive behaviors.