How to Interview Sexual Abuse Victims: Including the Use of Anatomical Dolls

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Marcia Morgan

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  • IVPS: Interpersonal Violence: The Practice Series

    Jon R. Conte, Series Editor

    Interpersonal Violence: The Practice Series is devoted to mental health, social service, and allied professionals who confront daily the problem of interpersonal violence. It is hoped that the knowledge, professional experience, and high standards of practice offered by the authors of these volumes may lead to the end of interpersonal violence.

    In this series…

    • LEGAL ISSUES IN CHILD ABUSE AND NEGLECT

      by John E. B. Myers

    • CHILD ABUSE TRAUMA: Theory and Treatment of the Lasting Effects

      by John N. Briere

    • INTERVENTION FOR MEN WHO BATTER: An Ecological Approach

      by Jeffrey L. Edleson and Richard M. Tolman

    • COGNITIVE PROCESSING THERAPY FOR RAPE VICTIMS: A Treatment Manual

      by Patricia A. Resick and Monica K. Schnicke

    • GROUP TREATMENT OF ADULT INCEST SURVIVORS

      by Mary Ann Donaldson and Susan Cordes-Green

    • TEAM INVESTIGATION OF CHILD SEXUAL ABUSE: The Uneasy Alliance

      by Donna Pence and Charles Wilson

    • HOW TO INTERVIEW SEXUAL ABUSE VICTIMS: Including the Use of Anatomical Dolls

      by Marcia Morgan, with contributions from Virginia Edwards

    • ASSESSING DANGEROUSNESS: Violence by Sexual Offenders, Batterers, and Child Abusers

      Edited by Jacquelyn C. Campbell

    • PATTERN CHANGING FOR ABUSED WOMEN: An Educational Program

      by Marilyn Shear Goodman and Beth Creager Fallon

    • GROUPWORK WITH CHILDREN OF BATTERED WOMEN: A Practitioner's Manual

      by Einat Peled and Diane Davis

    • PSYCHOTHERAPY WITH SEXUALLY ABUSED BOYS: An Integrated Approach

      by William N. Friedrich

    • CONFRONTING ABUSIVE BELIEFS: Group Treatment for Abusive Men

      by Mary Nõmme Russell

    • TREATMENT STRATEGIES FOR ABUSED CHILDREN: From Victim to Survivor

      by Cheryl L. Karp and Traci L. Butler

    • GROUP TREATMENT FOR ADULT SURVIVORS OF ABUSE: A Manual for Practitioners

      by Laura Pistone Webb and James Leehan

    • WORKING WITH CHILD ABUSE AND NEGLECT: A Primer

      by Vernon R. Wiehe

    • TREATING SEXUALLY ABUSED CHILDREN AND THEIR NONOFFENDING PARENTS: A Cognitive Behavioral Approach

      by Esther Deblinger and Anne Hope Heflin

    Copyright

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    Dedication

    This book is dedicated to my father, Les Morgan, whose love, creativity, encouragement, and support will always be in my heart and in my life.

    A special thank you to Joelle Steward for her research assistance on this project and to Virginia “Ginger” Edwards for sharing her expertise in working with young children. Without joining forces, Ginger and I would have never developed the anatomical dolls … and this book would have never become a reality.

    Declaration

    This book is intended to provide an introduction and a broad set of guidelines on how to interview children about sexual abuse. Individual practice with children may vary from that outlined here and still be competent and professional.

    Introduction

    Sexual abuse of children is not an easy thing to talk about—it has long been ignored by society. Yet it must be discussed. Every day in the news there are reports of children being sexually abused in day care centers, by relatives, in homes, in social clubs, and even by older children. It is estimated that approximately one out of every four girls and one out of every eight boys will be a victim of sexual abuse by the time he or she reaches his or her 18th birthday.

    Child sexual abuse, whether fondling or forcible intercourse, is a safety issue of importance to the entire community. Abused children often reach adulthood with unresolved conflicts, extreme insecurity, and a confused attitude toward authority. Their uncertainty, anger, and hatred may be turned against themselves, their friends, their own children, and society. A vast number of criminals convicted of robbery, burglary, rape, and arson were physically or sexually abused and/or neglected as children. Convicted male felons are five times more likely to have been abused than noninstitutionalized males. Likewise, national studies reveal that on the average, 80% of incarcerated felons were physically or sexually abused as children. One of the most alarming facts is that sexually abused children are more likely to grow up to be child abusers themselves—and the cycle of abuse continues.

    This book is designed for professional interviewers, including police, social service workers, and prosecutors. The purpose is to provide interviewing guidelines that not only will enhance the amount, quality, and validity of information obtained from a child, but will create an environment that minimizes the child's trauma. The book begins by describing how the criminal justice system has dealt with child victims and how the anatomical dolls were created as an interviewing tool. It examines the problems professionals face with young children and how preinterview preparation is essential for a successful interview. The book walks the reader through an interview from beginning to end: establishing rapport, avoiding leading questions, deciding whether to use anatomical dolls, how to use dolls appropriately, case law and legal issues, and going to trial. Additionally, the book includes training exercises, a glossary of terms, an annotated bibliography, and a listing of audiovisual resources.

    Much has been written about interviewing children. This book, however, is designed to provide the professional with basic ideas on interviewing of children that incorporates current case law and practice on the use of anatomical dolls. The in-depth discussion is based not only on the many years' experience of the author, who was the cocreator of the dolls, but on current research as well. The book is a comprehensive look at the very complex task of interviewing children. Although there is a great deal condensed in the following pages, the reader may also find other materials outlined in the appendices helpful.

  • Appendix 1: Glossary: Correct Terms and Slang for Sexual Parts of the Body

    Many times children describe sexual acts using words that are unfamiliar to the adult interviewer. The terms listed below are designed to help bridge the communication gap that might exist between interviewer and child. Remember not to put words in the child's mouth but rather to get clarification and definition of the child's terms, such as through demonstrating with an anatomical doll.

    • Anus: The opening in the buttocks from which a bowel movement comes. The posterior opening of the digestive tract. Slang: asshole, butthole, airhole.
    • Breasts: Glands on the chest of a person, located between the neck and abdomen. Slang: boobs, tits, knockers, hooters, headlights.

      Figure A.1. Anatomical Dolls With Labeled Body Parts

    • Buttocks: The rear or posterior part of a person's anatomy. Slang: ass, butt, bottom, buns, tush, bum, cheek, rear, seat.
    • Genitals: The reproductive organs (generally external) on a male or female. Slang: privates, private parts, personal area, bottom.
    • Penis: The male sexual organ used in sexual intercourse and from which a male urinates. Slang: wienie, cock, Johnson, peanuts, snake, thing, wagger, whacker, dick, prick, old fella, peter, dong, rod.
    • Sexual Intercourse (coitus): The act of putting the male's penis into the female's vagina, often followed by ejaculation. Slang: fucking, screwing, banging, doing it, knocking up, getting some, making love, making babies, humping, piece.
    • Sodomy: Anal intercourse or oral sex (mouth to genitals). Slang: go down, blow job.
    • Sperm: A male reproductive cell; spermatozoon. Found in seminal fluid in ejaculation from the penis. Slang: glue, wad, seeds.
    • Testicles: The two male genital glands, located behind the penis, which produce sperm. Slang: balls, nuts, bag, sack.
    • Vagina: An opening leading from the uterus to the vulva in a female's genital area. Slang: hole, beaver, cherry (hymen).
    • Vulva: External female genitalia. Slang: lips, cunt, pussy, jewels.

    Appendix 2: Research Review and Annotated Bibliography

    The following annotated bibliography consists of research articles on interviewing techniques with child sexual abuse victims. The intent is to provide an overview of the research in the field of interviewing and in particular the use of anatomical dolls, and does not purport to be a comprehensive review of the literature.

    August, R. L., & Formart, B. D. (1989). A comparison of sexually abused and non-sexually abused children's behavioral responses to anatomically correct dolls. Child Psychiatry and Human Development, 20(1), 39–47. http://dx.doi.org/10.1007/BF00706956

    A research study involving 32 girls, ages 5 through 7, compared children's responses to anatomical dolls. Half of the girls were from treatment or evaluation programs for sexually abused children; the other half were from a “nonabused” control group. The girls were observed playing alone with the dolls and talking about the dolls with a clinician later. The results support the contention that sexually abused children have a different approach to and interaction with the dolls than do nonabused children. The abused children often avoided the doll when an adult was present yet demonstrated more sexual behavior while alone with the doll.

    Bays, J. (1990). Are the genitalia of anatomical dolls distorted?Child Abuse & Neglect, 14, 171–175. http://dx.doi.org/10.1016/0145-2134%2890%2990028-R

    This study was undertaken in response to criticisms that the genitalia of anatomical dolls are disproportionate compared to real-life human anatomy. This overemphasis of sexual parts has been perceived as suggestive and misleading to a child when dolls are used in an interview. The results from comparing 17 dolls indicated that the dolls' genitalia were, in fact, appropriately proportioned to the body. The study was conducted only on adult anatomical dolls. However, Bays also offers guidelines for juvenile doll genitalia.

    Boat, B. W., & Everson, M. D. (1988). Interviewing young children with anatomical dolls. Child Welfare, 67, 337–352.

    This article is a comprehensive look at guidelines for interviewing children under the age of 5 for sexual abuse. It is similar to their earlier booklet of guidelines (see below). It cautions interviewers to obtain adequate training on how to use anatomical dolls and to possess knowledge on child development in order to accurately interpret a child's response. Boat and Everson make suggestions on information the interviewer should know about the child beforehand, the interview setting, and methods of documenting the interview. The interview protocol should focus attention on the child's sexual knowledge and experience in a nondirective manner. Before the interview escalates to questions about the alleged abuse, the interviewer should develop rapport and assess the child's developmental level through questions and play. Ending the interview should leave the child comfortable with having shared possibly difficult and fear-producing information.

    Boat, B. W., & Everson, M. D. (1986). Using anatomical dolls: Guidelines for interviewing young children in sexual abuse investigations. Chapel Hill: University of North Carolina, Department of Psychiatry, 113–129.

    Guidelines are essential when using dolls to interview young sexual abuse victims. This booklet gives suggestions for the qualities to look for in dolls, such as size, body materials and construction, expression, clothing, sexual features, race, and the number of dolls to use.

    The interview process is broken down into steps corresponding with the three protocol goals: focus the child's attention on sexual issues and experience in a nondirective manner; provide a safe and accepting atmosphere for the child; and provide encouragement and reassurance for the child to overcome reluctance to disclose the abuse. The first step is to build rapport and assess the child's understanding of key concepts. When the dolls are introduced, the interviewer should take a body parts and functions inventory with the child. The child's names for parts or functions should be used throughout the interview. The interview should escalate from a general discussion of times when abuse most likely occurred (e.g., bath time) to the critical event and individuals involved. Questions should be open-ended to avoid being leading. Questions can be asked even during times of play. The interviewer should remain casual and patient and underreact to anything the child says. If the subtle and indirect approach is not productive, the interviewer can ask about sexual abuse in general terms. Escalating beyond this may be leading and suggestive and may not be admissible in court. However, if strong evidence exists, for the safety of the child you may risk direct questions about specific individuals. The last stages of the interview process should focus on the child's specific fears and anxieties. Three appendices include a listing of doll manufacturers, developmental considerations, and criticism of dolls.

    Boat, B. W., & Everson, M. D. (1988). Use of anatomical dolls among professionals in sexual abuse evaluations. Child Abuse & Neglect, 12, 171–179. http://dx.doi.org/10.1016/0145-2134%2888%2990025-7

    Law enforcement officers, child protection workers, mental health practitioners, and physicians were surveyed to determine their use of anatomical dolls and how they evaluated children's responses. The results indicated that most had little specific training in using the dolls, yet the use of anatomical dolls is increasing. There was also variation among the types of doll features the respondents used. Fewer law enforcement officers considered the child's verbal statements of abuse as convincing evidence. Most of the professional groups believed that sexual demonstrations with the dolls by the children were more convincing if verbal descriptions were added. There was no consensus among the professionals on what behavior was considered normal curiosity or play by the child with the doll. The researchers contend that training in general on the use of the dolls as well as in child development should be a prerequisite for working with young victims of sexual abuse.

    Britton, H. L., & O'Keefe, M. A. (1991). Use of nonanatomical dolls in the sexual abuse interview. Child Abuse & Neglect, 15, 567–573. http://dx.doi.org/10.1016/0145-2134%2891%2990040-K

    This study addresses the criticism that anatomical dolls are “sexually suggestive” by testing the hypothesis that children who are referred for medical evaluation due to suspected sexual abuse will demonstrate sexual behavior with nonanatomical dolls as frequently as with anatomical dolls. The same researcher interviewed 136 children over a 2-year period. Anatomically detailed dolls were used the first year and nonanatomical dolls the second year. The results of the study supported the hypothesis that the children used the nonanatomical dolls to describe or demonstrate sexual events as frequently as they used the anatomical dolls. The researchers concluded that the use of dolls, whether anatomical or not, is valuable to interviewing young children for sexual abuse because they aid a child in expressing him or herself.

    Cohn, D. S. (1991). Anatomical doll play of preschoolers referred for sexual abuse and those not referred. Child Abuse & Neglect, 15, 455–466. http://dx.doi.org/10.1016/0145-2134%2891%2990029-D

    This study identified different reactions to anatomical dolls between preschool-age children referred to a hospital clinic for sexual abuse and a “nonabused” control group not referred to the hospital. The children played in a specially prepared room under four conditions. They were observed by two trained coders. The results indicated that the referred children were not more uncomfortable than the control group; neither did they exhibit more aggressive behavior. The two groups were about equally curious about the dolls; thus the researchers concluded that sexual abuse could not be determined solely on the basis of play with the anatomical doll.

    Everson, M. D., & Boat, B. W. (1994). Putting anatomical doll controversy in perspective: An examination of the major uses and criticisms of the dolls in child sexual abuse evaluations. Child Abuse & Neglect, 18(2). http://dx.doi.org/10.1016/0145-2134%2894%2990114-7

    Through an extensive review of guidelines and protocols on the use of anatomical dolls in sexual abuse evaluations, seven functional uses of the dolls were identified: Comforter, Icebreaker, Anatomical Model, Demonstration Aid, Memory Stimulus, Diagnostic Screen, and Diagnostic Test. These functional uses are discussed in light of several criticisms that have been raised about the use of anatomical dolls in sexual abuse evaluations. The relevance of these criticisms is shown to vary greatly by doll use. As a result, the authors argue that any critique of anatomical dolls must consider the specific function the dolls serve in the evaluation. Although there seem to be widespread perceptions in both lay and professional circles that young children's behavior with the dolls is commonly used to make definitive diagnoses of sexual abuse (Diagnostic Test use), such a use of the dolls was not endorsed by any of the guidelines reviewed and is open to significant criticism. The most common criticism of the dolls, that they are overly suggestive to young, sexually naive children, is not supported by available research. Finally, the continued, informed use of anatomical dolls in sexual abuse evaluations of young children is strongly supported.

    Everson, M. D., & Boat, B. W. (1990). Sexualized doll play among young children: Implications for the use of anatomical dolls in sexual abuse evaluations. Journal of the American Academy of Child and Adolescent Psychiatry, 29(5), 736–742. http://dx.doi.org/10.1097/00004583-199009000-00010

    This article begins with an assessment of seven previous studies dealing with explicit sexualized play with anatomical dolls by young children. The study undertaken for this article was to assess these behaviors in a group of nonreferred, nonsuspected children and to note the differences by the child's age, gender, race, and socioeconomic status, and the gender of the interviewer. Two hundred and thirty-three children between the ages of 2 and 5 were used. A 30-minute structured interview with the dolls was conducted with each child. The results of the study suggest that explicit sexualized doll play is not a common occurrence. Only 6% of the children in this study demonstrated this behavior. The behaviors varied in accordance with the various characteristics. The researchers conclude that the dolls are valuable as a communication aid for young children and for differentiating between casual and explicit knowledge of sexual mechanics.

    Everson, M. D., Meyers, J.E.B., & White, S. (1993). Suggested guidelines for use of anatomical dolls during investigations or evaluations of suspected child abuse. Unpublished manuscript, American Professional Society on the Abuse of Children.

    The guidelines offered are for investigative and diagnostic interviews of children by child protection services and law enforcement professionals. The purpose of the guidelines is to provide information on doll use as an adjunct to the questioning process. Seven functions of dolls in investigations and evaluations are identified: Comforter, Icebreaker, Anatomical Model, Demonstration Aid, Memory Stimulus, Diagnostic Screen, and Diagnostic Test. Diagnostic testing with dolls, however, is not an accepted practice. The article discusses where empirical support for doll use exists. For the inexperienced interviewer, more specific guidelines for using dolls in interviews are offered. These include essential features of the dolls, when and how the dolls should be introduced, how to avoid being leading or suggestive, and what to look for in documenting the interview. The appendix offers a list of resources on general interviewing techniques.

    Freeman, K. R., & Estrada-Mullaney, T. (1988). Using dolls to interview child victims—Legal concerns and interview procedures. National Institute of Justice Reports, 207, 2–6.

    This article is aimed at giving both prosecutors and police information on the advantages and disadvantages of, as well as techniques for, anatomical doll use. The advantages are establishing rapport, reducing stress, determining competency, and learning the child's sexual vocabulary. The disadvantages are that the interview techniques are vulnerable to the defense, complicate the case, and allow the possibility of a civil lawsuit. The article gives basic tips and techniques for preinterview considerations, introducing the dolls, learning the child's sexual vocabulary, and determining the case facts. It suggests that interviewers using the dolls should make appropriate selections, know the manual, and plan the interview in advance to avoid rendering the interview inadmissible in court.

    Friedemann [Edwards], V., & Morgan, M. (1985). Interviewing sexual abuse victims using anatomical dolls: The professional's guidebook. Eugene, OR: Migima Designs.

    This was one of the original books on how to use anatomical dolls in investigative interviews. Written by the creators of the anatomical dolls, it discusses how to select dolls, describes common communication problems in talking with children, and walks the reader step-by-step through the procedures of an interview: preinterview preparation, establishing rapport, introducing the dolls, appropriate questioning, interpreting children's actions, legal concerns, and validating the child's information. The last section includes training exercises for interviewers using dolls, such as role playing and practice using nonleading questions. The book is 8½ in. × 5 in., so professionals can easily carry it with them for a reference guide.

    Glaser, D., & Collins, C. (1989). The response of young, non-sexually abused children to anatomically correct dolls. Journal of Child Psychology and Psychiatry, 30(4), 547–560. http://dx.doi.org/10.1111/j.1469-7610.1989.tb00267.x

    The article begins with a brief discussion of previous studies on anatomical dolls. This study explored the response of nonabused children to the dolls, particularly if sexualized play occurred. The children were allowed to play in a nondirected context in familiar surroundings. The researchers recorded the emotional and behavioral responses and the naming of functions. The overall results indicated a positive response of the children to the dolls. Only five of the 91 children displayed any sexualized play.

    Goodman, G. S., & Aman, C. (1990). Children's use of anatomically detailed dolls to recount an event. Child Development, 61, 1859–1871. http://dx.doi.org/10.2307/1130842

    This study was conducted to address the concern that anatomically detailed dolls lead to false reports of abuse in nonabused children. The study videotaped 3- and 5-year-olds in a real-life social event with a male confederate. Children were questioned on the event later with either anatomical dolls, regular dolls, no dolls but visual cues, or no dolls and no visual cues. The findings support the view that the dolls do not contribute to children making false reports of sexual abuse. Although the 3-year-olds were not aided in recall by the props as much as 5-year-olds, those with props were able to recall a bit more than the children with no props. The 3-year-olds were also more susceptible to the suggestive or leading questions.

    Gwat-Yong, L., & Inman, A. (1991). The use of anatomical dolls as assessment and evidentiary tools. Social Work, 36, 396–399.

    This article reviews the literature on the use of anatomical dolls as well as implications for their use in social work. The literature subjects include the use of anatomical dolls, children's credibility, and validity and reliability concerns. Because of those many concerns, the authors warn that the dolls should still only be used as one of several assessment tools. Anyone who uses the dolls should undergo training on interview protocol as well as how to interpret and evaluate the responses.

    Hewitt, S. K., & Lund, S. J. (1988). Evaluating the very young child for sexual abuse. Unpublished manuscript, Midwest Children's Resource Center, Children's Hospital of St. Paul.

    This article makes suggestions for interviewing and evaluating sexually abused children between the ages of 18 months and 36 months. Their suggestions to reduce bias include limiting the number of interviews, using open-ended or free recall interview techniques, and using anatomically correct dolls. Their protocol involves four to five interviews to assess the child and establish rapport. Often very young children disclose abuse spontaneously, so objects to stimulate recall, such as anatomical dolls, are suggested. The dolls can also be used for the child's demonstration of abuse. However, the authors are careful to point out that very young children are often not developmentally capable of representational play. Allowing the child to use bodily reenactments may give a clearer picture of abuse in some instances. In order to document the abuse, it must be communicated by the child. The dolls offer one method of nonverbal communication. The article also offers more suggestions for assessing the possibility of parental coaching of allegations.

    Jampole, L., & Weber, K. M. (1987). An assessment of the behavior of sexually abused and nonsexually abused children with anatomically correct dolls. Child Abuse & Neglect, 11, 187–192. http://dx.doi.org/10.1016/0145-2134%2887%2990057-3

    This study was undertaken to observe possible differences in sexual behavior of sexually and nonsexually abused children while playing with anatomical dolls. The results showed that 90% of the sample of abused children demonstrated sexual behaviors with the dolls, whereas only 20% of the nonsexually abused children did. The researchers concluded that anatomical dolls are useful in sexual abuse investigations.

    Kendall-Tackett, K. A. (1992). Professionals' standards of “normal” behavior with anatomical dolls and factors that influence these standards. Child Abuse & Neglect, 16, 727–733. http://dx.doi.org/10.1016/0145-2134%2892%2990109-5

    This study attempts to build on previous studies in addressing “normal” behavior standards of a child's response to anatomical dolls among various professionals who work with victims 2 to 9 years of age. Characteristics of the professionals questioned were experience in working with children, experience in working with child victims of sexual abuse, profession, and gender. The majority agreed that overt representation with dolls of sexual behaviors such as oral-genital contact and vaginal intercourse was abnormal for nonabused children. There was disagreement about less obvious behaviors like touching sexual parts of dolls. The rankings depended on the various characteristics of the professionals. Those with the least amount of experience, law enforcement officers, and women were more likely to view the ambiguous behaviors as abnormal.

    Kendall-Tackett, K. A., & Watson, M. W. (1992). Use of anatomical dolls by Boston-area professionals. Child Abuse & Neglect, 16, 423–428. http://dx.doi.org/10.1016/0145-2134%2892%2990051-R

    This study was conducted as a response to criticisms that anatomical dolls are leading or suggestive to children and that interviewers lacked adequate training and experience to support their assessments of sexual abuse. The study sought to provide information on the characteristics of professionals, situations when doll use is most likely, and the presentation of the dolls to children. The results showed that 96.6% of professionals had received training, 97.3% had at least 1 year of experience with the dolls, and 77.8% followed some standard protocol. The training and protocol were usually derived from multiple sources. The dolls were most often used for children under the age of 10, particularly from 3 to 6 years. The majority of professionals present the dolls fully clothed and have the child undress them to avoid being leading. Also, most present the dolls with regular toys. The dolls are more likely to be used to have the child directly name the body parts and demonstrate what happened than to observe the child playing with the doll. This study contradicts previous findings and calls for further research and sampling in other parts of the country.

    Leventhal, J. M., Hamilton, J., Rekedal, S., Tebano-Micci, A., & Eyster, C. (1989). Anatomically correct dolls used in interviews of young children suspected of having been sexually abused. Pediatrics, 84(5), 900–906.

    This report describes the results of retrospective diagnostic interviews with children under the age of 7 using the anatomical dolls. The information from the doll interviews was classified into a category based on the explicitness of the demonstration. Then the information was compared to noninterview data derived from medical exams, witnesses, confession by perpetrator, or pattern of abuse. In this sample, the researchers found that the dolls were a valuable communication aid for the young children. Thirty-eight percent of the children believed to have been abused would have been missed without the interview using dolls.

    Levy, H., Kalinowski, N., Markovic, J., Pittman, M., & Ahart, S. (1991). Victim-sensitive interviewing in child sexual abuse: A developmental approach to interviewing and consideration of the use of anatomically detailed dolls. Chicago: Mount Sinai Hospital Medical Center, Department of Pediatrics.

    The objective of this monograph, as stated by its authors, is to offer an understanding of when the use of anatomical dolls is appropriate. It provides current research findings and practical training material to allow the reader to make his or her own judgments based on particular instances. It should be used as a supplement to experience or training in child development and/or formal training in interviewing.

    Anatomical dolls are only one of a number of facilitative tools. Any interview tool should be suitable to the particular child in order to assist in expressing him or herself. The dolls have been in use for many years; however, no one standardized procedure has been accepted, and there has been minimal consensus among professionals for interpreting children's behaviors with the dolls. The reliability of the dolls is still being debated in both the clinic and the courtroom. Interviewers should be aware of the criticisms that are mentioned by the authors. Despite these criticisms, the authors feel the dolls allow the child to communicate complex situations more easily. In order to make the reader more aware of the controversies over the dolls, the authors include a synopsis of six doll studies, three comparative and three normative. In addition to these, they summarize a research project conducted at Mount Sinai Hospital on the reliability of information obtained through the use of the dolls. Among the findings are a profile of children giving statements regarding abuse, an assessment of demonstrations made with the dolls, a comparison of response assessments by untrained observers and child development specialists, and an examination of interviewers' judgments of child's responsiveness in association with doll utilization. Great emphasis is placed on the interviewer being knowledgeable on child development and on interview techniques. One section offers an overview of child development and an example of an interview training program. Practical guidelines are given for approaching the interview in a sensitive manner. Various phases for conducting the interview are explained and include building rapport, assessing the child's developmental level, integrating the dolls, obtaining incident information, and terminating the interview. Examples of interviews are provided as well as suggestions for handling certain behavioral problems of the child during the interview. The authors also raise questions regarding the interviewer's role that could affect any legal outcome, such as the pros and cons of blind interviews (interviewing the child without obtaining any information about him or her beforehand) and the decision to videotape the interview.

    The appendices include a child developmental chart, training resources, assessment recommendations, an overview of interview process, a list of anatomically detailed doll suppliers, and information on available resources on dolls.

    MacFarlane, K., & Feldmeth, J. R. (Eds.). (1988). RESPONSE child sexual abuse: The clinical interview. New York: Guilford.

    This book is a good, practical overview of the clinical interview. It stresses that all interviews should be adapted to the situation and the child's level of development and skills. Besides enhancing the accuracy of information reported by the child, all interviews should have two goals: to make the child comfortable with the interviewer and to avoid causing trauma to the child by the process. In order to increase the accuracy of a child's story, the interviewer should be aware of some common aspects of child sexual abuse as well as barriers to and patterns of disclosure. In approaching the topic of abuse with a child, the interviewer should create a safe and open environment for discussion, encourage the child's disclosure without specific references, and allow the child to disclose in his or her own way and pace without a lot of interruption. By the end of the interview, the child should feel more self-confident and freed from the burden of his or her secret. In responding to the parents, the interviewer should carefully note their reactions to and with the child and aid the parents with reassurance, patience, and counseling. It is also important to take into account the possible legal criticisms of interviewing methods. Only one page of the book is devoted to the use of anatomical dolls and hand puppets. The authors give examples of how the dolls are helpful for interviews with children who have limited verbal ability. The authors state that the dolls have become the “most common aids used in evaluating suspected child abuse cases” and that “it would be a disservice to abused children to see the use of this valuable tool abandoned.”

    Quinn, K. M., White, S., & Santilli, G. (1989). Influences of an interviewer's behaviors in child sexual abuse investigations. Bulletin of the American Academy of Psychiatry and Law, 17(1), 45–52.

    Interviewers for child sexual abuse must be aware of how their behavior could influence the child's responses in order to avoid charges of contamination and avoid discrediting the interview. This article addresses both interviewers' behaviors and more technical aspects of the interview. One concern is that if the interviewer holds preconceived impressions, he or she could contaminate the session by implementing techniques that seek to confirm the impressions. Three behavioral aspects are outlined: inappropriate interactional patterns, emotional reactions, and discontinuity of specific behaviors. Interactional levels include assessing the developmental level of the child, touching the child, posture, location, closeness, and materials used in investigation. Emotional reactions may come from the interviewer's tone, language, facial expressions, eye contact, body distance, posture, and gesturing.

    Realmuto, G. M., Jensen, J. B., & Wescoe, S. (1990). Specificity and sensitivity of sexually anatomically correct dolls in substantiating abuse: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 29(5), 743–746. http://dx.doi.org/10.1097/00004583-199009000-00011

    The study these authors undertook was to see what scientific merit anatomical dolls have in confirming sexual abuse in young children. Their process involved using “blind” interviewers, both referred and nonreferred control subjects 7 years or younger, a structured interview format, and a defined rating scale. The results of the study found sensitivity to be 33% and specificity 67%. The study's limitations include using a single mental health professional for assessment, a restricted interview protocol, and a small sample size. The researchers concluded that based on these data, anatomical dolls are unsatisfactory as a single stimulus by which to judge abuse; however, they may be valuable as part of a comprehensive psychiatric evaluation in certain subpopulations.

    Shamroy, J. A. (1987, March/April). Interviewing the sexually abused child with anatomically correct dolls. Social Work, 165–166.

    Anatomical dolls, this author contends, are the most important tools an interviewer has for evaluating a young child for sexual abuse. The author gives suggestions for what to look for in anatomical doll features, as well as some general interviewing principles. Two short case examples are included to demonstrate the doll's usefulness in allowing a young child to express him or herself.

    Sivan, A. B., Schor, D. P., Koeppl, G. K., & Noble, L. D. (1988). Interaction of normal children with anatomical dolls. Child Abuse & Neglect, 12, 295–304. http://dx.doi.org/10.1016/0145-2134%2888%2990042-7

    One hundred and forty-four nonreferred children were used in this study, which sought empirical information on the play interaction of nonabused children. The children were observed with the dolls under three conditions: with an adult present, without an adult, and with the dolls undressed. The results indicate that nonabused children were not stimulated by the dolls. There were no incidents of aggression or explicit sexual behavior. The researchers conclude that unusual behavior in doll interactions should be taken seriously.

    White, S., Strom, G., Santilli, G., & Quinn, K. M. (1987). Clinical guidelines for interviewing young children with anatomically correct dolls. Unpublished manuscript, Case Western Reserve University School of Medicine, Cleveland.

    These authors provide a structured interview format, to be used with preschool-age children, that is designed to produce reliable, acceptable, and evidentiary data for the judicial system. Suggested interview aids include eight anatomical dolls, which are race appropriate. A “blind” interview, in which the interviewer knows only the child's name and little else about the alleged incident, is suggested. The article describes an interview from start to finish, including greeting the child, handling separation problems, beginning the interview, rapport building, the interviewer's role, the responsiveness of the child, doll presentation and its use through evaluation, developmental issues, and termination. General guidelines are suggested on the number of interviews, how to clarify children's responses, avoiding teaching child body parts and functions, management of interview, reinforcement, and the issue of coercion.

    Yates, A., & Terr, L. (1988). Debate forum: Anatomically correct dolls: Should they be used as the basis for expert testimony?Journal of the American Academy of Child and Adolescent Psychiatry, 27, 254–257. http://dx.doi.org/10.1097/00004583-198803000-00022

    Two professionals debate the issue of whether anatomical dolls should be used as a basis for expert testimony in child sexual abuse cases. Yates defends their use, stating that the dolls are useful in approaching sensitive sexual topics with children being interviewed. Although the dolls have been criticized in the courts, they should continue to be used so techniques can be improved. However, the dolls' importance should not be overstated. Guidelines for doll use, as well as standards or qualifications for examining children, should be established.

    The counterpoint to this position is argued by Terr. She writes that the strange appearance of the dolls makes children uncomfortable and suggests only one thing: that they “play sex” with the dolls. The dolls seem to allow interviewers shortcuts in time and training. The dolls also embody a legal conflict between protection of rights and activism.

    Yates, A., & Terr, L. (1988). Debate forum issue continued: Anatomically correct dolls: Should they be used as the basis for expert testimony?Journal of the American Academy of Child and Adolescent Psychiatry, 27, 387–388. http://dx.doi.org/10.1097/00004583-198805000-00021

    A California Supreme Court of Appeals decision in 1987 made it difficult to admit evidence from interviews with anatomical dolls. Yates again argues for the use of the dolls. In order to make them more admissible in court, the dolls should continue to be used in order to gain more knowledge and acceptance in the profession. However, she warns, conclusions should not be based on the doll use alone.

    Terr argues the negative side. The dolls are a shortcut in evaluation and they are too likely to cause sexual suggestion. She uses a brief interview transcript of a young girl as a case in point. The dolls, she claims, can taint a child's testimony.

    Appendix 3: Audiovisual Resources

    Act for Kids. (1990). Interviewing abused children [Video]. Spokane, WA: Author.

    This program examines two types of interviews with children—those conducted by caseworkers and those conducted by law enforcement. Although the style and techniques are similar, the type of information gathered is not.

    The professional is walked through the interview steps: (a) preparing for the interview; (b) proper setting for the interview; (c) establishing rapport and assessing the child's development; (d) questioning the child; and (e) concluding the interview.

    The video suggests introducing the dolls (referred to as “anatomically correct dolls”) if one of three conditions exists: (a) a child has a limited ability to express or verbalize an incident; (b) there is a need to clarify a child's previous statement; or (c) to ease the child's embarrassment by allowing him or her to transfer any anxiety to an inanimate object.

    The acting and technical aspects are not those of a highly slick, professional production. However, the information is solid, and this is a good general training video. (24 minutes)

    Alberta (Canada) Social Services. (1985). The child's account: The use of anatomically correct dolls in the investigation of child sexual abuse [Video]. Charlotte, NC: Kids Rights.

    This video is a basic overview of what anatomical dolls are and how they can be used in social service interviews. Although the video may be useful for those just beginning in the field, it may not be comprehensive enough to prepare an interviewer to use the dolls. It is one of the only videos showing male interviewers using dolls. There are some basic problems with the information, however, such as referring to the dolls as “anatomically correct;” making generalizations such as “Children don't lie” (without examining contaminating factors such as parent or offender coaching); displaying inconsistencies, such as saying, “Always interview in a two-person team,” but showing only one person; showing examples of interviewers who are very awkward and tense and not good role models; making biblical references, which may not be appropriate for some agencies due to the separation of church and state; using the pronoun she throughout the video, which was distracting when the pictures showed male victims; suggesting that the interviewer refer to dolls as “special friends” (a term often used by offenders when luring or engaging young victims); telling the interviewer to use four dolls (“the same as a family”); and having the interviewer initiate selecting and touching the dolls (“child doll first and perpetrator doll last”). The sound also fades in and out.

    Although there are many good suggestions on how to interview (be patient, use open-ended questions, listen, don't be judgmental), some of the information is not based on the most current, empirical data. (24 minutes)

    Center for Child Protection, Children's Hospital and Health Center, San Diego. (1988). Child sexual abuse: Interviewing the young child [Video]. San Diego: Author.

    This videotape encompasses the various stages and components of the forensic interview with the sexually abused child. It addresses the techniques used in interviewing the preschool-age child.

    The tape contains excerpts of forensic interviews of young sexual abuse victims conducted at the Center for Child Protection, Children's Hospital and Health Center, San Diego, California. The Center for Child Protection evaluates over 1,100 children annually for suspected sexual abuse and is recognized as a model for evaluating child sexual abuse. (33 minutes)

    Center for Child Protection, Children's Hospital and Health Center, San Diego. (1986). Evaluating developmentaly disabled victims of sexual abuse [Video]. San Diego: Author.

    This is a videotape of excerpts of three forensic social work interviews of developmentally disabled victims of sexual abuse conducted at the Center for Child Protection, Children's Hospital and Health Center, San Diego, California.

    Children and young adults with developmental disabilities are often not considered credible witnesses by investigating agencies, and consequently many allegations of sexual abuse of the developmentally disabled are not investigated.

    This videotape demonstrates to law enforcement, clinicians, and advocates for the developmentally disabled that these victims can give credible histories and that prosecution of the offender and protection of the victim can be achieved. (40 minutes)

    Migima Designs. (1985). Interviewing the young sex crime victim with the aid of dolls [Audiocassette tape]. Eugene, OR: Author.

    An informative cassette tape for training police officers, counselors, child protective service workers, district attorneys, and medical personnel in effective interviewing techniques and courtroom procedures using anatomical dolls. This was one of the early educational audio materials, and although the information is basic, it is still good. Cassette tapes can be listened to in many places, such as cars. They can also have slides added to them to create a low-cost, localized slide-tape training program. (25 minutes)

    Migima Designs. (1985). Sex education: A guide for parents and educators using anatomical dolls [Audiocassette tape]. Eugene, OR: Author.

    This program examines the question, How much information should I give my child about sex and at what age? Examples are given of appropriate verbal and nonverbal responses, terminology, and using anatomical dolls. Excellent for parents, PTAs, teacher training, and inservice programs, especially in the areas of health and family life. (22 minutes)

    Migima Designs. (1985). Talking to a child about preventing sexual molestation using anatomical dolls [Audiocassette tape]. Eugene, OR: Author.

    This program examines the problems and symptoms of sexual abuse, how to talk to a child about OK and not OK touches, and what to do if a child is molested. It is a good overview for parents, educators, and social workers and presents the information in a gentle, nonthreatening manner. (20 minutes)

    White, S., Quinn, K., Santilli, G., Knell, S., & Wachs, R. (1988). Child sexual abuse assessment: An investigatory interview [Video]. Cleveland: Child Guidance Center of Greater Cleveland.

    The goal of this video and accompanying study guide is to minimize contamination of interview and children's responses in order to collect data as accurate as possible. Contamination means distortion or falsification of sources of a child's memory of alleged events by factors inside or outside the interview. Guidelines and precautions are given to reduce the risk of contamination. Areas focused on in the preinterview procedures are scheduling interviews, parent management, and child management. The evaluation process includes history from parents and the investigatory interview (environment, interviewer characteristics, free play, and the anatomical doll interview). The video particularly stresses avoiding contamination through interviewer influences and the interviewer's pursuit of an agenda (use of techniques to prompt child to confirm interviewer's assumptions). In other words, it defends the advantages of conducting blind interviews. In documenting the interview, tips are given on methods, evaluation reports, and reviewing for contamination. (35 minutes)

    White, S., Strom, G., & Santilli, G. (1986). The young victims of sexual abuse: An interview protocol [Video]. Cleveland: Child Guidance Center of Greater Cleveland.

    This video and the accompanying study guide follow a protocol designed for use with anatomical dolls and toys to determine a child's knowledge of body parts and functions and a child's sexual experiences. This interview should be part of an assessment process that includes a medical examination, parental suspicions, and child statements. Questions and format for interview are given as well as a flow chart. A complete interview conducted by Gail Santilli is shown. (35 minutes)

    Appendix 4: Identifying Symptoms of Sexual Abuse

    Often children will not verbalize what is wrong but will convey that they are troubled by a change in behavior. The following indicators are helpful in identifying, but may not be isolated to, sexual abuse. Any of these signs could indicate the child has a problem and needs attention and help.

    Physical Indicators
    • Difficulty in walking, sitting, coordination
    • Genital or anal injury (swollen, bleeding)
    • Urinating or defecating in clothing (inability to control)
    • Venereal disease
    • Genital pain and itching
    • Change in neatness of appearance
    • Gaining weight (wearing loose-fitting clothes so as not to draw attention to the body)
    • Compulsive masturbation
    • Loss of appetite or sudden increase in appetite (and other more serious eating disorders such as anorexia)
    • Altered sleep patterns (bedwetting, restlessness, nightmares, fear of sleeping alone, needing a night light, being tired in class)
    • Newly acquired bodily complaints, especially stomachaches
    • Odor (is not taking care of personal hygiene)
    Behavior and Attitude Indicators
    • Extreme shifts of emotions/moods
    • Fears and phobias especially aimed at one person or location (if a child is afraid to be alone with someone, such as a relative or babysitter, find out why)
    • Suddenly turning against someone, such as a parent
    • Restlessness
    • Acting adultlike, inconsistent with age
    • Acting childlike (clinging to adult, sucking thumb)
    • Frequent absences from school
    • Daydreaming—having learning problems (e.g., drop in grades)
    • Irritability, short temper
    • Asking questions or having knowledge of terminology inappropriate for child's age
    • Expressing affection to adults in inappropriate ways (fondling genitals, French kissing)
    • Not willing to undress for PE at school (self-conscious of body)
    • Hostility and aggressiveness toward adults or overly trying to please adults
    • Afraid to be alone with adults, especially someone the same sex as offender
    • Isolation, especially with peers (avoids eye contact, withdrawn)
    • Few friends
    • Parents don't allow child to stay overnight at friends' houses
    • Shying away from being touched
    • Having low self-esteem and self-image
    • Excessive curiosity about sexual matters (with people and animals)
    • Precocious sexual play

    Appendix 5: Why Children Don't Tell Us They Have Been Abused

    Most children are sexually abused many times before abuse is ever discovered. There are various reasons why children don't tell us they have a touching problem.

    • They are afraid they won't be believed.
    • They are afraid of getting into trouble themselves. They feel it is their fault and/or they caused the abuse to occur.
    • They may fear threats made by the offender (e.g., break-up of the family, Dad might have to go to jail, fear of rejection by offender and/or family, fear of retaliation).
    • They try to protect offender, may love the offender, but don't like the touch.
    • Children may not know “how” to tell. They may not know correct words or may describe the situation in vague terms (“Mr. Jones wears funny underpants”).
    • Children may not know the sexual activity is wrong or even that it is something anyone would want to know about.
    • Some children fear peer reaction—being singled out, laughed at, or losing popularity.
    • If it was a sexual abuse involving an adult and child of the same sex, they might fear being labeled a homosexual.
    • Some older children are embarrassed to discuss sexual issues and intimate details, especially with people of authority (e.g., teachers, police).
    • Some children don't know whom to tell.
    • Children may not feel there was an “appropriate” time or opportunity to tell.
    • They don't want to be labeled a tattletale.
    • They have been told that “nice girls/boys” don't use those words that refer to body parts or sexual behavior.

    Why do children finally tell someone they are being sexually abused?

    • The molestation escalates in frequency or type of behavior and alarms the child.
    • The child receives some sexual abuse prevention information and realizes that what has happened to him/her is wrong (that the offender is at fault) and should be reported.
    • If the offender has told the child to keep the sexual abuse a secret, sometimes the child may brag or want to share the secret with a best friend, who then reports it.
    • The victim's younger brother or sister is now at the age when the victim was first sexually abused, and the victim does not want him or her to be abused as well.
    • The child reaches adolescence and fears pregnancy, resents the offender's efforts to control her or his life, dating, etc.
    • The child encounters a caring adult he or she can trust and feels confident in disclosing to.
    • The child has a urinary infection or other physical problem that causes him or her to seek medical care.

    Appendix 6: Anatomical Doll Companies

    • Hyland Anatomical Dolls
    • 4463 Torrance Blvd.
    • Torrance, CA 90503
    • (800) 333-4157 phone
    • Kids Rights
    • 10100 Park Cedar Drive
    • Charlotte, NC 28210
    • (704) 541-0100 phone
    • (704) 541-0113 fax
    • Migima Designs
    • P.O. Box 5582
    • Eugene, OR 97405
    • (503) 343-3440 phone
    • (503) 683-3821 fax
    • (503) 228-5651 Portland office
    • Teach-A-Bodies
    • 3509 Acorn Run
    • Ft. Worth, TX 76109
    • (817) 923-2380 phone
    • (817) 923-9774 fax

    References

    August, R. L., & Forman, B. D. (1989). A comparison of sexually abused and non-sexually abused children's behavioral responses to anatomically correct dolls. Child Psychiatry and Human Development, 20(1), 39–47. http://dx.doi.org/10.1007/BF00706956
    Bays, J. (1990). Are the genitalia of anatomical dolls distorted?Child Abuse & Neglect, 14, 171–175. http://dx.doi.org/10.1016/0145-2134%2890%2990028-R
    Boat, B. W., & Everson, M. D. (1986). Using anatomical dolls: Guidelines for interviewing young children in sexual abuse investigations. Chapel Hill: University of North Carolina, Department of Psychiatry.
    Boat, B. W., & Everson, M. D. (1988a). Interviewing young children with anatomical dolls. Child Welfare, 68(4), 337–352.
    Boat, B. W., & Everson, M. D. (1988b). Use of anatomical dolls among professionals in sexual abuse evaluations. Child Abuse & Neglect, 12, 171–179. http://dx.doi.org/10.1016/0145-2134%2888%2990025-7
    Britton, H. L., & O'Keefe, M. A. (1991). Use of nonanatomical dolls in the sexual abuse interview. Child Abuse & Neglect, 15, 567–573. http://dx.doi.org/10.1016/0145-2134%2891%2990040-K
    Bulkey, J. (1985). Papers from a National Policy Policy Conference on Legal Reforms in Child Sexual Abuse Cases. (Available from American Bar Association, 1800 M Street N.W., Washington DC 20036).
    Cohn, D. S. (1991). Anatomical doll play of preschoolers referred for sexual abuse and those not referred. Child Abuse & Neglect, 15, 455–466. http://dx.doi.org/10.1016/0145-2134%2891%2990029-D
    Dawson, B., & Geddie, L. (1991). Low income, minority preschoolers' behavior with sexually anatomically detailed dolls. Unpublished manuscript. (Available from Brenda Dawson, University of Montana, Department of Psychology, Missoula, MT)
    Dawson, B., Vaughn, A. R., & Wagner, W. F. (1992). Normal responses to sexually anatomically detailed dolls. Journal of Family Violence, 7(2), 135–152. http://dx.doi.org/10.1007/BF00978702
    Dooley, S. (1985). My day at the courthouse. West Linn, OR: Trials and Smiles.
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    Sivan, A. B., Schor, D. P., Koeppl, G. K., & Noble, L. D. (1988). Interaction of normal children with anatomical dolls. Child Abuse & Neglect, 12, 295–304. http://dx.doi.org/10.1016/0145-2134%2888%2990042-7
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    About the Author

    Marcia Morgan, Ph.D., is an author, consultant, researcher, and lecturer on sexual assault prevention and investigation. She lectures internationally to police, schools, and professional conferences on rape, sexual harassment, and sexual abuse of children. She was a deputy sheriff/crime prevention officer for 7 years, research associate on a 3-year National Institute of Mental Health grant evaluating rape prevention and resistance strategies, and for several years a lobbyist in Oregon and Washington, DC. She is the author of two books on sexual abuse, Safe Touch and My Feelings, and two videos on children's safety, It's OK to Say No and Aware and Not Afraid.

    Marcia Morgan and Virginia Edwards were the original developers of the anatomical dolls in 1976. The dolls are now used worldwide in child sexual abuse cases. They pioneered work in this field and coauthored the book Interviewing Sexual Abuse Victims Using Anatomical Dolls: The Professional's Guidebook (1985).

    About the Contributing Author

    Virginia Edwards, B.A., has worked for the State of Oregon since 1980. As a caseworker for Children's Services Division, she worked in protective services, permanency planning, and family sex abuse treatment services. As a casework supervisor, she has supervised substitute care caseloads, permanent planning caseloads, family sex abuse treatment, family treatment, parent training, and adoptions. Before working for CSD, she worked as a patrol officer and detective for a municipal police department specializing in sexual assault investigations. She offers workshops on interviewing children and case planning/case management for sexual abuse/sibling incest cases. She is a graduate of Oregon State University.

    Morgan and Edwards are available for professional training seminars and can be reached through Migima Designs, P.O. Box 5582, Eugene, OR 97405.


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