Behavioral Indicators and Child Abuse "Syndromes"

Mental health professionals may testify about behavioral characteristics of a particular child that are "typical" of sexually abused children. Such behavioral indicators include a wide variety of symptoms such as regression, withdrawal, aggression, nightmares, bed wetting, fears, masturbation, and tantrums but are completely nonspecific (Wakefield and Underwager, 1991b). They appear in many different situations, including conflict between parents, divorce, economic stress, wartime separations, father absence, natural disaster, and physical, emotional, but nonsexual abuse (Emery, 1982; Hughes and Barad, 1983; Jaffe et al., 1986; Porter and O'Leary, 1980; Wallerstein and Kelly, 1980; Wolman, 1983). There are no behaviors that occur only in victims of sexual abuse. With the exception of sexualized behavior, the majority of symptoms shown in sexually abused children characterize child clinical samples in general (Beitchman et al., 1991).

Even sexualized behavior cannot be used as proof of abuse. What children normally do sexually is more involved than most people believe (Best, 1983; Gundersen et al., 1981; Langfeldt, 1981; Leung and Robson, 1993; Martinson, 1981; Okami, 1992). Friedrich et al. (1991) asked mothers of 880 nonabused two- to twelve-year-old children to complete questionnaires concerning sexual behavior. Although behaviors imitative of adult sexual behaviors were rare, the children exhibited a wide variety of sexual behaviors at relatively high frequencies. Mannarino et al. (1991) report no differences in sexual behavior between abused girls and a clinical control group, although both scored higher than did the normal controls. Gordon et al. (1990) found no differences in sexual knowledge between their samples of sexually abused and nonabused children. Haugaard and Tilly (1988) found that approximately 28% of male and female undergraduates reported having engaged in sexual play with another child when they were children. Lamb and Coakley (1993) report that 85% of their sample of female undergraduates described a childhood sexual game experience. A third of these experiences, which the respondents rated as "normal," involved genital fondling with or without clothing and some reported oral-genital contact and attempts at sexual intercourse.

In addition, since many sexually abused children do not suffer significant trauma (Browne and Finkelhor, 1986; Finkelhor, 1990; Gomes-Schwartz et al., 1990; Kendall-Tackett et al., 1993; Wakefield and Underwager, 1988a), an abused child may fail to exhibit any behavioral signs. It is a mistake to use the absence of behavioral signs as support for an allegation being false.

Using behavioral indicators to assess sexual abuse may result in a mistake in either direction. Besharov (1990) observes that behavioral indicators, by themselves, are not a sufficient basis for a report. Levine and Battistoni (1991) state that none of these indicators, in any combination, are valid without a direct statement by the child about sexual involvement or sexual knowledge. A statement representing the consensus of a group of international, interdisciplinary experts in child sexual abuse (Lamb, 1994b) concluded:

No specific behavioral syndromes characterize victims of sexual abuse. Sexual abuse involves a wide range of possible behaviors which appear to have widely varying effects on its victims. The absence of any sexualized behavior does not confirm that sexual abuse did hot take place any more than the presence of sexualized behavior conclusively demonstrates that sexual abuse occurred; rather, both pieces of information affect the level of suspicion concerning the child's possible experiences and should to serve to promote careful and nonsuggestive investigation. (p. 154)

There are few scientific data supporting the claim of a sexual abuse syndrome or a child sexual abuse accommodation syndrome (CSAAS) (Summit, 1983). These syndromes are speculative and meet neither Frye nor Daubert. The revisers of DSM-III refused to include them in DSM-III-R because there is no evidence to support them (Corwin, 1988).

Myers (1993) notes that both diseases and syndromes share the medically and forensically important feature of diagnostic value. Both point with varying degrees of certainty to particular causes. However, whereas with many diseases the relationship between symptoms and etiology is clear, with syndromes, this relationship is often unclear or unknown. The certainty with which a syndrome points to a particular cause varies with the syndrome. Two syndromes often offered in expert testimony in cases of alleged child abuse are the battered child syndrome and CSAAS. The battered child syndrome has high certainty since a child with the symptoms is very likely to have suffered nonaccidental injury. Therefore, this syndrome has high probative value and, in fact, has been approved by every appellate court to consider it. This can be contrasted with the child sexual abuse accommodation syndrome (CSAAS) which does not point with any certainty to sexual abuse. The fact that a child shows behaviors of the CSAAS does not help determine whether the child was sexually abused.

The CSAAS is a nondiagnostic syndrome. It does not meet the test of falsifiability when used to support abuse since there is nothing that can count against it. Therefore Daubert would lead to the judicial decision that use of the CSAAS is inadmissible. By contrast, in the battered child syndrome there is research evidence accumulating to demonstrate that nonaccidental injuries can be successfully discriminated from accidental injuries by the nature of the injuries.