Certificates of Confidentiality and Mandatory Reporting.

This Viewpoint discusses the importance of obtaining federal certificates of confidentiality to free researchers to perform important research into child sexual abuse.

Themes Associated with Suicidal Ideation and Behavior Among People Attracted to Children.

Suicide represents a significant public health problem, with around 800,000 deaths per year worldwide and up to 20 times as many episodes of self-harm and suicide attempts. Members of stigmatized groups may experience increased risk of suicide due in part to stigma-related factors, such as expectations of rejection, internalization of negative stereotypes, or potential for greater social isolation. Research suggests that adults who are attracted to children face extreme stigma, even those who do not commit sexual crimes involving children. Adults who are attracted to children also experience significantly increased risk for suicidal ideation and behavior (SIB) compared to general population samples. The current study sought to explore experiences with SIB among adults attracted to children to better understand factors underlying suicidality in this population. The lead author conducted semi-structured interviews in a community sample of 15 adults attracted to children who self-reported some form of SIB in their lifetime. Using interpretative phenomenological analysis, the lead author explored and interpreted interview data to generate themes driven by respondents' characterizations of their SIB. Superordinate themes related to suicidality in this sample included low self-esteem or self-worth, cumulative impacts of the attraction and other stressors, and concerns about the ability to have a positive future due to the attraction. Findings underscore the importance of addressing internalized stigma, treating problems like depression and social isolation, and instilling hope for the future to promote mental health and prevent SIB among adults attracted to children.

Responsible Behavior With Younger Children: Results From a Pilot Randomized Evaluation of a School-Based Child Sexual Abuse Perpetration Prevention Program.

Many efforts to prevent child sexual abuse (CSA) aim to teach children strategies for recognizing, resisting, and reporting victimization. There is limited evidence that victimization-focused efforts actually prevent CSA. Moreover, these efforts often overlook the fact that many children and adolescents engage in problem sexual behavior against younger children. Responsible Behavior with Younger Children (RBYC) is a novel universal school-based perpetration-focused intervention that aims to prevent the onset of inappropriate, harmful, or illegal sexual behavior by adolescents against younger children.1 Responsible behavior with younger children was designed to provide adolescents and their parents with the knowledge and tools to help adolescents interact appropriately with younger children and avoid CSA behaviors. In this paper we describe intervention development, summarize lessons learned from implementing RBYC in four urban schools, and report results from our pilot randomized waitlist-controlled trial (RCT) with 160 6th and 7th grade students. Results indicate RBYC was associated with increased accuracy in youth knowledge about CSA and CSA-related laws, and with increased behavioral intention to avoid or prevent CSA with younger children and peer sexual harassment. Although the sample was small and the effects were relatively modest, the findings do suggest that RBYC holds promise for preventing the onset of problem sexual behavior.

The public's knowledge about child sexual abuse influences its perceptions of prevention and associated policies.

BACKGROUND: Child sexual abuse (CSA) prevention requires efforts from all members of society. OBJECTIVE: The current study aimed to examine factors associated with (1) perceptions of CSA as unpreventable and (2) support for policies to prevent CSA and to punish people who perpetrated CSA. We focused on the roles of knowledge and misperceptions about child sexual abuse. PARTICIPANTS AND SETTING: We collected survey data online from a large (N = 5068), nationally representative sample of adults in the United States. RESULTS: Analyses revealed factors promoting perceptions of CSA as unpreventable. Support for or against policies that aim to prevent CSA or to punish perpetrators of CSA were associated with individual factors such as older age (B = 0.08, -0.13), Republican political affiliation (B = 0.10, 0.07), and misperceptions about CSA (B = 0.15, 0.06). CONCLUSIONS: Findings highlight malleable factors that could be targeted to collectivize calls for CSA prevention and to promote support for effective policies to prevent CSA. In particular, ensuring accurate knowledge about CSA, and collective responsibility and government efficacy specific to CSA prevention, were identified as helping shape views of CSA as preventable.

Implementation of a Universal School-Based Child Sexual Abuse Prevention Program: A Longitudinal Cohort Study.

Child sexual abuse (CSA) is a public health problem of considerable magnitude. The prevailing primary prevention strategies are universal, school-based CSA prevention programs, some of which have been designated as evidence-based, such as Safe Touches. However, to reach their public health impact potential, effective universal school-based CSA prevention programs require effective and efficient dissemination and implementation strategies. The purpose of this study was to demonstrate the reach and effectiveness of a school-based CSA prevention curriculum, Safe Touches, when implemented on a wide scale. Using a longitudinal cohort design, children in second grade classrooms in public elementary schools in five counties received the Safe Touches workshop and completed surveys designed to assess gains in knowledge at four timepoints (one week prior, immediately post-workshop, 6- and 12-months post-workshop). In total, the Safe Touches workshop was delivered in 718 classrooms in 92% of school districts, reaching ~14,235 second graders. Multilevel models (n = 3,673) revealed that Safe Touches significantly increased CSA-related knowledge, and that these gains were maintained 12-months post-workshop (ps < .001). There were some small but significant time-varying effects among participants in schools with a greater percentage of low income and minority students, but these effects largely disappeared 12-months post workshop. This study demonstrates that a single-session, universal school-based CSA prevention program can effectively increase children's knowledge when implemented and disseminated on a wide scale and knowledge gains can be retained 12-months post intervention.

Self-Esteem, Perceived Social Support, and Suicidal Ideation and Behavior Among Adults Attracted to Children.

Introduction: People who are attracted to children may be at elevated risk for suicidal ideation and behavior compared to the general population. However, factors associated with suicidal ideation and behavior in this population represent a gap in the literature.Methods: The current study used multilinear regression to explore the impact of self-esteem and perceived social support on suicidal ideation and behavior in a sample of 154 adults attracted to children. Mediation analysis was conducted to investigate the role of lifetime major depressive disorder and hopelessness in these relationships.Results: Results showed high prevalence of past-year and lifetime suicidal ideation and behavior in the sample. Both self-esteem and perceived social support demonstrated significant, inverse relationships with suicidal ideation and behavior after adjustment for covariates. Mediation analyses provided support for the role of hopelessness, but not depression, in these relationships.Conclusion: Results demonstrate high rates of suicidal ideation and behavior among adults attracted to children and highlight important opportunities for prevention and intervention. Improving self-esteem, bolstering perceived social support, reducing hopelessness, and removing barriers to help-seeking may be targets for improving mental health and preventing suicidal ideation and behavior in this population.

Is the Affordable Care Act Medicaid Expansion Associated With Reported Incidents of Child Sexual Abuse?

There is substantial evidence that adequate access to healthcare among low-income adults through the Affordable Care Act Medicaid expansion mitigates risk factors associated with childhood maltreatment, including parental financial insecurity, substance use, and poor mental health. Indeed, studies identified reduced reports of child neglect in states that expanded Medicaid, relative to those that did not. However, it is unknown whether Medicaid expansion is associated with reported child sexual abuse (CSA). We present findings from a study evaluating the association of Medicaid expansion with incidents of CSA reported to child protective services. Using a difference-in-differences approach, we analyzed data from the National Child Abuse and Neglect Data System to examine the effects of state-level adoption of the Medicaid expansion on CSA reports per 100,000 children across 2008-2018. Results indicated no statistically significant association between Medicaid expansion and CSA incidents. We discuss potential reasons for differential association of macro-level policies on types of child maltreatment.

No Check We Won't Write: A Report on the High Cost of Sex Offender Incarceration.

Child sexual abuse is a preventable public health problem that is addressed primarily via reactive criminal justice efforts. In this report, we focus on the cost of incarcerating adults convicted of sex crimes against children in the United States. Specifically, we summarize publicly available information on U.S. state and federal prison and sex offender civil commitment costs. Wherever possible, we used government data sources to inform cost estimates. Results indicate the annual cost to incarcerate adults convicted of sex crimes against children in the United States approaches $5.4 billion. This estimate does not include any costs incurred prior to incarceration (e.g., related to detection and prosecution) or post-release (e.g., related to supervision or registration). Nor does this estimate capture administrative and judicial costs associated with appeals, or administrative costs that cannot be extricated from other budgets, as is the case when costs per-prisoner are shared between prisons and civil commitment facilities. We believe information on the substantial funding dedicated to incarceration will be useful to U.S. federal, state, and local lawmakers and to international policymakers as they consider allocating resources to the development, evaluation and dissemination of effective prevention strategies aimed at keeping children safe from sexual abuse in the first place.

Adverse Childhood Experiences, Mental Health, and Risk Behaviors in Adulthood: Exploring Sex, Racial, and Ethnic Group Differences in a Nationally Representative Sample.

This study examined sex, racial, and ethnic differences in the short- and long-term associations between adverse childhood experiences (ACEs), mental health, and risk behaviors in a nationally representative sample. Analysis was based on the National Longitudinal Study of Adolescent to Adult Health, a longitudinal cohort of U.S. adolescents followed in five waves of data collection from adolescence to adulthood. Analysis included design-based regression models to examine the associations between ACEs and proximal and distal outcomes (i.e., depression, suicidal ideation, number of sexual partners, binge drinking, current smoker) assessed in the transition to adulthood (mean age 21; 2001-2002) and adulthood (mean age 38; 2016-2018). Sex, racial, and ethnic interactions were included in regression models to examine effect modification in the association of ACEs, mental health, and risk behaviors. In this analytical sample (N = 9,690), we identified a graded association between ACEs and depression, suicide ideation, and current smoker status at both time points (i.e., mean age 21 and 38). Sex moderated the relationship between ACEs and depression at mean age 21, while race (i.e., American Indian versus White) moderated the relationship between ACEs and number of sexual partners at mean age 38. A greater number of cumulative traumatic experiences in childhood may amplify adverse health outcomes among women and adults of American Indian descent in particular.

Impact of Child Sexual Abuse on Socioeconomic Attainment in Adulthood.

PURPOSE: While child sexual abuse (CSA) victimization is linked to adverse mental and behavioral health outcomes, few studies have examined the association between CSA and socioeconomic attainment in adulthood, particularly for men. This study assesses the impacts of CSA victimization on socioeconomic outcomes in adulthood, separately for men and women. METHODS: Analyses are based on the National Longitudinal Study of Adolescent to Adult Health restricted use dataset. Adolescent to Adult Health is a nationally representative cohort of teenagers in grades 7-12 (1994-1995; N = 20,000) followed to ages 33-44 (2016-2018; N = 12,300). These analyses were based on N = 10,119 participants. We used propensity score weighting to equate on observed confounders of those who experienced CSA victimization with those who had not. All analyses were conducted in the R statistical software. RESULTS: In this analytical sample, 25.2% of women and 9.8% of men reported of having been sexually abused as a child. Results from propensity score weighted models showed that by their late 30s, men and women who experienced CSA had lower educational attainment, lower odds of being financially stable, and a decrease in household income compared to their peers. CSA was associated with lower odds of being employed among women only. DISCUSSION: Findings from this study suggest that men and women who survive CSA, experience socioeconomic disadvantages in adulthood relative to peers who did not experience CSA. Preventive programs and treatment and other services for survivors of CSA could positively impact individuals' economic productivity over the life course, reducing the individual and societal costs associated with CSA victimization.

Health insurance expansion and family violence prevention: A conceptual framework.

Family violence, including child maltreatment (CM) and intimate partner violence (IPV), plagues far too many American families, particularly those in low-income communities. CM and IPV are intertwined and impose a significant emotional, health and financial burden on children and families and an economic burden on our country. Although these and other forms of violence are influenced by shared risk factors across the socioecological spectrum, prevention efforts typically intervene on a single type of violence at a microsystem level via individual or family intervention. Research is needed to identify policies operating at macrosystem levels that reduce, at scale, multiple forms of violence affecting children. In this paper, we propose a three-step theory of change through which health insurance expansions might reduce rates of CM and IPV, using Medicaid expansion as an exemplar. The proposed framework can inform research examining the link between health insurance and the primary prevention of CM and IPV.

Adverse childhood experiences and comorbidity in a cohort of people who have injected drugs.

BACKGROUND: Childhood adversity is associated with the onset of harmful adult substance use and related health problems, but most research on adversity has been conducted in general population samples. This study describes the prevalence of adverse childhood experiences in a cohort of people who have injected drugs and examines the association of these adverse experiences with medical comorbidities in adulthood. METHODS: Six hundred fifty three adults were recruited from a 30-year cohort study on the health of people who have injected drugs living in and around Baltimore, Maryland (Median age = 47.5, Interquartile Range = 42.3-52.3 years; 67.3% male, 81.1% Black). Adverse childhood experiences were assessed retrospectively in 2018 via self-report interview. Lifetime medical comorbidities were ascertained via self-report of a provider diagnosis. Multinomial logistic regression with generalized estimating equations was used to examine the association between adversity and comorbid conditions, controlling for potential confounders. RESULTS: Two hundred twelve participants (32.9%) reported 0-1 adverse childhood experiences, 215 (33.3%) reported 2-4, 145 (22.5%) reported 5-9, and 72 (11.1%) reported ≥10. Neighborhood violence was the most commonly reported adversity (48.5%). Individuals with ≥10 adverse childhood experiences had higher odds for reporting ≥3 comorbidities (Adjusted Odds Ratio = 2.9, 95% CI = 1.2 - 6.8, p = .01). CONCLUSIONS: Among people who have injected drugs, adverse childhood experiences were common and associated with increased occurrence of self-reported medical comorbidities. Findings highlight the persistent importance of adversity for physical health even in a population where all members have used drugs and there is a high burden of comorbidity.

Impact of Medicaid Expansion on Reported Incidents of Child Neglect and Physical Abuse.

INTRODUCTION: The U.S. Affordable Care Act Medicaid expansion, which allowed states to expand Medicaid coverage to low-income adults beginning in 2014, has reduced the risk factors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental illness. This study examines the associations between Medicaid expansion and the rates of overall, first-time, and repeat reports of child neglect and physical abuse incidents per 100,000 children aged 0-5, 6-12, and 13-17 years. METHODS: The 2008-2018 National Child Abuse and Neglect Data System was analyzed using an extension of the difference-in-differences approach that accounts for staggered policy implementation across time. Owing to evidence of nonparallel preperiod trends in the 6 states that expanded Medicaid from 2015 to 2017, the main analyses included 20 states that newly expanded Medicaid in 2014 and 18 states that did not expand Medicaid from 2008 to 2018. Analyses were conducted in 2020-2021. RESULTS: Medicaid expansion states were associated with reductions of 13.4% (95% CI= -24.2, -9.6), 14.8% (95% CI= -26.4, -1.4), and 16.0% (-27.6, -2.6) in the average rate of child neglect reports per 100,000 children aged 0-5, 6-12, and 13-17 years, per state-year, relative to control states. Expansion was associated with a 17.3% (95% CI= -28.9, -3.8) reduction in the rate of first-time neglect reports among children aged 0-5 years and with 16.6% (95% CI= -29.3, -1.6) and 18.7% (95% CI= -32.5, -2.1) reductions in the rates of repeat neglect reports among children aged 6-12 and 13-17 years, respectively. There were no statistically significant associations between Medicaid expansion and the rates of physical abuse among children in any age group. CONCLUSIONS: Insurance expansions for low-income adults may reduce child neglect.

Changing the paradigm: Using strategic communications to promote recognition of child sexual abuse as a preventable public health problem.

Child sexual abuse (CSA) is common, severe, and substantively contributes to the global burden of disease through its impact on physical, mental, and behavioral health problems. While CSA is preventable through non-justice system response efforts, the vast majority of resources support criminal justice efforts to identify, prosecute, punish and monitor offenders after CSA has already occurred. Policy makers have not supported CSA prevention efforts in part because the public does not view CSA as a preventable public health problem. Here, we describe a program of research to be conducted to bridge the gaps between expert and public opinion about CSA as a preventable public health problem. We propose such research use a three-step approach to alter the way experts communicate about CSA to increase audiences' understanding of CSA as preventable. The three steps are: 1) identify consensus expert and public perspectives about CSA and the differences between these perspectives; 2) develop and test communication strategies to align public with expert perspectives; and 3) broadly disseminate validated communication strategies. Through this approach, we seek to develop and disseminate an informed communications strategy that effectively and accurately translates the science of CSA prevention to the public and the media.

Responsible Behavior with Younger Children: Examining the Feasibility of a Classroom-Based Program to Prevent Child Sexual Abuse Perpetration by Adolescents.

Child sexual abuse (CSA) is a preventable public health problem typically addressed with either after-the-fact interventions or prevention programs focused on teaching children to protect themselves and report abuse. Such responses do little to prevent CSA victimization, leading to calls for prevention efforts targeting individuals most at risk of perpetrating CSA. These individuals include young adolescents, who are prone to making mistakes and bad decisions when it comes to their sexual behaviors. To begin to address this call to action, we developed Responsible Behavior with Younger Children (RBYC), a universal school-based prevention program to provide sixth and seventh grade students (and their parents and educators) with the knowledge, skills, and tools to prevent engaging younger children in sexual behaviors. School-based CSA prevention interventions are often met with feasibility and acceptability concerns including that (a) people at risk of offending are impervious to prevention efforts, (b) schools do not have the resources to take on additional programs, and (c) the content is too sensitive for educators, parents, and students. The goal of this article is to describe how the RBYC program was developed to address these concerns. We also summarize data on the feasibility of the RBYC program obtained from focus groups with educators, parents, and students during the development of the program and interviews with educators after a pilot randomized controlled trial (RCT). Feedback received during program development and after the pilot RCT suggests that RBYC is relevant, salient, palatable, and feasible for implementation in middle schools.

An Evaluation of Mechanisms of Change in Multisystemic Therapy for Juvenile Justice-Involved Youths A Decade Following Treatment.

Although researchers have identified the more immediate mechanisms of change in family-based treatments for juvenile justice-involved youths, it is not known whether these same mechanisms continue to prevent criminal offending into adulthood. The present study evaluated whether caregiver-directed improvements in family relations, youth prosocial peer relations, and youth academic performance during multisystemic therapy (MST) for serious and violent juvenile offenders had an impact on young adult involvement in criminal activity and sentencing 10.2 years following treatment. The results showed that improvements in family relations were associated with reduced odds of criminal outcomes a decade later for former MST participants. Furthermore, improvements in youth prosocial peer relations and academic performance were also related to lower odds of long-term criminal activity. These results are consistent with the underlying theory of change in family-based treatments and demonstrate that caregivers are critical to achieving and sustaining decreased antisocial behavior for youths with serious and violent criminal histories.

Caregivers' Perceptions and Responses to a New Norm: The Missing Link in Addressing Adolescent Sexting Behaviors in the U.S.

Youth sharing of self- or peer-produced sexual content via electronic communications, dubbed by the media as "sexting" (i.e., sexting behaviors), has generated concern among a wide variety of adult stakeholders in the U.S. Experts recognize the need to integrate perspectives and knowledge about adolescents' sexting behaviors from individuals who interact with adolescents (e.g., their caregivers) to inform the development of prevention policy and practice. The present study fills this gap by interviewing 10 separate groups of caregivers in three different states, with the sole focus on adolescent sexting behaviors. Results indicated seven themes: (1) characteristics of adolescent sexting behaviors, (2) influences on sexting behaviors, (3) communication about sexting behaviors, (4) gender and sexting behaviors, (5) sociohistorical conditions and sexting behaviors, (6) consequences of sexting behaviors, and (7) ways to address sexting behaviors; multiple themes emerged within each of the seven parent codes. Findings inform the need to integrate adolescent sexting behaviors into comprehensive sexual education curricula and to develop educational content on adolescent sexting behaviors for adolescents and caregivers in online and printable handout formats. Clearly defining sexting and norms around sexting are of particular importance in such educational materials.

Preventing and responding to child sexual abuse: Organizational efforts.

BACKGROUND: Child sexual abuse (CSA) remains an ongoing threat to the wellbeing of children who might be victimized, to the liberty of individuals who might engage in abusive behavior, and to the reputations and livelihood of organizations in which abuse might occur. In the U.S., millions of children participate in youth-serving organizations (YSOs), and it is known that a proportion of CSA occurs in these settings. Despite the severity of these threats, there is little knowledge of the steps that organizations take to prevent and respond to CSA. OBJECTIVE: Our study aimed to index current measures to prevent and respond to CSA in organizational settings, using four of the largest U.S.-based YSOs as exemplars. METHODS: In partnership with our partner YSOs, we completed a qualitative analysis of 74 organizational documents including written policies, codes of conduct, trainings, and other documents that formalize these four organizations' current CSA prevention and intervention efforts. RESULTS: These organizations collectively implement hundreds of distinct measures aimed at preventing, detecting, and responding to CSA. These measures were categorized under eight overarching themes, including: overall commitment to child safety, code of conduct, training and education, assessment, implementation and monitoring, screening and hiring, reporting and responding to child sexual abuse, youth problem sexual behavior, and boundaries for teen leaders and young adult staff. CONCLUSION: Findings from the current study, outlining key prevention and policy areas undertaken by participating YSOs, offer a starting point for discussion about core elements needed to keep children safe from sexual abuse in YSO settings.

Help wanted: Lessons on prevention from young adults with a sexual interest in prepubescent children.

BACKGROUND: Adolescents and young adults with a sexual interest in young children represent an underserved population. The needs of this group, and their implications for child sexual abuse prevention program development, are not well understood. OBJECTIVE: The objective of this research is to advance knowledge about adolescents and young adults with a sexual interest in children to better inform the development of effective prevention and mental health efforts. PARTICIPANTS AND SETTING: The sample consisted of 30 young adults, ages 18-30, from North America, South America, Europe, and Australia. METHODS: Researchers conducted telephone interviews with participants, and asked about when their interest in children emerged, how they responded to this sexual interest, and what resources could have been helpful during this process. Participants also completed a brief, online survey. Interviews were transcribed and analyzed using Dedoose software. RESULTS: Participants reported that their sexual interest in children emerged during adolescence, and as part of that process, they experienced a variety of emotions, including fear, shame, and feelings of isolation. Participants also noted the need for role models who are sexually interested in children and successfully navigating life, positive messaging, and support from families and the community. CONCLUSIONS: Young people with a sexual interest in children are largely hidden, vulnerable, and looking for help. Findings from this research can be used to direct the development of the prevention and mental health programs that are responsive to the needs of this community.