The effectiveness of child advocacy centers and the multidisciplinary team approach on prosecution rates of alleged sex offenders and satisfaction of non-offending caregivers with allegations of child sexual abuse: a systematic review protocol

Review question/objective The objective of this review is to identify the effectiveness of the multidisciplinary team (MDT) approach of child advocacy centers (CACs) on prosecution rates of alleged sex offenders and satisfaction of non-offending caregivers of children less than 18 years of age, with allegations of child sexual abuse (CSA). Background The International Society for the Prevention of Child Abuse and Neglect (IPSCAN) was established in 1977 to prevent all types of abuse and protect children around the globe.1 Globally, 20 percent of girls and five to 10 percent of boys encounter sexual abuse.2 The estimated number of physically abused children globally is between 25 to 50 percent.2 A meta-analysis by Stoltenborgh et al. showed that CSA is not exclusive to any particular country but impacts children worldwide.3 The World Health Organization (WHO) defines child abuse as harm to a child's health caused by physical or emotional harm, sexual abuse, neglect and exploitation.4 The WHO contends that child maltreatment presents a global health concern. For this review, CSA refers to a forceful sexual interaction with a child of having a sexual relationship without informed consent where it is exploitative because of an age difference or caretaking responsibility.5 Sexual abuse of a child who is physically, mentally, or cognitively impaired is also considered CSA.5 The Women's World Summit Foundation (WWSF) actively participates in the global campaign for the prevention of abuse and violence against children. The WWSF is a secular, non-governmental, international organization affiliated with the United Nations and is comprised of 240 organizations in 88 countries. 6 Child sexual abuse is a severe problem in the United States and around the world. According to Stoltenborgh et al., on the global perspective of CSA the projected self-reported rate among girls was 127 per 1000 and 180 per 1000 for boys.3 The uppermost rates for boys were found in Africa (193/1000) and for girls in Australia (215/1000).3 Asia had the lowest rates for boys (41/1000) and for girls (113/100). 3 The United States Department of Health and Human Services (HHS) 2011 Child Maltreatment report found the number of child abuse fatalities per 100,000 children was 1570, and 81.6% of these were pre-schoolers.7 A meta-analysis of 65 studies from 22 countries that was conducted in 2009 by Pereda et al. at University of Barcelona revealed disturbing results. 8 The results showed that before reaching 18 years of age, 7.9% of men and 19.7% of women are victims of CSA.8 Africa showed the highest rates (34.4%) globally while the lowest rates (9.2%) were found in Europe.8 The highest rates for male CSA victims (60.9%) as well as for female CSA victims (43.7%) were found in South Africa.8 Child sexual abuse is a very complex and burdensome societal issue. Historically, CSA has existed for decades in the United States involving all groups of people regardless of culture, religion, educational level and socioeconomic factors.9 It has been documented that more than three million reports of child abuse are generated in the United States every year.9 Most shockingly, six children are reported to be abused every minute. 9 Child sexual abuse produces genuine public health concerns, human rights and social issues. Child sexual abuse is a major public health problem that can have effects long into the future.10 The sequelae may include an impact on performance in school, early pregnancy, depression, poor physical health and alcohol and substance abuse.10 These can lead to increased treatment costs.10 According to the Copenhagen Consensus Center, the total minimum cost of CSA is around $37 billion (0.043% of world GDP).11 The consequences of CSA are profound, which indicates a crucial need for the government and healthcare system to advocate and invest in evidence based interventions for investigation of CSA. Investing in adequate interventions to protect children's rights and prevent child abuse has a positive influence on a nation's human capital and economic development.12 It decreases the encumbrance of government spending on the long-term cost and consequences of child abuse.12 The sexually abused child, non-offending caregiver and the community are negatively affected by this crime. The CAC or MDT intervention has been developed to investigate allegations and treat children while minimizing trauma and maximizing prosecution.13 For this review, non-offending caregivers' of children with allegations of CSA are parents or caregivers who are not involved with the alleged sexual abuse of the child, and have acted appropriately to protect the child when confronted with knowledge of the abuse. Prosecution is the legal filing of a complaint against an alleged sex offender in criminal court.14 Successful prosecution is when the alleged sex offender pleads guilty or is found guilty of the alleged sex crime. Caregiver support and satisfaction are important facets that impact the family relationship.14 The attitudes and satisfaction of non-offending caregivers during the investigative process can influence that of the child.15 Caregivers play an important role in victim recovery following allegations of CSA.15 Reducing additional trauma and managing family dynamics during and after the investigative process can reduce the psychological effects of CSA.15 Support of the non-offending parent is paramount to the adjustment of the child following allegations of CSA. There has been a lot of criticism of the management of child abuse allegations such as Child Protective Services (CPS) working independently to investigate reports of CSA, lacking coordination between other involved agencies.16 CPS also known as Social Services in the United States or Child welfare in other countries are governmental agencies that perform the initial investigation of CSA and neglect. A vital role of CPS is to assess alleged reports of child abuse and protect children from further child abuse and neglect. Child advocacy centers were established to enhance child abuse investigative services provided by CPS.17 Child advocacy centers are child-friendly, facility-based programs with agents from various disciplines functioning together to efficiently examine, prosecute, and treat allegations of child abuse.17 Child advocacy centers form a sense of safety and security for child victims.17 The CAC model was developed in 1985 in Huntsville, Alabama, USA, as a response to the problem of child abuse.18 The goal of CACs is to protect children against further exploitation by the systems designed to defend them.18 The CAC model is valuable because it focuses foremost on the child by decreasing the number of interviews and providing the victim and family support that leads them to make better informed decisions.18 Child Protective Services and law enforcement agencies have worked independently to investigate reports of child sexual abuse. Role conflicts and organizational structural differences have led to barriers in effective collaboration.19 The services previously provided to victims of CSA by social services and the criminal justice system were not seamless. This lack of cohesiveness worsened the traumatic experience of the victims and the families. The awareness of the tortuous process led to former congressman Robert E. Cramer's creation of the CAC model.19 Child advocacy centers use MDTs consisting of medical personnel, law enforcement, CPS, prosecutors, advocacy services, forensic interviewers and mental health providers to examine child abuse cases.17 The medical practitioners of CACs may include pediatricians, nurse practitioners or registered nurses that specialize in the assessment of abused children.14 A MDT is the collaboration of agencies and departments to effectively respond to child abuse, both sexual and physical.17 It has been used to better coordinate services and to protect children affected by CSA.17 The services delivered by CACs are based on standards for accreditation. 17 These standards provide a framework to accomplish the overall mission. The ten standards proposed by the National Children's Alliance include: “(1) Multidisciplinary team (MDT); (2) cultural competency and diversity; (3) forensic interview; (4) victim support and advocacy; (5) medical evaluation; (6) mental health; (7) case review; (8) case tracking; (9) organizational capacity; and (10) child focused setting”.17(p.2) When attempting to review and compare the CAC approach around the world, an initial scoping search found there were few CACs in other countries. Some of the countries that have CACs include: Sweden, Australia, Canada, China, United Kingdom, India, Hong Kong, Turkey and Poland. In 2012, CACs, also called Children's Houses', in Sweden were located in 22 cities.20 The CAC Model in Sweden utilizes the collaboration of MDT which results in great satisfaction for the security and safety rendered.21 There are MDTs responsible for fulfilling similar roles as CACs worldwide. The MDT approach has now been used in approximately 12 countries internationally.19 The National Children's Alliance has helped to provide training and evidence based practice guidelines to support the Ankara Children's Advocacy Center in Turkey.22 In Turkey, the CAC model is unique to Ankara. Legislation was enacted as a response to the need for more effective treatment and management of CSA following the improper management of a particular case in 2009.22 The use of the CAC is a cultural change from the previous methods used, which were subdivided and uncoordinated.22 The NCA's support is reflective of the children's advocacy movement globally. The International Society for the Prevention of Child Abuse and Neglect is the only multidisciplinary organization with an international focus on child maltreatment.1 Curtailing undue distress to children and expanding services to the families are the foci of the CAC model's objectives. 23 The resulting outcomes from the multidisciplinary teamwork were an increase in rates of arrest and prosecution of CSA offenders.23 The CAC model's objectives include: reduction of children's suffering, increase of services to the families, bolstering arrest and prosecution rates of CSA perpetrators through the process of multidisciplinary collaboration.23 Cross et al. conducted a quasi-experimental study, the multi-site evaluation of CACs involving CACs in four communities and comparison communities without CAC services.24 This study noted that CAC cases had the ability to include important components such as: MDT interviews, joint police/child protective services investigations, involvement in CPS cases, video/audiotaping of interviews and case reviews.24 Miller and Rubin examined the contribution of CACs to felony prosecutions of CSA across two neighboring districts of a large urban city.14 According to this study, the district that increased their use of CAC had an increase in felony prosecutions of CSA cases.14 Another study evaluated how long it took to prosecute cases of CSA for a community using a CAC and two comparison non-CAC communities.25 The three vital events evaluated by this study include: (a) case-processing time, (b) case resolution process and (c) charging decision time.25 This study noted that the time frame for 69% of the CSA cases investigated at CACs took 60 days for a charging decision time.25 This demonstrates a faster time frame than suggested by the American Bar Association.25 CACs had a faster charging decision time than comparison communities.25 Prosecution rate can be measured by a valid and reliable tool such as Fisher-Freeman-Halton Exact Test or Pearson's chi-squared test (χ2). A study evaluated whether caregiver satisfaction and child satisfaction scores were higher among child abuse cases seen at CACs than for cases seen in comparison communities without CAC services.22 A study by Jones et al. evaluated whether CACs improve families' experiences of CSA investigations.26 Satisfaction scores of children with allegations of CSA and non-offending caregivers' of children with allegations of CSA were assessed during research interviews.26 Participants comprised of 284 sexual abuse cases (55 comparison cases and 229 CAC cases). This study showed that non-offending caregivers' of children with allegations of CSA seen at CACs were more satisfied with the investigation than comparison communities without CAC services.26 An additional study by Bonach et al. explored non-offending caregiver satisfaction with CACs.27 This study found that non-offending caregivers of abused children that received services at CACs were mostly satisfied with the services, investigation and interview processes.27 Non-offending caregiver satisfaction can be measured by a valid and reliable tool such as a 14-item Investigation Satisfaction Scale (ISS) for caregivers or a Tailored Design Survey Method. 26,27 Outcomes from research findings have shown that the use of CACs: (a) increases felony prosecution of child sexual abusers, (b) improves child forensic interviewing, (c) leads to increased referrals for mental health services, and (d) increases non-offending caregivers' satisfaction.14,23,26 To date, there are no published systematic reviews specific to the effectiveness of CACs on prosecution rates and satisfaction of non-offending caregivers in CSA cases. A systematic review will seek to determine the effectiveness of CACs in CSA cases.

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