Child Abuse Review Vol.

5: 239-251 (1996)

The Role of
Psychological
Instruments in the
Assessment of
Child Sexual Abuse

Gloria Babiker
Martin Herbert
University of Exeter

Psychological instruments such as behavioural rating scales or

psychometric tests have a useful part to play in the evaluation of child
sexual abuse, not as screening (i.e. diagnostic) devices but primarily
as adjuncts to the assessment interview. However, the use of formal
psychological instruments in their own right (i.e. on their own) for such
purposes is, as yet, very limited and problematic. In their strictly
adjunctive role they may provide additional evidence and/or indicate
areas for further investigation, without directly questioning the child
about the abuse and without being intrusive and leading. Finally, they
may help us to assess and measure psychological processes that are
influenced by and thus secondary to, sexual abuse. This paper seeks
to review the different types of psychological instruments and to
comment on their clinical and their research usage.
KEYWORDS:assessment; child sexual abuse; psychological instruments

The evaluation of
sexual abuse may
have dzgerent
aims and serve
dzgerent purposes

he evaluation of sexual abuse may have different aims

and serve different purposes. Individuals who are
known to have been sexually abused may be evaluated to
assess the effects of the abuse on their functioning, to
identify the seriousness of the abuse for treatment purposes,
for research, or to determine the allocation of resources.
Alternatively, investigations may be carried out in order to
determine whether or not an individual has been abused or
information may be sought in order to provide proof or
evidence of abuse for legal purposes. Glaser and Frosh (1988)
emphasized the distinction between investigating an allegation and investigating a suspicion of sexual abuse. While the
former would lead to investigation, and the gathering of
evidence, the latter would rely on clinical diagnosis or an
examination of the effects of sexual abuse.

Address for correspondence: Dr G . Babiker, University of Exeter, Exeter, UK.

CCC 0952-9136/96/040239-13
@ 1996 by John Wiley & Sons, Ltd.

Accepted 20 June 1996

240

Babiker and Herbert

Sexual abuse is not a diagnosis. Sexual abuse is an event

or a series of events which occur within a relationship and in
which the child is involved. However, the physical or
psychological consequences may be diagnosed and may be
deemed to be consistent with sexual abuse.
Many authors (e.g. Asher, 1988; Briere, 1992; Finkelhor,
1986; Hartman and Burgess, 1989) have called for specialized, well-standardized instruments which facilitate the
work of professionals involved in an investigation. These
need to be less intrusive and leading than traditional disclosure interviews would presuppose.
Psychological instruments potentially fulfil these requirements: They have the advantage of being standardized and
reusable, and therefore have a potentially valuable part to
play in the routine assessment of sexual abuse and in the
clinical interpretation of findings. They may help us to discover psychological processes-cognitions, emotional states
or attitudes-that are influenced by sexual abuse, and which
may serve as the link between sexual abuse and subsequent
functioning (Asher, 1988). Sexual abuse evaluations require
a creative process which weighs different pieces of information from various sources and places them in context.
Waterman and Lusk (1993) reviewed the American research
on psychological testing in sexual abuse. The following
paper addresses itself to the mainly clinical British context
and reviews psychological instruments which might usefully
play their part, usually as an adjunct to an assessment
interview. First, a brief overview of different types of
assessment interview.

Many authors
have called f o r
specialized,
well-standardized
instruments

Assessment Interviews

It may be
necessary to
undergo a series of
evaluative
sessions

The Cleveland enquiry report (Butler-Sloss, 1988) first

endorsed the view that calling interviews Disclosure interviews assumes that abuse has occurred. Facilitation interviews help the chiid to tell or elaborate. The Cleveland
Report advised no more than two focused interviews probing
for the possibility that abuse has occurred. However, others
have stated (Jones, 1989; Jones and McQuiston, 1988;
MacFarlane, Waterman, Conerly, Damon, Durfee and
Long, 1986) that it may be necessary to undergo a series of
evaluative sessions by a child psychologist or psychiatrist
with the possibility of sexual abuse brought up at the
appropriate moment. Current concern includes videotaping
and video-linking as a means of presenting interview
material. The Memorandum of Good Practice (HMSO,

Psychological Instruments in Assessment

24 1

1992) provides guidelines for the conduct of interviews with

potential child witnesses.
With regard to what constitutes trauma to the child, it may
be not so much a question of the number of interviews as of
the number of times the child has to answer the same
question (MacFarlane e t al., 1986; Jones and McQuiston,
1988). It is necessary that the interview be as structured as
possible to avoid accusations of leading the child witness
(Brooks and Milchman, 1991). However, structure may
sometimes have to be foregone if one is to be sensitive to the
needs of the child.

B ehaviour Scales
It was possible until only a few years ago to read that a
decision had been made as to whether a child had or had not
been abused based on whether the child did or did not
present with certain core symptoms, for example behavioural regression, somatic complaints, fearfulness, bedwetting, and so on (Conte, 1991). However, it is patently an
erroneous idea that such disturbed behaviour necessarily
proves sexual abuse. It is recognized (Herbert, 1993) that
these problems are indicators of stress in childhood which
parallel those of children experiencing other traumas.
Stressors might be any of a number of events, including,
but not exclusively, sexual abuse.
One of the effects of sexual abuse can be some form of
inappropriate sexual behaviour on the part of the child. But
as with other behavioural disturbance, not all abused
children exhibit sexualized behaviour while some nonabused children do. One avenue for research in this area
would be the development of a standardized measure, based
on developmental psychological theories of childrens knowledge about sex, to assess the appropriateness of childrens
sex knowledge.
The Louisville Behaviour Checklist (LBC) (Miller, 1981)
appears to be one of the well-established behaviour rating
measures frequently used in sexual abuse research (Tufts,
New England Medical Centre, 1984; Gomes-Schwanz,
Horowiz and Sauzier, 1985; Gomes-Schwartz, Horowitz
and Cardarelli, 1990). This measure consists of a true-false
questionnaire that addresses childhood behaviour problems
and is completed by the parents.
Conte, Berliner and Schuerman (Conte and Berliner,
1988) developed two measures to assess the effects of sexual
abuse in a large sample of 369 sexually abused children
assessed at or near the point of disclosure. One of these

Stressors might
be any of a number
of events,
including, but not
exclusively, sexual
abuse

242

Parents and
professionals are
likely to view
events and
behaviour
dzperent ly

Babiker and Herbert

measures, the Child Behaviour Profile, was designed for
parents to complete and the other, the Symptom Checklist,
for the social worker to use. Both social workers and parents
were consistent in how they described the child on their
respective measures; however, they found a relatively poor
agreement between the two versions and this raised a
number of issues. The authors considered the hypothesis
that social workers focused on disturbance while parents
described a range of behaviours; and also that parents and
professionals are likely to view events and behaviour differently, in part because they use different perspectives to
assess the behaviour and in part because they see the child in
different environments and under different conditions.
It is clear that although significant differences emerge
between groups of abused and non-abused children on these
instruments-a matter of clinical importance-they do not
discriminate between the groups in a manner that makes
them useful in the evaluation of sexual abuse in an individual
case.

Questionnaire Assessment

Many of the
questions on both
tests had to be
thought through,
explained or
discussed

Some researchers have attempted to establish the intermediate (several years subsequent to abuse) negative effect of
sexual abuse on self-esteem, and the Piers-Harris has been a
popular test for this purpose in the United States (Elmer,
1977; Oates, Forrest and Peacock, 1985).
Whether or not the Piers-Harris would be useful in this
country to assess the long-lasting impact of sexual abuse on
self-esteem remains to be seen. Some preliminary work with
this test by one of the authors (GB) of this study suggests
that three out of the 80 test questions would almost certainly
need to be anglicized in order to make it applicable to
English schoolchildren. The Culture-Free Self-Esteem
Inventory (SEI) (Battle, 198l), on the other hand, appeared
to live up to its name in that within the same group of
children, in a parallel study to the work presented here,
Babiker (1991) found that it did not seem to pose problems
with comprehension.
Babiker (1991) found when both of these questionnaires
were administered to a sample of children (abused and not
abused) on care orders with Avon Social Services, many of
the questions on both tests had to be thought through,
explained or discussed, as they referred, for example, to
parents and it was not clear to many children which parents
(natural, old foster parent, new foster parent) were intended.
Similarly, questions about school could not be assumed to be

Psychological Instruments in Assessment

entirely reliable with children who had possibly had a greater
than average number of changes of school or whose school
work and social adjustment at school might be influenced
temporarily by the instability of changes in home placements. This points once again to the need for tailor-made
measures for use with the population being studied (see
Sabiker and Herbert, in preparation).
It is also important to bear in mind when using questionnaires with children that standardized administration could
pose some difficulties; the tests may have to be administered
differently to different children, according to their reading
age, needs or preference. In this respect, the Culture-Free
Inventory is more flexible, as it is designed for oral administration for younger people and written administration in
the adult version.

243

Standardized
administration
could pose some
dificu1ties

Cognitive Tests
Until very recently, reports of standardized empirical
investigation into the cognitive signs of sexual abuse have
been extremely scarce. However, there have been reports of
cognitive testing of physically abused and neglected children. Many well-validated psychometric tests exist for this
purpose. For a detailed review of the effects of maltreatment
on cognitive development, the reader is referred to the
chapter by J. L. Aber et al. (1989) in Cicchetti and Carlsons
book on child maltreatment. Examination of intellectual
factors in child abuse detecrion is lacking in consensus as to
conclusions. The area of development most likely to be
affected was language, as these could be sea, as families
whose members find it hard to communicate their feelings in
words, using actions to express themselves instead (Lynch,
1988). This raises the question of whether a similar dynamic
could underlie sexual abuse and whether it would also be
expressed in difficulties with language.
The closest sexual abuse research has come to the area of
cognitive assessment is in evaluating scholastic achievement.
Behavioural and academic problems at school are commonly
reported symptoms for sexually abused school-aged children
(Adams-Tucker, 1981; Tong, Oates and McDowell, 1987).
Few, if any, studies, however, have been carried out which
were solely concerned with the measurement of the cognitive
effects of sexual abuse in children.
Nevertheless, an assessment of a childs functioning that
indicates an abnormal pattern of psychometric results is, of
necessity, a matter of clinical concern (and action), whether
or not it is linked to physical or sexual abuse.

Examination of
intellectual factors
in child abuse
detection is
lacking in
consensus
An assessment of
a childs
functioning that
indicates an
abnormal pattern
of psychometric
results is a matter
of clinical concern

244

Babiker and Herbert

Projective Tests

A variety of
techniques are
used to ascertain
how a child feels
and what they have
experienced

The use of projective tests as an adjunct to psychological

investigation of child sexual abuse merits special mention.
Zivney, Nash and Hulsey (1988) have suggested that as
researchers seek to clarify how and when sexual abuse
impinges on psychological adjustment, they might consider
including in their test batteries some form of standardized
and normative projective testing. Standard projective tests,
as well as those designed specificallyfor sexual abuse evaluations, may be used. For a review see Babiker (1993). Despite
criticisms (e.g. Eysenck, 1960)about the theoretical basis and
reliability of projective methods, and some decline in their
popularity during recent years, they continue to be used
extensively (see Babiker, 1992), especially as refinements in
scoring and standardized interpretative systems have been
introduced (e.g. Exner, 1990). The projective hypothesis is
that if an individual is presented with ambiguous stimuli
(as in the Rorschach) or open-ended story-telling pictures
(as in the Thematic Apperception Test), hislher response
will depend on their own personality and experience. These
two techniques have been used inconclusively in sexual abuse
studies (Babiker and Wilkinson, 1994).
It is widely understood that in the evaluation of children
with emotional conflicts it is often difficult for the child to
express feelings. Consequently, a variety of techniquesnotably human figure drawing (HFD)-are used to ascertain how a child feels and what they have experienced.
Drawings are an invaluable means of establishing an easy,
pleasant rapport with a child. In the last few years clinical
presentations of case material by practitioners of assessment
and therapy with sexually abused children have shown an
overwhelming interest in the drawings of abused individuals. It is not possible in this article to do more than allude to
this area of work.
There are two main approaches to the use of H F D for
psychological interpretation. The first of these is a developmental approach which uses HFD as a measure of
intellectual maturity. An interesting explanation which has
been put forward for discontinuities in drawing development
has suggested that drawing skill may be arrested a t the age
when a trauma occurs and that the developmental age of the
drawing remains fixated on the trauma (Moore, 1990). The
second approach, which is the one that concerns us here, has
been adopted mainly by clinicians as a projective technique
to assess personality and psychological adjustment. The
hypothesis that sexually abused children are more likely to

Psychological Instruments in Assessment

draw genitalia in human figures than are non-abused

children, and which appears to be borne out by clinical case
reports, was investigated by Hibbard, Roghmann and
Hoekelman (1987). These authors compared drawings from
57 children aged 3-7 years, alleged to have been sexually
abused, with the drawings of a group of 55 non-abused
children matched for age, sex, race and socioeconomic
grouping. The comparison group of children were receiving
well-child care in medical settings. A standardized format
for collecting drawings was used, with children being asked
to produce both HFD and a completion drawing: a human
figure outline to be finished and made into a whole person
by the child. Five evaluators then independently examined
the drawings blind for the presence or absence of five body
parts: eyes, navel, vulvalvagina, penis and anus. Hibbard
et ul. (1987) reported that 10% of the alleged sexual abuse
victims and 2% of the comparison children drew genitalia.
The estimated relative risk was 5.4: that is to say, alleged
sexual abuse victims were 5.4 times more likely to draw
genitalia than were comparison children. Children known to
have been sexually abused were 6.8 times more likely to draw
genitalia. However, the authors cautioned that although the
presence of genitalia in the drawing may suggest the possibility of sexual abuse, it does not prove it, any more than a
normal drawing excludes .the possibility of sexual abuse.
Mary Verdon (1987) investigated human figure drawing as
a possible screening device for sexually and physically
abused children. Five groups of children, matched for age
and IQ, were studied: (1) sexually abused; (2) physically
abused; ( 3 ) both sexually and physically abused; (4) child
psychiatry outpatients; (5) normal controls. The childrens
DAPs were scored blind by two raters for presence/absence
of Koppitzs 30 emotional indicators. The utility of drawings
as screening devices for abuse received minimal support
from the findings of this study. The group of children who
had been both physically and sexually abused and the normal
control group had significantly more emotional indicators
than children in the other groups. Unfortunately, this study
did not use a standardized interview. Very few of the
drawings were obtained from the child in viva, relying
instead on archival material from the childrens case files,
and this may have introduced unnecessary variation into the
data. Nevertheless, the findings of this study would seem to
suggest that away from individual case studies and by using
adequate experimental controls, doubt is thrown on the
usefulness of emotional indicators as discriminants for
abuse.

245

The presence of
genitalia in the
drawing m a y
suggest the
possibility of
sexual abuse, it
does not prove it

246

Girls who had

been incest victims
were significantly
more likely to
either exaggerate
or minimize the
sexual features of
their figure
drawing

Projective tests
are of potential
value aythey are
used judiciously as
a means to help
children to
communicate
personal
information

Babiker and Herbert

Yates, Beutler and Crago (1985) compared drawings by 18
girl victims of incest aged between 3 and 17 years with the
drawings of children referred to the same psychiatric clinic
for non-sexual issues. The comparison group of 17 girls aged
4-17 years was matched for age and socioeconomic background. Each drawing was rated blind on 15 dimensions
extracted from the clinical literature by two raters using their
subjective clinical judgement. The findings of this study
suggested relatively few mean differences between girls who
were incest victims and the comparison group on the various
dimensions,although one significant difference did emerge,
suggesting that girls who had been incest victims were
significantly more likely to either exaggerate or minimize the
sexual features of their figure drawing.
Because of methodological problems, both Verdons
(1987) and Yates et aZ.s studies provide little more than
speculative data about the effects of sexual abuse on
childrens drawings. However, the paucity of empirical
literature on the subject, especially when contrasted with the
large amount of reported case material, underlines the
necessity for further research. For extensive review of the
use of HFD in sexual abuse see Babiker (1992).
The Object Relations Test (ORT) (Phillipson, 1955) and
the Childrens Object Relations Test (CORT) (Wilkinson,
1970, 1975) were used by one of the authors (Babiker and
Wilkinson, 1994) to assess the effects of sexual abuse in a
sample of children on care orders in Bristol. The thematic
techniques were able to differentiate quite well within a
restricted sample of children who had been sexually abused
(12 children were correctly identified as having been abused,
two were not). The advantage of these tests is that they have
been developed and researched in the UK, and the CORT
had been used previously in research with children in care.
Probably because they were developed as clinical rather than
research instruments, however, objective scoring of these
tests provides the researcher with a challenge. A review by
Elkan (1988) of 11 studies in which scorable features of the
ORT have been identified and counted in a variety of
samples points to its usefulness as a research tool. However,
the Babiker and Wilkinson study suggested that this
required further systematic investigation in studies where
blind interviewing and blind scoring by independent raters
are requirements. As yet, however, there is no case for the
use of the ORT or CORT for the assessment of sexual abuse
or for planning therapeutic interventions.
There is little doubt that projective tests are of potential
value if they are used judiciously as a means to help children

Psychological Instruments in Assessment

to communicate personal information (see Herbert, 1993).

Their weakness lies in their interpretation, and the difficulties of objectifying this. In sexual abuse evaluations,
projective tests are perhaps best used along with other
measures as part of a multi-dimensional assessment of a
childs general psychological state, not as screening
(i.e. diagnostic) devices which discriminate abused from
non-abused children.

Multi-Dimensional Assessment
Very few studies appear to have provided a multi-dimensional psychological assessment of the effects of sexual abuse.
Einbender and Friedrich (1989) examined the relation of
abuse to several broad categories of childhood functioning,
including cognitive abilities and school achievement, emotional functioning and overt behaviour problems. They
hypothesized that a higher number of behaviour problems
and a lower quality of psychosocial functioning would be
evident in young sexually abused girls when compared with
a matched non-abused control group. This was a welldesigned study in which the 3-hour assessment included:
two subtests from the Wechsler Intelligence scale for
Children-Revised (WISC-R) to assess the childs intellectual abilities; the Rorschach Test to provide information
about aspects of the childs emotional adjustment; the Wide
Range Achievement Test-Revised (WRAT-R) to provide
achievement scores for arithmetic, reading and spelling;
five cards from the Roberts Apperception Test for Children
to calculate pathological indicators for each child. In
addition, two self-report questionnaires were administered:
the Childrens Depression Inventory and the Piers-Harris
Childrens Self-concept Scale. Parents or guardians completed a checklist about each child.
Sexually abused children demonstrated: (1) a heightened
sexual awareness and sexual preoccupations (as measured by
the projective testing) and (2) lower cognitive abilities and
school achievement as measured by the WISC-R IQ and
scoring on the WRAT-R. In addition, the standardized
interviewing of the adults concerned revealed that (3) the
sexually abused children had more stressful life events in
their past histories.
The finding that the sexually abused girls in this study
were more sexualized and had more sexual preoccupations
is consistent with other studies reporting this difference
between sexually abused subjects and controls. Some
authors (Conte, 1991) would even claim that this is the most

247

Projective tests
are perhaps best
used along with
other measures as
part of a multidimensional
assessment

Sexually abused
girls in this study
were more
sexualized and had
more sexual
preoccupations

248

The sexually
abused children
had several out-ofhome placements
while the
comparison
group had none
I

None of the
three tests
discriminated
adequately
between sexually
abused subjects
and other groups

Babiker and Herbert

reliably differentiating characteristic of sexually abused
children to date,
Einbender and Friedrichs ( 1989) finding concerning
cognitive functioning, however, requires further research
with larger, more random samples. The main weakness
of this finding is that the sexually abused children had
several out-of-home placements while the comparison
group had none, and this factor is very likely to have
exerted an influence on academic achievement and test
performance.
Babiker (1992) used a battery of indirect psychological
measures to test whether they would differentiate accurately
between children who had been sexually abused and
children who had not. The study aimed to answer the
following questions: (1) what psychological measures
might be of use in the detection of sexual abuse in children
and adolescents; (2) which combination of psychological
measures had the best predictive value in identifying sexual
abuse. Three groups of children (sexually abused, physically
abused and non-abused) were compared using blind interviewing for their responding on measures of human figure
drawing (HFD)and an explorative, sexual abuse oriented
modification of a word association task (WA).The younger
children were also compared on anatomical doll play (ACD).
This study attempted to address the issue of adequately
matching sexually abused children with comparison groups
on important covariants of abuse. Towards this end, all the
children (N = 49) were the subjects of care orders by social
services and living away from home. The three groups were
matched as closely as possible with respect to age and sex.
The three study measures were investigated by means of
univariate and multivariate analyses. The findings of the
univariate analyses were that while the utility of W A as a
measure received minimal support, none of the three tests
discriminated adequately between sexually abused subjects
and other groups. However, multivariate analysis indicated
that combinations of all three variables were significant
predictors in the study sample of correct classification by
abuse group. Physically abused subjects were in some ways
more reserved than the other groups: they demonstrated no
sexual activity with dolls and significantly longer search
times with words. Non-abused subjects did not emerge as
significaritly less disturbed than the two abused groups. It is
possible that whatever reasons led to their being taken into
care, while not constituting abuse, were nevertheless
traumatic. But whether trauma, which may be common to
all three groups, comprises specific effects in each group

Psychological Instruments in Assessment

remains to be determined. Therefore, although there were

some interesting differences observed in the results of the
analyses, none of these appeared sufficiently powerful to
suggest that any single measure could be used in isolation to
detect sexual abuse.
Babiker (1992) makes the point that sexual abuse takes
place within a sociocultural context, and diagnostic
decisions are greatly influenced by the estimated costs of a
false diagnosis. The cost is determined to a large extent by
decisions about the trade-off between the two types of error:
the risk of misclassifying children who are being abused and
possibly subjecting them to further trauma versus the risk of
misclassifying children who are not being abused and
possibly subjecting them and their families unnecessarily
to the stress of intervention. Babiker concludes from her
findings that although the retrospective discriminant function analyses appear fairly promising, before any conclusions
can be reached as to the meaningfulness of the combinations
of variables they contain, the models generated must be
replicated (i.e. cross-validated) on an independent sample.
Clinicians are encouraged to combine the use of standardized measures with the traditional interview in their work
with sexually abused children for the general purposes of
research and the clinical identification of those most in need
of help in these areas, and to refrain from using, in isolation,
the kinds of measures for which we have above found so little
empirical evidence.

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249

None of these
appeared
suficiently
powerful to
suggest that any
single measure
could be used in
isolation to detect
sexual abuse

Clinicians are
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standardized
measures with the
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interview

250

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