Since 1991, Victim Services has led efforts to improve the response of New York City's criminal justice, social welfare, medical and mental health systems to victims of child sexual abuse. In interviews with child sexual abuse victims and their families we discovered that the current response to child sexual abuse in New York City subjects victims to significant additional trauma and emotional chaos beyond the original abuse--children have to tell their story repeated times to many people, families often feel blamed for the victimization, and in general are not treated well.

Through the Multidisciplinary Response Protocol (MRP) , Victim Services convened an interagency effort which attempted to minimize the trauma to children by coordinating the response of police, courts, victim advocates, medical personnel, and social welfare agencies in cases of child sexual abuse. While the MRP project has demonstrated the difficulty of effectively coordinating New York's complex systems to significantly reduce the multiple investigations, it has also illustrated that the participating agencies are committed to improving the response to child sexual abuse victims.

Both the research project and the multidisciplinary pilot project led us to our principal policy recommendation that government policy makers should join with the voluntary sector to establish a center for child abuse victims. The center would be staffed by police, prosecutors, child welfare workers and victim counselors, with medical care on site or nearby. Only such a "Child Advocacy Center" would succeed in dramatically reducing the additional trauma now inflicted on child sexual abuse victims, as well as decreasing long-term costs to New York's response systems. An ideal place for the first Child Advocacy Center is in Brooklyn, where the groundwork for interagency co-operation is in place through the MRP project. This recommendation has been endorsed by our partners in this project: the Kings County District Attorney, the New York City Police Department, the Child Welfare Administration and the New York City Health and Hospitals Corporation.

To document how the current system is treating child sexual abuse victims, a research project was designed to explore the experiences of child sexual abuse victims and their families after disclosure of the abuse, and to find ways to mitigate the trauma to the child victim. We conducted 61 interviews with child and adolescent victims, non-offending parents, and adult survivors of child sexual abuse, as well as a sample of professionals representing the agencies and institutions that respond to child sexual abuse. We asked victims and families about their interactions with a variety of systems and institutions after disclosure or discovery of abuse, and about the emotional impact of both these interactions and the abuse itself. Survivor interviews focused on emotional consequences of the abuse and perceptions of how children can be helped to disclose abuse; and interviews with professionals obtained diverse perspectives on how policy and programmatic responses to sexual abuse can be improved.

The pattern of findings supports the model presented in the child sexual abuse literature of disclosure/discovery of the abuse as an event that triggers a crisis for the family and child that can feel as intense as the abuse itself. This 'system-induced' trauma prolongs the trauma of the abuse rather than helping to move the child and family closer to recovery.

Although some families described highly positive experiences with the police, medical professionals, child protective staff, attorneys and other court personnel, and social service professionals, most reported problems in their interactions. One mother told us:

Typical of most interactions were long waits; multiple interviews; the sense that those doing the work were unqualified and insensitive; and a lack of information provided to the victims. Addressing these problems would reduce trauma to the child victim and family, and reduce long-term costs as the process of handling cases of child sexual abuse becomes more efficient and effective. The savings in human and financial costs are likely to be dramatic.

The following are some of the specific findings:

	On average, each child victim had to tell her/his story to eight different people, some of whom interviewed the child multiple times; in one case, the number rose to twenty-seven people.
	Families were distressed by the inconvenience and difficulty for their children of numerous trips to such places as police precincts, hospitals, courts, and other agency offices.
	Families and professionals expressed a strong need for immediately available psychological treatment for the child victim and the non-offending parent(s).

Police

Police were often the first "system" encountered by child victims and families, putting them in a position to secure immediate help for the victim. However, they seldom provided referrals for counseling or treatment.

Medical Systems

	Medical exams typically occurred in the emergency room of a local (often municipal) hospital, resulting in a long wait for the child and non-offending parent. This was especially true in evening and nighttime hours, when children were sometimes referred to emergency rooms even though there was no medical emergency.
	Families expressed concern about the lack of experience among some physicians in handling sexual abuse cases; parents whose children were seen at a clinic specializing in sexual abuse reported much more positive experiences.

Child Welfare Administration

	Non-offending parents often felt that child protective services workers blamed them for "failing to protect" their child; this served to antagonize mothers and increase their level of distress.
	Some parents found the CWA workers to be inexperienced at interviewing children about sexual abuse.
	Child and adolescent victims experience foster care placement as disruptive and traumatic, and expressed a preference for removal of the offender.

Court Systems

	With respect to Family Court, the biggest concern of both child victims and parents was the number of times they had to return to Family Court (because of adjournments and other delays), and how long they had to wait there each time.
	Families perceived court-based victim advocates as playing an important part in reducing the difficulties of going to court with their children.
	A child victim whose case goes to trial in Criminal/Supreme Court often had to speak with at least three different Assistant District Attorneys. This number may be higher if one or more ADA's "rotate" out of the Sex Crimes Bureau before case disposition.
	Parents and children alike expressed fear and distress about (children) testifying against their offender; a central issue for most was the presence of the offender during the testimony.
	Non-offending parents were often uncertain about the progress of ongoing court cases, or, in disposed cases, about the final outcome with respect to mandated treatment for the abuser. Those helped by a victim advocate were more satisfied with the information and treatment they got.

Schools

Few families in this study mentioned the involvement of the child's school in this process; however, adult survivors frequently told us they would have disclosed to a teacher if the schools had created an opportunity to do so.

To address the fragmented and duplicative way that child sexual abuse investigations are conducted in New York City, Victim Services invited the participation of the key child protective, law enforcement, medical and treatment providers in Brooklyn to develop a new way of responding. With funding from the New York State Department of Social Services, Victim Services convened the Multidisciplinary Response Project (MRP) which sought to increase the effectiveness and sensitivity of public intervention while minimizing the trauma to the child. Over a 15-month period, Victim Services created a multidisciplinary advisory board, protocol working group and investigative team; drafted a protocol for coordinated intervention for each team member; conducted trainings; tested the protocol in twelve pilot cases from a selected area of Brooklyn; evaluated the project's progress; and prepared recommendations for further change.

Key elements of the resulting protocol include: immediate cross-notification of a new case among child protective workers, hospital personnel, police and the project co-ordinator; co-interviewing of the child victim by a detective and a child protective worker to eliminate one interview; use of a "universal fact sheet" on a case to eliminate the need for duplicative interviewing; early treatment referrals; and regular team meetings to coordinate individual cases and evaluate implementation of the MRP.

The project's greatest successes were in increasing timely communication of vital case information and increasing coordination among agencies. The project has created an on-going multi-agency forum for problemsolving, and an active team is continually testing and evaluating solutions. Participants praised the project's expediting of the law enforcement investigation and the quick onset of treatment for victims and non-offending parents.

Participating agencies agree that while the efforts of the work group and team have been commendable, the MRP did not succeed in fully realizing the project's goals. We were unable to significantly limit interviews of child victims and decrease the number of staff assigned to each case. Major territorial and logistical barriers continue to exist. In order to build on the communication and trust that has developed among work group members, the participating agencies were asked to continue their commitment to reducing institutional barriers by supporting interagency agreements, designating staff to the MRP, and making changes in their internal agency procedures. The agencies that worked on the pilot are committed to continuing to work together to refine the protocol with the ultimate goal of expanding and institutionalizing the protocol throughout Brooklyn.

Principal Recommendation
Based on findings of both the public policy study and the MRP, our foremost recommendation is that the various agency personnel involved in a case of child sexual abuse should be stationed in a central, neutral, child-friendly location, where the child victim can undergo all interviews, exams and other investigative and judicial processes with a team of specially trained professionals.

This model, known as a "Child Advocacy Center", is being established in a growing number of jurisdictions around the country. The interagency staff at such a center function as a team that conducts coordinated interviewing and investigations. This approach facilitates information-sharing, reduces the number of interviews, helps ensure that the child receives services, speeds case dispositions, and reduces the trauma to the child associated with being taken to police stations, hospitals, courts and other unfamiliar and potentially frightening venues. Such a model is a natural outgrowth of the work of the MRP.

In its ideal form, a Child Advocacy Center would be located in a facility developed (or renovated) specifically for that purpose, with the physical plant designed to be "child-friendly" and to meet the medical, psychological and general welfare needs of the child. A less costly and more achievable interim step would be "outstationing" specially trained personnel from each organization on one floor of an existing building. Renovations could be limited to constructing a room for a physical exam, as well as a room with a one-way mirror for joint interviewing.

We recommend that the first Child Advocacy Center in New York City be located in Brooklyn, where groundwork for interagency cooperation has been in place since 1992 with the Multidisciplinary Response Project. Further the volume of cases shows that a Child Advocacy Center in Brooklyn would be well utilized: each year over 1,000 child sexual abuse allegations are made to the State Central Registry regarding over 1,300 children in Brooklyn. and the Brooklyn Special Victims Squad of the New York City Police Department investigates over 400 child sexual abuse cases each year. In addition, Brooklyn reports more serious sexual abuse cases to the District Attorney than the other boroughs.

The results of both this project and recommendations have been circulated to the participating agencies. We are pleased to report that we have received the endorsement of the Kings County District Attorney, the New York City Police Department, the Child Welfare Administration, the Office of the Criminal Justice Coordinator, the Board of Education as well as medical, social service providers and child advocates to develop a Child Advocacy Center in Brooklyn. With funding from the Ittleson Foundation and the New York State Department of Social Services, Victim Services launched a planning project in 1994 which is guided by an interagency Planning Group. Plans are underway to open the center in Brooklyn in 1995.

System-Specific Recommendations
While work proceeds on the Center, there are many individual changes that can be made immediately, at little cost, to make New York's response to child abuse victims less traumatic. These include coordinated response protocols citywide; increasing capacity of treatment programs; sexual abuse units within pediatric facilities in hospitals; and training of CWA and law enforcement staff. A more complete list of these recommendations as well as recent action taken by the responsible agencies is included in the appendix.

When we began to study the city's response to child sexual abuse victims, we knew that we would find gaps and redundancies in the system. The research documents the negative impact of these systemic problems on victims. We learned from the MRP that coordinating responses across different agencies to bridge the gaps and eliminate the redundancies is only the first step to significant change. We need a centralized location to provide services to child sexual abuse victims and their families. While this model may require more investment initially, it will save resources in the long run by reducing staff time, expediting investigations, reducing the post-disclosure trauma to child sexual abuse victims and families.

The Child Advocacy Center, together with the other specific recommendations for agencies, present a comprehensive plan for improving public policy responses to victims of child sexual abuse and their families. They advocate both heightened sensitivity to the psychological needs of victims and strategies for streamlining and expediting medical, investigative and judicial proceedings. Such a dual approach should enable those charged with protecting the welfare of society's youngest victims to meet that mandate in a manner that avoids revictimizing the children and helps them begin to recover from the trauma of sexual abuse.

The research and coordination projects yielded a number of specific policy recommendations both citywide and for individual agencies. During the time it will take to establish a Child Advocacy Center, and for those children who will not be served by such a center even after it is established, Victim Services believes these changes would make a big difference in how child sexual abuse victims and their families are treated. Below is a summary of these more specific policy recommendations which have been issued to the appropriate agency and action that has been taken to address them as of July, 1995.

Citywide - Across Agencies

Coordinated response protocols should be developed citywide, in which child protective, law-enforcement, medical, judicial and social service agencies conduct joint investigative interviews and coordinate all other activities; these models should be expanded to include cases of extra familial as well as intrafamilial child sexual abuse. Work that is already being done on a borough-by-borough basis to increase agencies' responsiveness to victims should be coordinated and centralized through the Mayor's Office.

Action: The Office of the New York City Criminal Justice Coordinator, through its Criminal Justice Child Abuse Task Force, has developed a hospital-based Prompt Response Protocol to expedite the police response to serious child physical and sexual abuse cases throughout the city. The Task Force also serves as a network for coordinating the different borough-based multidisciplinary projects including the Brooklyn Child Advocacy Project, the Bronx District Attorney Team, the Queens District Attorney team and the Columbia-Presbyterian Medical Center Multidisciplinary Team. In addition, in June, 1995, the Task force sponsored a city-wide training in investigative interview techniques in which detectives, caseworkers, assistant district attorneys as well as other professionals from throughout the city were trained.

Counseling/Social Services:

Increasing the capacity of treatment programs to see child victims immediately after disclosure/discovery should be a top priority of the mental health system. Such early intervention should save substantially in long-term mental health costs.

Non-offending parents should be seen as secondary victims of child sexual abuse and should be provided with counseling and support services. Research has demonstrated that the child's recovery is closely linked to that of the non- offending parent in intrafamilial sexual abuse cases. The Mental Health system should ensure that providers have training and capacity to ensure appropriate treatment of non-offending parents.

Police

Police should be mandated to refer the victim and/or family to a counselor within 24 hours of the first police interview.

Medical Systems

	Hospitals and clinics should test the viability of units specializing in sexual abuse, to be located within their pediatric facilities, with trained personnel assigned to them, waiting time be kept to an absolute minimum, and emergency night visits for child victims avoided.
	Action: The Health and Hospitals Corporation and the Child Welfare Administration have worked collaboratively on a policy that discourages the use of the emergency room for child sexual abuse cases which are not medical emergencies. (See CWA below.),
	Action: In addition, the Medical Subcommittee of the Brooklyn Child Advocacy Planning Group has instituted plans to increase the number of specialized child sexual abuse clinics in Brooklyn with the goal of having one clinic in operation each day of the week.
	Action: The New York State Department of Health has recently established a task force to develop a Child Sexual Abuse Medical Protocol which will promote a standard of care for the medical evaluation of child sexual abuse cases throughout the state.
	Child sexual abuse should be included in the core curriculum of every medical school, and practicing physicians should be mandated to receive ongoing training.

Child Welfare Administration

	Only sexual assaults that have occurred within 72 hours of discovery should lead to immediate medical exams. The current policy of Emergency Children's Services-- to remove child sexual abuse victims to an emergency room no matter when the abuse occurred -- requires children to needlessly face hospital emergency rooms, often in the middle of the night.
	Action: The Child Welfare Administration issued a policy change (Protocol for Handling Emergency Abuse/Neglect Cases) in May, 1994 directing staff to utilize medical clinics and CWA nursing staff prior to emergency rooms in all but obvious medical emergencies.
	All CWA caseworkers should receive in-depth training on child sexual abuse and techniques for multidisciplinary coordination and case planning.
	Specialized units for child sex abuse cases should be reinstituted within each Borough Field Office. Unit members with special interest and training would be the only people within the agency who work directly with child sexual abuse victims. Only one worker from each agency would contact the child and would handle the case for that agency from start to finish.
	Action: Each borough has at least one Sexual Abuse Unit but they do not consistently serve the entire borough. Despite the current budget crisis, CWA should be encouraged to maintain specialized units to serve the majority of sexual abuse cases in each borough.
	Foster care placement of child victims should be seen as a last resort; one alternative to be explored is the development of specialized preventive or mental health programs for child sexual abuse cases which provide, immediately upon disclosure, crisis counseling to the family, an intensive assessment, and develop a long-term plan with the family.

Court Systems

	All court personnel handling sexual abuse cases should be educated about the prolonged trauma to the child resulting from adjourning such cases.
	To minimize numbers of court visits, courts should set up an "alert" system for child sexual abuse cases, in which victims are "on call" for the day their case is scheduled, and are called to come in only if their case will definitely be heard.
	Courts (Family, Criminal, and Supreme) across the city should consider, on a demonstration basis, having specific judges specialize in child sexual abuse cases.
	In the Criminal Court system, District Attorneys should minimize the number of ADA's who handle a case from the initial complaint through indictment and trial. Whenever possible, the child victim should speak to only one ADA throughout the life of a case.
	Action: The Office of the Kings County District Attorney has revised its procedures for child sexual abuse case by eliminating the separate Riding ADA. Currently a specially trained Special Victims Bureau ADA rides the case, interviews and videotapes the child for Grand Jury and presents the case. Efforts are made to maintain the same ADA for trial, but due to turnover, this is not always possible.
	The criminal justice system should have earlier involvement in sexual abuse cases to facilitate removal of the offender rather than the victim from the home, as soon as possible after disclosure/discovery.
	Action: Through the participation of both the Police Department and the District Attorney's Offices in the various coordinated response programs in New York City, they are becoming involved in cases earlier than in the past.

Legislation should be passed to permit alternatives to children testifying in open court and to facilitate prosecution of "ongoing" sex abusers.

Schools

Presentations to children on sexual abuse should be expanded to include detailed information on possible outcomes of disclosure as well as specific information about a "contact person" to whom children can disclose abuse.

Action: In the spring of 1994, the Joint Commission of the Chancellor and the Special Commissioner for the Prevention of Child Sexual Abuse was convened to address the issue of child sexual abuse in the school system as well as the response of Board of Education personnel to children's disclosure of abuse in their own homes. Included in the draft report are recommendations on improving the student education on child sexual abuse, appointing a child abuse case coordinator in each school to ensure reports are made and children have someone to tell, and the cooperation of the Board of Education in the establishment of Child Advocacy Centers throughout New York City.