A Champion for Abused Children: An Interview with Dr. Allison Jackson
Victims of sexual abuse are unfortunately getting younger, as are their perpetrators. Despite the depiction of adolescents as “young adults” in our media, we must remember that they are not. They are children. A 17-year-old assault victim is a child who has been assaulted. The distinction between adults and children is critical. We must remember that the human brain is not fully developed until the early 20s. Although we often use the rhetoric that children are “resilient”, this is not borne out when children are abused. We know that victims who don’t receive the proper treatment are more likely to suffer future abuse and lose their “life momentum”. It is critical, therefore, that we seek out medical treatment when childhood abuse is suspected.
I had the privilege of talking with Dr. Allison Jackson who serves as the division chief of the Child and Adolescent Protection Center of the Children's National Medical Center. She's also an Associate Professor of Pediatrics at the George Washington University. For over 19 years Dr. Jackson has been evaluating and treating children victimized by all forms of child maltreatment. In addition to her medical responsibilities, she provides physician leadership to the District of Columbia's multidisciplinary team on child abuse.
The following is from our interview.
It seems as if the perpetrators and victims of abuse are getting younger. Do you think that reflects a change in reporting or do you think that there are some other trends that are driving this?
I think that it's a combination of the two. I think for victims of sexual abuse or sexual assault, there may be a component of increased reporting. You know, there's been a lot of public attention [on] child sexual abuse. So I think that there may be for younger children a tendency to report those more, given the increase awareness.
As far as the perpetrators seeming to get younger and younger, I would agree. In my clinical experience, I would say anecdotally, that is our shared experience with the stats.
I think that the internet is playing a role in that [abuse and perpetration] as young children have access to the internet in ways that other children of different generations never had. I think, unfortunately, the internet has become a source of sex education, albeit inaccurate or inappropriate.
How does access to the internet impact how kids view sexuality?
Kids [with] these malleable, developing brains see some images that are well beyond the time frame [developmentally] where they should be seeing them or hearing them. [If] what they're seeing is completely inappropriate, but it's their first experience or exposure, it creates a distorted view of their understanding about sex, their understanding about relationships and how we should interact with one another.
From a medical perspective, can you describe the sort of experience that a suspected victim would have if they are brought into your clinic with a claim of sexual assault? What should parents expect?
It depends on how soon [they are brought in] after the incident occurred. These are not easy things for kids of any age to talk about. Because the perpetrator is usually not a stranger, it makes it that much more difficult to tell [someone]. The difficulty of disclosing can often lead to a delay in getting medical attention.
What we seek to do in our office is to address both the emotional and psychological needs of the patient and [the] non-offending caregiver, and the medical needs of the patient.
Child abuse pediatricians practice in a variety of settings which means that the response or kind of team that is involved in the care of these patients may vary from place to place. But if I'm looking at it purely from what happens on the medical side of things, it should be no different than any other medical visit. There should be a history which means that we should be asking the patient, “Why are you here?” and allow the patient to share what they are able to share at that time.
What do you do if the child is not forthcoming with information?
We are not in the business of forcing disclosures from any child or young person. They have to be able to tell when they are ready and that [visit] may not be the time that they're ready, or they may be ready to tell some of it, but not all of it. And that is okay. They have to know that is all right, that they can share whatever they feel comfortable sharing. And we should be responding to not only their verbal cues but their body language as well in terms of how they are handling the encounter.
What happens during the physical exam?
The medical exam should be a complete head to toe physical exam which includes an exam of the genital and anal areas as well. If the concern is for some sort of sexual victimization or physical abuse [the exam] will include documentation using photography or videography to document the exam. [This] allows for that provider to be able to have a colleague look at something (anonymously) that may be in question without putting a patient through another exam with another person.
There may be testing for infection or pregnancy to determine whether or not there are any other consequences of the abuse that they described or is suspected. We use the history to guide our practice.
There needs to be closure to the visit and that closure should include giving the results of the exam.
Of course, test results won't be available that quickly, but certainly [it should be communicated] whether or not there are any abnormalities in the exam or whether it's normal—which is usually the case. That [normal exam] can be very reassuring for a victim who may come in thinking that something is wrong with their body or that they're somehow damaged physically because of what happened. Knowing that, for a survivor, can go a very long way.
Does the exam change if the child is very young?
In the case of a child who is pre-verbal or has limited verbal skills [we] use the history that is provided by the caregiver. Any signs or symptoms that have been reported or observed, [we] use those things to guide our assessment and [to determine] what level of testing might be required.
Are there any privacy concerns that come into play that parents should be aware of?
There are issues related to the care of adolescents. In our area, a 12-year-old can receive care for sexually transmitted infections, pregnancy, mental health concerns, substance abuse concerns—things of that nature without a parent. We know that for some adolescents, if the parents have to know, then the (child) just won't get care which could have devastating consequences. To overcome that barrier, there are legal accommodations that allow young persons to seek medical care for certain things related to that.
Sexual assault is tricky because we can use actual victimization as a safety concern, much like we would suicidality or a mental health issue. Because sexual victimization and sexual assault is a crime of power and control in most instances—which is not quite the same as I had sex with my boyfriend and now I have a discharge or my stomach is hurting—it's a little bit different. So it makes it much more challenging in that sense.
If the perpetrator is disclosed to be a parent, a family member or someone in a position of control, like a coach or a minister, then the child abuse laws limit the confidentiality of the visit.
My practice, even with younger children, is to talk with them without their parent in the room. That is a more traditional approach with adolescents because we know that the level of modesty increases as kids get older and their experiences become much more private. But it's important that they know what the limits of confidentiality might be.
Let’s turn to relationships. How can we support adolescents to develop healthy relationships and an understanding of where the boundaries are in a healthy relationship?
I think we have to start before adolescence. I think that the relationships that we model or that they observe in their homes [and] in their community are teaching them well before they're ready for those kinds of relationships.
When your children are younger and you're observing something that is unhealthy or a high-risk kind of scenario [in public], just set the tone [with your children] of what they should expect and what they deserve [and] how they deserve to be treated. In doing that, it creates a dynamic where a parent and child can dialogue freely and in a safe way about things that are less traditional. Better to learn these things at home with a value system that you support, [rather than] from peers, media, internet or music that may be promoting things that are unhealthy.
How can parents specifically support strong conversations?
I think it's important just to listen to kids without judgment.
That can be hard for parents, especially parents of teenagers because developmentally teenagers think they know everything. That is a normal developmental thing. They're achieving new milestones of their critical thinking skills and they're going to test it out, and they're going to think that they know more than you!
The truth of the matter is, even the most loving couples disagree. The question is ‘how do couples resolve disagreements in a healthy way?’ Help them think about that? [Try] posing further follow up questions. ‘Do you think that's how to settle disagreements?’ ‘So why do you think that or what makes you think that?’
What is your opinion on what we can be doing to support boys in their growth and development to become healthy men?
I think we have to first acknowledge that sexual abuse doesn't just happen to females. So about 1 in 4 females and about 1 in 6 males may experience sexual victimization. So it's common regardless of gender. Sexual abuse is common in males, females and transgendered young persons. In many ways, they (boys) are even more susceptible to poor consequences or outcomes as a result of sexual assault.
What are some barriers to good conversations between parents and children that could put kids at risk?
You have to talk to kids about sex. That may be awkward for a lot of parents. Knowing the statistics, we also have to remember that a lot of parents are survivors. They may be survivors who didn't tell, survivors who told and were not believed, survivors who told and were ousted from the family. That affects their parenting and their ability to explain these things to their children. We have to support parents in getting help.
Historically the lesson was "Don't talk to strangers" which is completely false. It's not that I'm encouraging kids to talk to every stranger. But the truth of the matter is that the perpetrators are usually someone known to the family. It could be in the family or very close to the family.
What resources are there for parents who want to ask those good questions and start the dialogue on healthy relationships with their children?
I think going to the pediatrician is so very important. Parents should partner with a pediatrician in the sense of saying, there is going to be a time when I am going to need to step out of the room because that's your doctor, not mine and I want you to be able to talk to your doctor about things. I think most pediatricians would probably appreciate that help [to support children to] feel empowered about seeking their own healthcare.
The national center for missing and exploited children has some great resources around internet safety that parents and kids can look at.
There's a wonderful program called Stewards of Children, which is a child sexual abuse prevention program. There are training programs that might be offered by organizations in your community that you could participate in. Some schools have curricula around safe dating and there are health programs.
Ask your school, what [it is] doing to teach around healthy relationships. Hopefully, schools know, but some may not know. There are some evidence based 'safe-dating' curricula that schools can implement in their health classes.
The American Academy of Pediatrics does have a link for resources and some anticipatory guidance for parents at each kind of developmental stage on the website.
What final advice do you have for parents who want to support healthy adolescent behavior?
Anticipating what might be on the horizon is important to do—and just spending time with your children.
Before the baby's born, we're looking up things. We should be just as eager to find information about [older kids]. “Okay, my kid is 10 and they're going to be in middle school soon. What should I expect with that? What kind of things should I be talking with them about?”
The physicality of being a parent of young children lends itself to that kind of interaction just by default. But as kids get older and they are able to do more for themselves and their interest is more outside of the home than inside the home, we have to create those opportunities [to be] together. And it's not just together for certain tasks, but just simply spending time together—going to a movie, going out to eat, one-on-one time to get your nails done, whatever it is with your child to continue to foster a relationship.
What one thing would you like victims or caretakers of victims of abuse or assault to know?
There is help. You are not alone and it is not your fault.
What one thing would you encourage caretakers of victims of abuse or assault to do?
To get help. We don't keep this in the family. There is no shame in being a victim of sexual violence. Help is available. I think people always do better when they are able to avail themselves of the help that is there.
Please name some things that we as a society should be doing to stop childhood abuse or an assault.
Stop stigmatizing mental health-- I like to call it brain health. Hold perpetrators accountable more consistently. Support parents.
We need to de-stigmatize the experience of sexual victimization and [address] the subject of consent. What is consent? What does that mean? What does it look like? This certainly needs to be taught.
What is the most important thing we should be doing right now to help support victims?
Listening to them in a nonjudgmental way and responding in an affirming way is invaluable to a survivor. People who have experienced sexual victimization almost always do better when they are believed and supported. The outcomes are often devastating or tragic when a victim is not believed. [This] is not the same as somebody going to jail. This is how do the people who are supposed to love and care for me respond to my disclosure.
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About Dr. Jackson
Dr. Allison Jackson who serves as the division chief of the child and adolescent protection center of the Children's National Medical Center. She's also an Associate Professor of Pediatrics at George Washington University. For over 19 years. She's been evaluating and treating children victimized by all forms of child maltreatment. In addition to her medical responsibilities, she's providing physician leadership to the district of Columbia's multidisciplinary team on child abuse.
Dr. Jackson is the 2014 recipient of the administration on children, youth and families commissioner's award and was the inaugural recipient of an endowed professorship by the Washington Children's Foundation in 2017. Her advocacy on behalf of victims of child abuse and neglect is reflected in her service on the DC Children's Justice Act Task force, the DC Victims Assistance Network, and as the Ray Heffler society's representative to the National Coalition of Child Abuse.
