Is the use of anatomically detailed dolls in CSA Evaluation a proper method for testing child witnesses?

Georgios Fragakis
Person-Centered Psychologist/ Author

Most of sexual crimes against minors lack undisputable evidence (O’Keefe, 2004). Thus the only possible source of evidence is child’s deposition (Spencer, 1993). However, inquiring on reports of sexual abuse is not so simple because specialists have to take into account multiple factors in order to assess for their liability and validity. Indicatively, the following could be mentioned: a. Only in few cases do pathological findings exist while physical examination might not provide pathognomonic findings (Kerns & Ritter 1992).  After reviewing 21 studies on sexually abused children, conducted in 1993, findings were normal for 26-73% of the girls and 17-82% of the boys.  Only 3-16% of the children did provide findings of sexual abuse (Bays & Chadwick, 1993).  Reasons could be various, such as child’s examination distant from actual SA time, b. Among sexual abuse reports we often encounter falsely denied cases or report withdrawals. Mental health specialists and investigators should find out if sexual abuse denial of a child or a withdrawal of the initial deposition is due to the fact that children’s verbal abilities are compromised by embarrassing feelings or threats made by the abuser or family pressure  (Paine & Hansen, 2002).  Sorenson and Snow, within a sample of 116 children strongly evidenced that they had been subjected to sexual abuse, found out that initially 72% denied sexual abuse, but later on, after several interviews admitted it with the exception of 4% of them.  Totally 22% of the children withdrew their reports throughout the process. In another study examining 22 children with sexually transmitted disease only 43% of them disclosed that they had been abused (Sorenson & Snow, 1991) c. Abused children have several kinds of limitations that also hinder their ability to reveal sexual abuse (Heath & Anderson, 2006; Lyon, 2002;) d. Children’s behavior might not be related to abuse.  Even the most obvious sexual interests they might display could have different reasons.  It is reported that a common behavior among 2 to 6 year-old boys is to touch their mother’s breasts, which could erroneously be attributed to sexualized behavior caused by sexual abuse (Friedrich, 1993).

Although research is a most precious source of knowledge, it is often restricted by social intervention and consequently a number of aspects are not -or- improperly addressed.  Research supports the use of anatomical dolls in interviews, but it is important to examine its implications. Conte, Sorenson, Fogarty, and Della Rosa (1991) suggested that the majority of experts (92%) used anatomical dolls as the main interview tool in sexual abuse assessment, in a study conducted on 212 sexual abuse experts from 40 states.  Other research findings (Kendall-Tackett and Watson, 1992) are similar (i.e., 80% of mental health professionals, and 62% of law enforcement officers used anatomical dolls, in a study of 201 Boston area professionals).  

There are a number of professionals proposing the use of anatomical dolls in interviews of sexually abused children (Everson & Boat, 2002), reporting some plausible reasons for their use.  In any case, given young children’s underdeveloped skills, they might be helped with the usage of nonverbal communication aids (Vizard & Tranter, 1988), such as dolls.  On the other hand, since most of the elder children are verbally able to express experiences, the use of dolls with them may be less justified.  Nevertheless, the latter might be reluctant to express sexual abuse with words either because they feel ashamed, embarrassed, scared or because they have been threatened not to speak to anyone (e.g., Lyon 2002) and thus, they could prefer to express it by showing it with the help of anatomical dolls. Anyway, we could assume that even older children who have mastered speech still can express themselves better through play, which constitutes their  “natural” language and most powerful means of communication.  As Mishne (1983) indicate, play is to children what verbalization is to adults.  Indeed, play creates security so that one can obtain cooperation of preschoolers in unfamiliar environment.  From what was said above we can deduce that the use of anatomical dolls could probably enhance the means of communication (e.g. Katz et al., 1995) and professionals could be more confident in the information obtained (Faller, 2003), especially when children’s words are not clear enough for them. 

More specifically, children’s underdeveloped cognitive state regarding sexual matters as well as their memory’s vulnerable neurological operation are two factors that make it hard for the interviewers since it is difficult for both children and adults to recall traumatic sexual experiences (Paine, 2002).  One of these main factors is the unreliable neurological operation of memory.  In fact, there are no pure memories.  The information of our memory depends on our future expectations, self-image and a great deal of others variables and does not represent pure reflections of reality (Newman, 2009).  Erroneous investigating procedures such as repeated interviews and guided questions are likely to affect children’s words and latent memories (Ceci, 1995). Hence, the quality of information recalled from one’s memory during a conversation depends directly on the way one is being approached by the interviewer (Bays & Chadwick, 1993).  For this reason, anatomically detailed dolls should be used in any investigative procedures with care and only by those properly trained to use them.  Through “voir dire”, which for instance, might include questions on their training and supervision in the use of the dolls etc., the interviewer’s expertise is evaluated (Sherrie Bourg Carter, 2004). 

Due to the varied training the interviewers might have received, as they assume different roles in the investigated process, one might expect different approaches concerning structure, conduction and interpretation of the doll interview. For example, a child protection worker might draw different conclusions from a police officer while investigating the same case (Sherrie Bourg Carter, 2004).  Therefore, a question arises here “how does one assess when an anatomical doll interview was conducted properly?”  One solution could be to address an expert in child abuse who would either remain behind scene helping the attorney to prepare cross-examination questions for the interviewer or as an expert witness that helps the judge or jury realize the proper ways to carry out such interviews. However, sometimes sex crime defendants can’t afford the necessary funds to hire the best experts and some of them are limited by the funding restrictions in their respective jurisdictions (Sherrie Bourg Carter, 2004).

Minors’ investigative procedure aims at getting a child to recall reliable information on possible sexual incidents. Research outcomes on dolls’ usefulness were mixed.  Some of them indicated that dolls might lead to false abuse reports (Skinner & Berry, 1993), while others suggested that they effectively improve children responses when asked about touching (see review by Faller, 2005). The effective use of dolls as a demonstration tool calls for caution on the proper time to introduce them and show children the right way to use them.  Despite the existence of accurate instructions of their use, which reflects the most recent knowledge acquired in this field, there can’t be one single way of proper use.  Local practice or the traits of a case could impose changes (APSAC, 2002). Furthermore, methodological inconsistencies (e.g. sample size) influence studies outputs supporting or questioning the use of dolls (for a review, see Faller, 2007b).

Another issue of the use is the ability of a child to use the doll as a representation of their body and therefore the interviewer has to establish a mapping relationship between the child and the doll. Dolls should be selected by the interviewer, according to the child’s age, race, gender and the type of allegations made by the child or other trustworthy persons, in order to help the child get involved in the procedure.  Otherwise, (e.g. doll of a different gender) the child will find it hard to make the representational shift required (e.g., Everson & Boat, 2002). But, have all children got the ability to use these dolls as a demonstration aid? Some children, especially the younger ones, have limited abilities.  For instance, those up to age 3 usually can’t make a representational use of a doll (DeLoache, 1995a).  Though most of older children understand the concept, preschoolers’ ability should always be evaluated by professionals taking into account that as the child is in the room could be confusing for them to try to use a doll as a representation of themselves.  They might, instead, be able to use a doll for someone who is not in the room (Faller, 2003) or they might understand the use of two dolls doing something to one another before they understand the one-doll concept (DeLoache & Marzolf).

The aforementioned lack of ability constitutes a great challenge for the professionals involved.  Such lack is evident when children prefer to use their own body than that of the doll.  If the child can choose well which doll looks like which person, the next step is to ask them to “show” a normal action such as how a parent puts them to bed.  If a child can’t do this, they might be unable to make the representational shift required.  Informing the child of the symbolic use of the doll and then introducing it to the child (including body part identification) are all crucial steps  (Deloache, 1995b), as the doll offers them the necessary body map (APSAC, 1995; Everson & Boat, 2002).  However, children and caretakers could get upset by the presence of dolls’ private parts, with the latter arguing that children feel distress viewing these parts, an argument not supported by follow-up studies on the impact of the anatomical dolls on children with (Cohn, 1991) and without sexual abuse history (Boat, Everson, Amaya-Jackson, 1996). The above-mentioned procedure is highly important but what precedes the interview consistently contributes to its quality.  If the professionals provide children with explanations regarding what is going to follow, they tend to give more information and more reliable details during the interview, reduce their pre-trial stress and are statistically less likely to get traumatized by this experience (Westcott et al., 2002).  Besides, knowing what an anatomical doll is facilitates them to testify in courts. Additionally, dolls can also be used for the sake of clarification, consistency, distinction, and communication (e.g., CornerHouse, 2003; Faller, 2007b), especially in case of increased confusion. 

The kind of questions asked to a child is an important qualitative factor of an interview.  The closed ones activate a type of memory called retrieval and consequently lead to usually latent answers, they could somehow “infect” the information a child has been asked to recall (Bruck et al., 2006) and they might challenge the legitimacy of a testimony since they might be considered leading questions (Quas et al., 2000). On the other hand, open questions give access to free recall, a type of memory regarded as reliable and if asked properly tend to provide 5 times more information than the closed ones (Sternberg et al., 2001). Collecting detailed information about the incident is a major challenge for the interviewers and through dolls’ anatomical parts they can obtain details (Katza et al., 1995) by asking children selective focused questions in order to avoid particularly embarrassing direct questions (Faller, 2003).  Dolls should be used only as a demonstration aid, and not for play, something that has to be made clear from the very beginning (APSAC, 1995).  The risk here is that these dolls may stimulate fantasy or the will to play, given that children mainly use dolls as toys.  Moreover, some uses of these dolls require free play with them, which increases the above-mentioned risk and interviewers’ admonition may not be enough (Everson & Boat, 2002; Faller, 2003).  Therefore, interviewers should use these findings in practice with caution.

In case a professional suspects adults of instructing children to falsely report sexual abuse may use dolls to track down this possibility by asking for demonstrations (Faller, 2003). Distancing is another useful quality of dolls (CornerHouse, 2003). This is a valuable alternative, which could remove stress from children, as they do not have to use their own bodies to demonstrate sexual abuse (Holmes, 2000).  Last but not least, dolls are very useful for children with language and/or emotional barriers to enhance their communication abilities.

At this point, it would be useful to compare these findings with an emerging theory such as art therapy, and see what could come out.  Creative Activity Therapy is rather recent as it was only instituted in the mid-20^th century in UK and the USA. A large number of Art Therapy pioneers (Naumburg, etc.) came from art education and psychoanalytic tradition.  Later on professional formation courses were introduced, leading to its recognition by the USA and UK Health Systems (Hodnett, 1973).  Similarly to other approaches, the most essential point of art therapy is the relationship created by the therapist and the patient. Nevertheless, what makes the difference in art therapy is a third element intervening in the therapeutic alliance and completing their relationship, and this is the patient’s work of art, turning the therapist into an observer of the creative process and the patient into an artist and spectator of their own work (Irvin, 1988). 

Concerning dolls, such a relationship will not occur as there isn’t enough time to let it happen and therefore we could wonder whether it could be possible for the child to express the hidden images of the experiences they lived and, in absence of trust conditions, could this process be considered as violating?  A useful key to answer this question is provided by therapist’s or art advisor’s role in the therapeutic artistic process.  The therapist uses art in order to make it easier for the patient to explore everything their personal inner world is made of.  According to AATA (American Art Therapy Association), art therapists are professionals specialized both in Art and Therapy. They must have knowledge of human development at any level, of psychological and art theories, research methods, psychotherapy, clinical practice, traditions, as well as art therapy possibilities.  Since an interviewer might lack all these traits their reliability can be questioned.   

Play therapy is the art therapy closest aspect to anatomical dolls.  According to Moustakas (1959), it can be considered as a number of activities through which children are able to fully express themselves so that they can achieve security, efficiency and recognition feelings by means of emotional insight.  In other terms play expands the person’s understanding of the world with no high risks.  Taking into account Amster’s words (1943) on the play therapy main goals, we can conclude that it helps children open and create a proper environment where they can name situations and through emotional expression can acquire the knowledge and sensations provided by images, gestures, etc. At this point a question arises if doll interviewers possess all that is provided by art therapy so that they can attentively help the child to express their most horrifying nightmares.

To conclude this essay, its purpose was to investigate whether the use of dolls in CSA evaluation is the right method for assessing children’s testimonies as a demonstration tool, concerning clarification, consistency, distancing and communication as well as how and in what conditions one can make an optimum use of it. Their use is supported by preliminary evidence. According to the previous findings, interviewers consider dolls to be useful in: (a) clarifying children’s verbal testimonies, (b) offering consistency between children’s verbal testimonies and doll demonstration, (c) helping children keep distance from their own bodies, and (d) helping children communicate with interviewers in case they are not totally able to express their experiences in words due to possible language or emotional barriers among other reasons.

A review of the relative literature provides no support for the fear of eliciting false allegations through the use of dolls and it supports the efficiency of body mapping in interviews concerning private parts touch.  Nevertheless, more research is needed in this field (Everson & Boat, 1997).  The advantages of dolls seem to exceed the respective disadvantages.  All professionals involved could selectively use dolls in interviews with allegedly sexually abused children.  However, before deciding to use them they should consider child’s traits, response to the dolls, and developmental stage and make sure their use is conforming to guidelines on proper use  (APSAC, 1995, Everson & Boat, 2002).  Let alone the existing controversy on the use of dolls, there is general acceptance in the mental health field that they shouldn’t be used as the only but one of the tools, since children’s demonstrations with the dolls should not been taken as definitive. Furthermore, there is a need to empirically evaluate the multiple functions of dolls.  We also examined the possibility to bridge art therapy (especially play therapy) with the dolls method and found contrasting results. It emerged that dolls have a number of drawbacks (i.e. interviewer’s background).  Play therapy helped us realize that the therapist and the patient need to share a “common world view” (Moreno), something quite difficult to achieve during dolls processes, as the interviewer could be a policeman who might lack appropriate training.  This constitutes a negative factor since the common view mentioned right before leads to cognitive coherence indispensable for starting a therapeutic relationship or in our case a sexual abuse interview. Besides interviewer’s training we should also considerate their personality and traits as another important factor. Thus, concerning the interviews, there should be some kind of control on interviewers’ quality that is, their ability to carry out such a delicate process.  Furthermore, the child per se is a key factor. Last but not least, it is the skillfulness needed to conduct such a delicate process. From this point of view, the interviewer should be a “good” teacher who helps the child feel emotionally secure so that they can efficiently go through this process.

Therefore, we could draw the conclusion that the use of anatomically detailed dolls in children’s sexual abuse evaluation it can be a proper method for testing child witnesses but there are undoubtedly several points demanding reconsideration and reexamination in the future since, it is a tool calling for high attentiveness, given child’s fragile and sensitive nature.

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