How does COVID-19 impact intrafamilial child sexual abuse? Comparison analysis of reports by practitioners in Israel and the US

Abstract

Background

There is consensus in child sexual abuse (CSA) literature that intrafamilial child sexual abuse (IFCSA) has a tremendous impact on children and families while simultaneously creating challenges for practitioners. COVID-19 impacted countries worldwide and generated a global crisis resulting in impacts on daily life, however, it’s effect on IFCSA is unknown.

Objective

This study aimed to compare professional perspectives and experiences working with IFCSA with respect to the context of the COVID-19 pandemic within the United States and Israel.

Participants and setting

Participants were therapeutic, child welfare and legal professionals, who provided services to children involved in IFCSA.

Methods

This qualitative cross-cultural comparative study analyzes professional experiences of IFCSA during COVID-19 based on an open-ended questionnaire answered online, with 37 responses from the US and 23 responses from Israel.

Results

Findings reveal mostly negative changes in the dynamics of IFCSA families during COVID-19, including financial, environmental, and emotional hardships, as well as some positive changes in the relationships among family members. In terms of professional interventions, concerns were raised that COVID-19 has been detrimental to the disclosure of IFCSA, with plummeting child abuse reports. Further, risk and benefits of transferring to internet based or telephonic therapeutic interventions were shared.

Conclusions

Governmental and community efforts are needed to develop a safety net of protective factors to reduce IFCSA risks and increase resiliency during the COVID-19 pandemic and future global crises. Moreover, enhanced strategies to accessing and supporting families remotely such as using technology could improve identification and response to IFCSA.

1. Introduction

Intrafamilial child sexual abuse (IFCSA) by definition occurs within the family unit. This phenomenon has a tremendous impact on children and their families and poses unique challenges for practitioners. The current study was designed to examine how COVID-19 has impacted the dynamics and interventions with families in the context of IFCSA, from the experiences and perceptions of practitioners in the United States (US) and Israel.

1.1. IFCSA

Though prevalence rates vary widely, IFCSA is considered one of the most common forms of child sexual abuse (CSA), with particularly severe short- and long-term consequences (Finkelhor, 2012; Gekoski, Davidson, & Horvath, 2016). Victimization rates of IFCSA are variously estimated as high as 3–17 % of males and 8–31 % of females (Barth, Bermetz, Heim, Trelle, & Tonia, 2013). Yet, disclosure of IFCSA is a significant barrier to establishing the real extent of CSA since many of the survivors will not disclose the abuse, often for long periods of time, or never (Gekoski et al., 2016). A portion of IFCSA cases can be considered problematic sexual behavior (PSB), which is defined as behaviors involving sexual body parts that are developmentally inappropriate or potentially harmful to the child with PSB or others (Swisher, Silovsky, Stuart, & Pierce, 2008). These behaviors can be seen especially among siblings closer in age. The distinction between playing with an older sibling, as opposed to being abused by one, can be difficult to make, especially when the perpetrator is a beloved sibling, and the relationship is one which includes elements of pleasure, attentiveness and care (Ballantine, 2012).

1.2. Disclosure of IFCSA

The process of disclosure of IFCSA may have unintended negative consequences, depending largely on the reactions of other family, friends, and community members (Ullman, 2011). Reactions include family denial and disruption, blaming and stigmatization of victims by the family and community, legal processes, and even life-threatening consequences resulting from cultural practices (Celik et al., 2018).

Concealing and disclosing sexual abuse during childhood is facilitated and inhibited by a range of personal, interpersonal, and sociocultural factors (Tener & Murphy, 2015). Some of the factors influencing the failure of disclosure include (1) authority and power of the perpetrator, and the child’s dependence on him/her; (2) social isolation; and (3) a violent family system that lacks open communication channels (Schönbucher, Maier, Mohler-Kuo, Schnyder, & Landolt, 2012; Sivagurunathan, Orchard, MacDermid, & Evans, 2019; Tener, 2018). Barriers for child sexual abuse disclosure described in the literature include: fear of what will happen when the disclosure is made; others’ reactions to the disclosure, including fear of not being believed; emotional impact of the abuse; opportunity to disclose; concern for self and others; and feelings for the abuser (Morrison, Bruce, & Wilson, 2018).

McElvaney, Greene, and Hogan (2012) have described the “pressure cooker effect” when children want to tell about their abuse but at the same time do not want others to know. Some adult survivors of CSA have described that when they did not have confidence and trust in their family to support them that they tended to not disclose to them (Crisma, Bascelli, Paci, & Romito, 2004; Schönbucher et al., 2012).

1.3. Risk and protective factors for IFCSA

In his preconditional classic model, Finkelhor (1984) included factors of both perpetrator and victims’ individual characteristics and social features, incorporating unprotective surroundings and lack of non-offending parents’ presence/supervision, as well as social isolation as variables affecting the risk of CSA. In a recent metanalysis on risk factors and CSA victimization based on 72 studies, some of the strongest risks were attributed to parental problems and prior or concurrent forms of child abuse in the child’s home environment (Assink et al., 2019).

It should be noted that though a considerable body of research has been devoted to identifying familial risk factors for CSA victimization, it is not clear whether the same risk factors apply equally to intra- and extrafamilial sexual abuse, e.g., the absence of the biological father might leave the child at greater risk for abuse by other males, inside and outside of the family (Laaksonen et al., 2011). Yet, in a meta-analysis comparing intra- and extrafamilial CSA offenders it was found that intrafamilial offenders were more likely to have family problems, including histories of maltreatment and poor parent–child attachments than extrafamilial offenders (Seto, Babchishin, Pullman, & McPhail, 2015). In another study, more legal proceedings and histories of domestic violence were found among intrafamilial sexual abuse families as opposed to extrafamilial sexual abuse families (Loinaz, Bigas, & de Sousa, 2019). The current literature does not supply sufficient grounds for examining specific risk factors in the context of COVID-19 and therefore this study relies on the general literature of CSA risk factors.

1.4. COVID-19 and its impact on children and families in the context of child abuse

COVID-19 dramatically impacted many countries worldwide and generated a global health and socio-economic crisis resulting in real and immediate impacts on daily life (Rasmussen & Thompson, 2020). The most common worldwide response created to combat COVID-19 was mandated lockdowns (Nay, 2020). As such, both the disease and associated lockdown response heightened risk factors in already vulnerable populations, including families and children in the context of abuse (Wang, Pan et al., 2020).

Moreover, the lockdowns potentially increased stress for many children and families who were already living in difficult conditions, and created additional harm to the welfare of millions of children worldwide. It was found that for parents who do continue to work, over one-third (35 %) report struggling to handle childcare responsibilities (Pew Research Center, 2020a). It is therefore reasonable to predict that many families who were at risk of IFCSA will be further impacted by the consequences of COVID-19 in that parents’ ability to take care of their children during this time will be hampered given real and potential financial distress, exacerbated mental health issues, loneliness, and lack of support. Evidence from the COVID-19 crisis suggests that children and youth are more likely to be subjected to maltreatment and family violence, while experiencing limited access to the usual services that support them (Collin-Vézina, Brend, & Beeman, 2020). On the other hand, a few studies indicated that families spending more time together because of the lockdown was supportive in some cases. In a study conducted on a sample of 627 married persons surveyed online during COVID-19 the results indicated that 20 % of the sample reported a positive change in relationships with spouses and children (Chin et al., 2020).

Specifically, regarding CSA, economic stress and unemployment, social isolation, and neighborhood-level factors are impacted by COVID-19 and may create a crucial risk for CSA. Yet, it should be taken into consideration that different risk factors can be connected to different forms of child maltreatment. Research on the effects of the pandemic on the lives of children at risk is still in its infancy. Accordingly, future studies are necessary in order to examine the effects of the pandemic on CSA and the general risk factors presented here should be considered carefully.

1.4.1. Economic stress and unemployment

Economic stress and unemployment are central stressors in family lives and often have negative consequences on parents’ abilities to meet their children’s basic needs (Conger & Conger, 2002; Conrad-Hiebner & Byram, 2020). The link between poverty and child maltreatment was discussed by various researchers (Doidge et al., 2017; Slack et al., 2011), wherein food and housing insecurity are observed to contribute to child abuse and neglect (Marcal, 2018; Slack et al., 2011; Wood, Pecker, Russo, Henretig, & Christian, 2012). COVID-19 generated a worldwide economic crisis, with millions of people around the globe suddenly unemployed when restaurants, entertainment, and commercial venues were closed with little notice. Given the tremendous impact that COVID-19 has had on families worldwide there is a substantial risk for many to slide into poverty.

It is crucial to emphasize that not all family economic crises end with parents’ inability to provide children with their basic needs; however, an economic crisis often negatively impacts the parents and entire family wellbeing with financial concerns tending to erode parents’ mental health functioning (McConnell, Breitkreuz, & Savage, 2011). Initial reports suggest that depression is rising immediately following the rapid global spread of COVID-19 (Wang, Pan et al., 2020). Such evidence of mental health challenges is likely to translate into an escalation in the risk for any type of child maltreatment (Rodriguez, Smith, & Silvia, 2016; Stith et al., 2009). Indeed, in a recent study it was revealed that parents who lost their jobs were more depressed, and if they had previously psychologically maltreated their children they were more likely to do so again during the pandemic (Lawson, Piel, & Simon, 2020). Another study conducted in India during COVID-19 found that families with children who were sexually abused prior to the pandemic (mostly from underprivileged sections of society) were having increased difficulties dealing with the aftermath of CSA due to a sudden loss of income and a lack of social support (Unni, 2020).

1.4.2. Social isolation

Adding to increased economic and mental health stressors, forced lockdown has created social isolation for many families. The social isolation generated in response to COVID-19 created a sudden absence of both formal and informal systems from the lives of families. The link between seclusion and child abuse has been repeatedly reported by researchers (Elliott, Cunningham, Linder, Colangelo, & Gross, 2005). In the context of the pandemic, in a paper reviewing clinical and empirical studies on abuse and neglect during epidemics and crises, the authors indicated that children in West Africa during the Ebola virus epidemic from 2014 to 2016 suffered from elevated rates of neglect and sexual abuse while schools were closed (Roje Đapić, Buljan Flander, & Prijatelj, 2020). Examining this concept from a supportive perspective, Priel and Besser (2002) found parents’ ability to access social, emotional, financial and in-kind assistance helped them to care for their children more effectively.

1.4.3. Neighborhood-level factors

Research exploring constructs contributing to children’s safety and risk factors has identified a number of relevant neighborhood-level factors (e.g., Leventhal & Brooks-Gunn, 2000; Ross & Mirowsky, 2009; Sampson, Morenoff, & Gannon-Rowley, 2002). These factors are often characterized as being structure- or process-oriented. Structural traits include factors such as a number of single-parent households, or a number of households living in poverty. Process-oriented constructs include items such as collective efficacy (Sampson & Morenoff, 2004; Sampson, Raudenbush, & Earls, 1997; Sampson, 2003), social capital (Coleman, 1988; Putnam, 2001), and neighborhood cohesion (Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Silk et al., 2004). In addition to having been associated with outcomes such as health (e.g., Browning & Cagney, 2003) and youth development (e.g., Leventhal & Brooks-Gunn, 2004), these constructs have been associated with children’s safety and well-being (for reviews, see Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Maguire-Jack, 2014). Looking at these concepts in the context of CSA, studies have suggested that registered sex offenders are more likely to move into socially disadvantaged neighborhoods (e.g., Wang, Pei, Wu, & Dillard, 2020), specifically neighborhoods with higher levels of social disorganization and lower levels of collective efficacy, which offer anonymity (Socia & Stamatel, 2012). It is not clear yet how COVID-19 would relate to these neighborhood-level factors in the context of IFCSA.

1.5. Child protection in the context of COVID-19

COVID-19 and its lockdown response stress the need to look at potential effects on child protection, in both structural and process-oriented constructs. Child protection in the context of a global crisis such as COVID-19 involves the “prevention of and response to abuse, neglect, exploitation and violence against children” (Impacts of Pandemics and Epidemics on Child Protection Lessons Learned from a Rapid Review in the Context of COVID-19, 2020). Child protection services provide support and care for both children and parents in routine times, however, COVID-19 generated an unforeseen enormous challenge to accepted protocols for systems and practitioners worldwide. During COVID-19 various countries have reported on their attempts to innovate quickly (ISPCAN web resources), however, no one knows for certain what can best support children and families given the heretofore never encountered risks and restrictions.

Adding to this, child abuse reports worldwide may decrease during COVID-19, as systems shutdowns result in the inability of schools and other individuals who often unmask child abuse to safely see children and families and assess risks (De Cao & Sandner, 2020). Data from international conflicts and disasters have in fact suggested a paradoxical decrease in child protection reporting rates, possibly due to one or a combination of stresses on frontline child protection workers, the child protection reporting system and physical (e.g. telecommunication) infrastructure issues (SS Teo & Griffiths, 2020). Active steps by child protection services are necessary during COVID-19 in order to overcome the lockdown consequences for children (Katz, 2020).

1.6. The current study

Pandemics such as COVID-19 damage the environment in which children live, therefore increasing their susceptibility to abuse, neglect, violence, exploitation, psychological distress and impaired development (NCA Engage, 2020). Studies concerning the effects of the pandemic on abused children and adolescents worldwide are at initial stages. Exploring the way practitioners from both Israel and the US perceive and experience IFCSA in the context of COVID-19 is of interest given several dissimilarities between the two countries. The first difference relates to the family structure, which in the Israeli agency participating in this study is characterized with a higher percentage of biological parents than in the US agencies which have a higher percentage of families with step or adopted children. Additionally, in Israel, the most common out-of-home placement is residential care (74 %) as opposed to foster care that is more common in other Western countries (Kosher, Montserrat, Attar-Schwartz, Casas, & Zeira, 2018).

Furthermore, in Israel in recent years there have been massive governmental efforts to actively reduce the number of out-of-home placements, stretching the ability of the child protective service (CPS) to protect those children in the community, support the families and avoid out-of-home placements (Kosher et al., 2018; Zemach-Marom, Halavan-Eilat, & Sabo-Lael, 2012). Along with these efforts, an Exemption Committee review is now routinely used in CPS cases, particularly in cases of sibling sexual abuse and cases with strong cultural elements. The Exemption Committee, comprised of a senior representative of the State Prosecutor’s Office, a police officer, and a district-level Child Protection Officer, can allow a temporary exemption from reporting CSA to the police and make a referral instead for theraputic intervention, permitting victims, the child with PSB, and families to receive community services while avoiding legal process. In a previous study comparing the responses of two US and Israeli CAC’s to cases of sibling sexual abuse, it was found that the Israeli CAC team tended to use the Exemption Committee frequently in order to provide the family therapeutic rather than legal interventions. The US CAC team did not have an Exemption Committee alternative and thus emphasized the needs of the victim while following legal procedures (Tener, Newman, Yates, & Tarshish, 2020).

Thus, the current study was designed to examine the impact of COVID-19 on IFCSA and to compare Israel and US responses by analyzing perceptions of professionals intervening with IFCSA cases. The following questions were addressed: (1) How did COVID-19 affect the dynamics of IFCSA families (already known to authorities) and intervention by those authorities? (2) how did characteristics and interventions of cases of IFCSA disclosed during COVID-19 differ from those cases disclosed prior to the pandemic? (3) how will COVID-19 affect reporting of IFCSA as well as future intervention with these families? The need to enhance the development of both a conceptual and an empirical framework for the understudied domain of IFCSA during COVID-19 was the rationale for the qualitative approach used in the current research.

2. Method

2.1. Sample

Data collection consisted of two groups, Israeli participants and participants from the United States. The research team developed an open-ended questionnaire in Hebrew for the Israeli participants and in English for the US participants, guided by the key research questions which were marked from exploration.

The US sample consisted of 37 professionals, 32 (86.8 %) women and 5 males (13.2 %), all of whom had experience in the field of CSA. The participants’ ages ranged from 25 to 73 years of age (m = 43.5, sd = 39). There was a wide range of experience in the field of CSA of the respondents, ranging between less than one year to 32 years (m = 11.67, sd = 9.5) of experience. Participants’ professions were divided into three sectors: 21.7 % therapeutic (clinical social workers, family therapists, psychologists, counselors, etc.); 64.9 % child welfare (social work caseworkers, family advocate, outreach professional, etc.); and 13.5 % legal (law enforcement, forensic interviewer, attorney, etc.).

The Israeli sample consisted of 23 professionals, 17 (73.9 %) women and 6 males (26.1 %), all of whom also had experience in the field of child sexual abuse. The Israeli participants’ ages ranged from 27 to 67 years of age (m = 40.52, md = 38), with experience ranging between one to 15 years (m = 6.9, md = 6.5). The professions of the participants were divided into two sectors: 65.2 % therapeutic (clinical social workers, therapists, professional counselors, etc.); and 34.8 % child welfare (social work caseworkers, family advocates, etc.)

2.2. Procedure

The questionnaire was developed in order to assess the professionals’ opinions and experiences regarding the challenges and changes of the IFCSA families’ dynamics during COVID-19 and their interactions with those families. The questionnaire was composed of open-ended questions as well as demographic and professional data. Respondents replied to the questionnaire during the month of May, 2020, and was distributed to participants via internet in both countries using online resources such as Facebook and WhatsApp, and professional mailing lists. Written explanation on the study was provided and after participants signed informed consent they were transferred to the questionnaire.

Approximately 10 % of US participants were from areas where the lockdown at its most severe asked communities to stay ‘safer at home.’ The majority of US participants were under ‘shelter at home’ mandates which varied from 1 to 3 months’ time, unless they were considered essential personnel. Law enforcement and CPS team members were always considered ‘essential’ personnel, while CAC staff designation varied based on the severity of the case. At the same time, similar to most of the US respondents, the Israel participants where under quarantine, and were required to stay and work at home. Contrary to the US, in Israel most of the CPS and therapeutic teams were not defined as essential workers and therefore the majority of them were not allowed to work during the forced quarantine between mid-March to April 19, only then they were redefined as essential workers. The work from home was done through web-based technology, and in most cases children and families were not seen in person.

The questions in the questionnaire were divided into ‘past,’ ‘present,’ and ‘future’ sections. ‘Past’ questions focused on the professionals’ work with families that started before COVID-19 and continued during the pandemic. ‘Present’ questions asked information about working with families in which IFCSA was discovered during the COVID-19 outbreak. Future questions focused on the possible consequences of COVID-19 on cases of IFCSA. Questions focused on professionals’ perceptions of the dynamics of IFCSA during COVID-19 (e.g., What are the challenges IFCSA families are facing during Covid-19?) as well as on changes in professional interventions with IFCSA families during COVID-19 (e.g., What changes have occurred to your intervention regarding the family you have been involved with pre- and post- Covid?).

2.3. Data analysis

The data analysis in the current study was guided by a thematic analysis approach (Braun & Clarke, 2006) in order to analyze the narratives that were yielded from the questionnaires in both countries. This included several interrelated stages. Before beginning the analysis, the researchers read the data several times in order for the authors to become familiar with the data and to identify initial themes. In the next stage, we divided the data into three sections following the questionnaire: past, present, and future. Open coding was then performed to elicit initial categories (for every section) and the answer were broken down into “units of meaning,” with each unit labeled according to its content.

In the next stage, the codes were grouped together as initial themes. As the authors read the data again, some of the themes were removed or changed and additional codes and categories were added. For example, several codes were defined as 'positive outcomes of COVID-19' and 'negative outcomes of COVID-19' but after consideration became 'outcomes' that consisted of both sides as the findings were noted to actually be more nuanced. In addition, the division into 'past', 'present' and 'future' were united and themes were created that combined the data. In the third stage, the themes and subthemes were reviewed and classified by their dimensions and properties (Corbin & Strauss, 2008). For example, all the various changes in responses of professionals were merged and separated from all other topics and grouped together. During this stage, the researchers repeatedly read the answers in order to unearth additional data that could further develop the categories (Maykut & Morehouse, 1994).

Finally, in the fourth stage, themes were refined, named, and interrelationships between them were suggested (Braun & Clarke, 2006). The first stage of analysis was performed by the first and second author; a researcher and lecturer in social work specializing in child sexual abuse and qualitative research methods, and a doctoral student in social work specializing in child sexual abuse and practitioner in the field of IFCSA. These researchers speak both languages and they translated the Hebrew quotes to English in order for the other researchers to be able to join the data analysis. All authors took part in the last stages of the analysis.

Selected excerpts from the source materials were discussed throughout in several peer-debriefing sessions. In further stages the analysis was shared and discussed with all other authors, and changes were made according to their comments. Every question was resolved with a mutual discussion of all authors until agreement was achieved. The entire analysis process was accompanied by reflexive writing by the authors on their ideas, perceptions, thoughts and feelings as they evolved (Cope, 2014; Nowell, Norris, White, & Moules, 2017). In order to ensure trustworthiness, detailed documentation was performed: raw data excerpts were attached to all interpretations and peer debriefing was documented in writing (Bowen, 2009).

2.4. Ethical considerations

The study was approved by the ethics committees of the Hebrew University of Jerusalem. Participants’ informed consent was obtained before anonymously responding to the questionnaire. All possible identifying details of respondents were deleted and removed from the dataset before analysis.

3. Findings

The two main themes that emerged during analysis related to (1) professionals’ perceptions of the dynamics of intrafamilial child sexual abuse (IFCSA) during COVID-19, including mostly negative but some positive changes between family members and; (2) changes in professional interventions with IFCSA families during COVID-19, relating to both the reporting of abuse and therapeutic interventions. The results do not draw specific comparisons between the cultural contexts, unless specifically noted, as much of what was shared was similar across both groups of participants. It is important to emphasize that the framing of the study was on issues of IFCSA. All the questions asked about the implications and changes in the work were all under the heading of IFCSA; even if an answer was not directly related to the issue it was given as a response to a question regarding IFCSA.

3.1. IFCSA families’ dynamics during COVID-19

When asked about the dynamics encountered with families experiencing IFCSA, and the way COVID-19 affected those families, professionals mainly focused on the negative dynamics, which were at times extreme, and the consequences of COVID-19 and its restrictions on families. They described 2 dimensions of stressors/difficulties: global stressors and internal family stressors. The global aspects included financial and environmental stressors that were recognized by professionals in both countries but were emphasized more by US professionals, as explained in the quote:

Families are facing increased financial and environment stressors and many are experiencing extreme stress related to job loss, food insecurity, access to healthcare, lack of child care, isolation, (and) fear related to personal and relational safety. (US)

Professionals further detected the loss of interpersonal contacts with both informal figures (such as extended family members and friends) as well as formal figures (such as educators, therapists, and other adults trained to recognize and report abuse) as another cause of increased stress in IFCSA families. This additional stressor was aptly illustrated by one of the US professionals:

Since COVID-19, the families are stuck at home for the most part, together much more than usual. Parents working as usual, or working from home, but now having their child at home doing limited on-line school work they may need help with, and no access to sports, playgrounds, or any of the typical activities their children are usually involved in, and feeling agitated with their limitations and with each other more often than usual. The extended support systems are mostly cut off trying to not spread the virus to grandparents who are typically very involved in childcare. (US)

Another professional observed that:

Child victims are isolated from typical reporting or monitoring sources like teachers, counselors, after school programs. (US)

The second stressor related to internal family aspects. Professionals in both countries expounded upon how the emotional conditions of parents and children added another level of hardship, and pointed to harsh feelings felt by both, including anxiety, anger, frustration, anger, depression, and helplessness. This point was emphasized by an Israeli professional when describing the emotional state of one family where sibling sexual abuse had occurred by stating: “The house is like a pressure cooker and they feel like they are losing control.” The range of negative mental states was revealed by a US professional who emphasized how often extreme feelings after IFCSA were becoming even worse during COVID-19:

There is evidence of extreme anger, confusion, blame, feelings of guilt and shame. Added to these, because of COVID-19… are feelings of isolation, loneliness, self- deprecation, and suicidal ideation is advanced. (US)

Another internal family aspect that emerged that was of major concern raised by professionals was the victim feeling trapped with their abuser. The constant sharing of living space by both perpetrating adult family members as well as siblings with inappropriate sexual behavior and the children they abuse, increased the chances for further abuse of the abused children. As described by one of the US professionals, “children are trapped with their abusers,” and “perpetrators (language of the participants) residing in the child's home have more opportunity and time with the victim child”.

Maintaining safety plans in cases of siblings with problematic sexual behavior (PSB) was noted to be more difficult during COVID-19 isolation. An example of this difficulty was described by one of the professionals:

There are homes where not all siblings are in the routine (of sleeping in the home during the week if they are at boarding schools) and sleeping arrangements are different between midweek and weekends - for example a child sleeping in the living room (when home for the weekend), and now that all the family and parents are at home 24/7, it is not possible (for them to be separated). (Israel)

Israeli professionals also observed conflicts between the parents and the sibling with PSB. One of the survey participants, a therapist specializing in treatment of siblings with PSB, stated:

The family spends a lot of time together, there is a feeling of lack of air… there are not enough resources to address the different needs of the household members. The ability to hold back frustration is low and the reactions are very extreme. It seems that the parents who are sometimes able to contain the perpetrating sibling are now "blasting" the harsh statements, blaming loudly, even on past events. In one family, they even wanted to "settle the score" [against the child with PSB] and call police because of a violent incident against animals conducted by the offending sibling, but the feeling actually was that this was an opportunity to punish him for the abuse he conducted. (Israel)

Both the American and the Israeli professionals saw many more challenges and problems caused for the families during COVID-19, and perceived the COVID-19 period as a risk for the parents and children’s mental health as well as an opportunity for further abuse to occur. When asked in the interviews whether the COVID-19 period will produce more challenges or resilience for families, the most common answer for both Israeli and American participants was “Definitely more challenges.” Yet the shared limited space was also perceived by some professionals in both countries as an opportunity for the formation of familial protective factors. As one of the Israeli participants explained this opportunity:

The truth was that I thought the situation would only be bad and bitter but it turns out that there are good parts too. (Israel)

The positive aspects described by professionals were connected to the fact that families were together all the time sharing the same space, and thus had the chance to spend more time together. Thus, while close sharing of the same space was a stress factor for some of the families, in others it helped to create better relationships and more meaningful discourse between parents and children:

In all families, there seems to have been a turnaround regarding the focus being on the home and the parents feeling more emotionally available to the family atmosphere itself. Attention to details increased and pleasantness and containment. Towards the return to school, regression was observed and increased general anxiety at home. (Israel)

One of the professionals analyzed the dynamics between a father and his 16-year-old son who previously sexually abused his sister. During COVID-19 the son was returned from the boarding school:

The first two weeks were very tensioned and the boy almost completely broke off, locked himself in his room and was in great distress. Then there was a surprising adjustment that began from the lack of choice, and even close conversations took place between the boy and his father - which has not been for at least two years […] as for the abused sister, most of the time there was no connection with her brother, who keeps his distance to allow her to feel safe. However, here too, there were a number of positive interactions - for example, a game that he did for all the little siblings (including the sister), which created a renewed connection. (Israel)

Finally, one of the US professionals recognized that positive and negative aspects should not be seen as separated from one another:

I don't think the issue of challenges and resilience can be listed as either/or. Some children and families will benefit from increased time together. Others will not. Some children are thriving because they no longer deal with bullying at and other stressors at school. Others won't because they are exposed to parental stress and all the tensions of the household -- and have little relief (as they would when attending school or visiting relatives). The situation is likely to exacerbate psychiatric symptoms. This can also go either way. Some individuals will realize that they can "handle" things on their own. Others may see it as further evidence of their "weakness" or vulnerability. (US)

Though both Israeli and US professionals shared an understanding concerning potential differences in IFCSA dynamics during COVID-19, it is important to note that some of the participants in both countries stressed that their understanding of changes in the dynamics are limited because of the limited contact with the families. They stressed that such knowledge will be achieved after the contact is renewed post-COVID-19:

The biggest challenge has been reaching (victims) who are currently being abused given social isolation. I don't think we are really going to see the impact COVID-19 has had on child sexual abuse until the victims can interact with others outside of their family unit. (US)

3.2. Professional interventions with IFCSA families during COVID

Two themes emerged related to professional responses to IFCSA in families during COVID-19: (1) reporting abuse and (2) therapeutic interventions for those families with IFCSA which were treated before the COVID-19 pandemic.

In terms or reporting child maltreatment, professionals in both countries (but more evident with the US participants) were extremely concerned by the lack of opportunity to report the abuse:

Families are self-quarantining often with the perpetrator. Children have little to no contact with mandated reporters. Courts have been shut down for about a month. Cases in the pipeline haven't been heard. Only the most serious known cases/ reports are being addressed. (US)

Undetected child maltreatment during COVID-19 was further illustrated by one US professional who stated:

I feel like there are a lot of victimized children going under the radar at the moment and as a professional I feel helpless. I can only interview children who come to the agency and want to talk to me about the abuse. Less and less children can be with mandated reporters who can possibly open up a case. These children are home alone with not a lot of trusted adults or people they can speak with. (US)

The harsh feeling that there are many more children who are injured in their homes but the professionals now have no way to reach them is reflected in the words of the next professional from the US:

Very frustrating to me & our deeply dedicated Team! We know there are abundant cases of child sexual & physical abuse that are NOT BEING REPORTED! This is disturbing to us all! (form of writing as originally written)

A surge in reports of IFCSA was predicted after the COVID-19 period ends by professionals in both countries. As explained by the following US professional:

School is out and will be out until maybe September. Many of our reports come from mandated reporters in schools. Camps/ pools/ kid friendly summer programs won't operate either this summer. But when schools do open back up I believe there will be an avalanche of reports coming in. (US)

In terms of the impact of COVID-19 on therapeutic interventions with families, most of the Israeli professionals and some of the US professionals depicted a shift in therapeutic interventions with IFCSA families and children. The focus of intervention was shifted from the abuse as the focus to family maintenance/stabilization as the focus. The Israeli professionals often used the term “holding” the families, describing the need to help these families in their activities of daily living and daily survival during COVID-19, as explained by one of the Israeli professionals:

Before the COVID we were busy processing the abuse, its implications for the dynamics between the boy and his parents, and how that is reflected in the interactions and relationships with them today. These processes have largely been halted, and the nature of the intervention during this period has become more of holding – focusing on the family's daily routine, anxieties, financial worries, etc. - and it is more difficult to conduct an online treatment with direct discourse about the abuse. (Israel)

This sentiment was closely echoed in the US:

I have been more focused on stabilization and helping the families form a routine due to changes in their daily lives as a result of the pandemic. (US)

Israeli professionals talked about how the professional interventions with families and children switched to internet based or telephone communication. The professionals talked about the complexity in this type of communication, with difficulties manifested in the technical aspects (such as frequent disconnections in the conversations) and the emotional aspects (such as difficulty in containing emotional complexity through this kind of communication). Cultural difficulties have also been added to this, as ultra-Orthodox families in Israel who have been in treatment do not use internet communication due to religious restrictions. One Israeli professional illuminated how it was difficult to create space for separation between the clinic and home:

It should be taken into account that the boy is conducting the call from his home, as opposed to regular treatment where there is processing time on the way to the meeting, and afterwards. In online meetings if the patient exits flooded or disturbed, his family members are outside the door. (Israel)

The issue of lack of proper separate space for therapy was further discussed by a US professional, working with younger children using web-based video:

I have little to no control of the environment on their end. I cannot ensure privacy or minimize distractions or triggers on their end. I had often incorporated play, movement, art, music, role-play, games […] We had routines of how the session would go. […] Often a ritual of leaving it in my office. This work was something they would pick up and work on with me each week, and then put away (often symbolically in my office). Now, I have not figured out how to do what I was doing in this new way […] We're primarily trying to do a talk therapy version of what I would normally do with clients. It's not as engaging, and they are not as engaged- especially the younger ones. The closing rituals have been more of closure to this time, and leaving this work in the space between us?? They can't leave it in my office now. We are doing this work in their safe place at home […]

As expressed by the same professional, age of the child also played a role in the difficulty of using web-based therapy:

Children 8 and under I'm requiring a parent or guardian to stay with us. They've lost their private session with me. But I need someone to be physically present with them to help them stay present and do work. Older kids I would typically include parent at the beginning or end of their sessions. Now most parents are not available, and I'm doing most of my communications with them through email. (US)

Positive aspects for therapy were also described such as conducting the intervention in the natural space of the child and family, and being able to conduct a home visitation online. One Israeli professional described how the online communication improved therapy sessions when these were renewed in Israel:

Something was opened with him, and he could share photos and videos of his life and there was also correspondence by email. Something at the time when he did not meet with me sharpened the quality of his meeting at the clinic and made him more devoted to it when he was back to the physical meetings. (Israel)

The complexity of online communication with its positive and negative sides was illustrated by one of the participants:

With most boys, the response to the video format was initially positive but after a while the video seemed to be short of containing the range of emotions. The benefits were the comfort and availability of the sessions, the flexibility of the times, the look into the boy's private room and life. Cons, improvised and unstable setting, difficulties in understanding the audio and cuts in the network. In my opinion if there was a pre-organization without the crisis for the zoom treatment and the therapeutic contract was formulated to create a setting on the Internet it would have worked better. (Israel)

The devotion of professionals in trying to adjust to the new and rapid change in reality was emphasized by the following US participant:

Sometimes it feels like just taking it each day and addressing new issues or concerns beyond the normal role of intervention/treatment for sexual abuse. This includes constantly thinking outside the box for new ideas of how to help families. (US)

Some professionals in both countries, when asked about whether COVID will change future interventions with IFCSA, show the online therapeutic communication as an opportunity for families to be more engaged with therapy, as clarified by a US professional:

I don't think things will "go back to normal." There are some things that may change moving forward as a result of people realizing we can accomplish what needs to be done in other ways. Several of my contacts in the field report increased participation in tele-health appointments because caretakers have time and it eliminates previous barriers such as lack of transportation. (US)

Professionals in the US discussed how COVID-19 will specifically affect the way forensic interviews will be conducted:

Learning how to perform tele-forensic interviews in the best way possible according to protocol and best practices. I believe learning this new skill will be helpful in the future to bring forensic interviews to children who would not have access to them if it was not done over a virtual setting. For example, children in very rural settings (US).

Finally, a US participant was reflecting on the benefits such experience can make on his professional capacities:

I think we are being very resourceful and learning new ways to function. It's like exercising a new muscle. Uncomfortable at first but ultimately will make you a better person. (US)

4. Discussion

Intrafamilial child sexual abuse (IFCSA) by definition occurs within the family unit. World events, such as the COVID-19 pandemic, directly impacts the social context, structure, and access families have to supports, increasing risk and decreasing protective factors. Further, such a global pandemic has implications for IFCSA including identification, reporting, response, and intervention. Insights into how this current pandemic and related governmental responses have influenced IFCSA are captured through the stories of professionals in Israel and the US. Professionals’ opinions and stories were collected via responses to an online questionnaire, asking them to reflect on the past, describe the present, and anticipate the future in working with families to address IFCSA. Themes shared by these professionals’ address factors related to increased risk related to family stress, barriers to detecting and reporting IFCSA, strategies used in assessment and investigation, and changes to the therapeutic process and context with families.

The stigmatizing, secluded, and secretive nature of IFCSA has historically hindered the process of early identification and response by complicating children’s disclosure. Results from these interviews heighten these concerns. With COVID-19 lockdown or similar (e.g., safer-at-home) policies, families experience greater isolation and reduced ability to access both informal and formal support systems. Significantly, greater presence of these risk factors due to COVID-19 was prevalent in the results from the current study. Concerns about the potential rippling impact of unemployment and economic stressors on the mental health and well-being of the caregivers and children were notable. Without essential supports for healthy responses, increased rates of depression, suicide, aggression, alcoholism, drug abuse, and other mental health concerns rise for the caregivers and their children. Concerted efforts by the government and community to develop and implement a safety net of protective factors are needed to reduce these risks. Economic provisions (e.g., stipends, disallowing evictions, access to food and utilities), access to health and mental healthcare, and facilitating social collections with others (even virtually) could reduce the swelling of negative impact overall and on rates of IFCSA due to COVID-19.

Moreover, the current study pointed to an important additional risk factor to children and families during COVID-19, which is the clear lack of availability of children to other significant adult figures in their lives. Protection of children from IFCSA often occurs through detection by and disclosure to others in the children’s lives. Traditional trusted adults, such as teachers and neighbors, who facilitate the process of identifying CSA have limited or no contact with the children during COVID-19. Without access to social networks, IFCSA was perceived to be growing in the Petri dish of COVID-19, in a manner that will last undetected for a longer time period. Professionals in the current study expressed concern that they were not receiving as many reports of child abuse as was typical, and they predicted a deluge of reports once children were back in contact with professionals, schools, and other activities. This expectation of the professionals deserves further examination as only time will tell the impact of COVID-19 on the reporting of IFCSA.

Resources necessary to respond if anticipated increased reports of child sexual abuse are reported may be compromised due to COVID-19. Forensic interviews are a core component of investigations of child sexual abuse (Lamb, Hershkowitz, Orbach, & Esplin, 2011); those who provide forensic interviews are trained in a specific interview style that is meant to obtain disclosure if abuse occurred and details about the abuse are inquired about in an open-ended, non-leading style. Of course, forensic interviews during COVID-19 are challenged by needs for social distancing and remote procedures for health and safety. Opening up to a stranger (i.e., the forensic interviewer) about such a sensitive and secretive topic is already difficult for children. Adding on the need to manage this through a tele-platform or with someone wearing a mask may further hinder the process of accurately assessing the child’s history as well as related risk and protective factors. As efforts to provide guidance for forensic interviews during COVID-19 (e.g., NCA Engage, 2020) are disseminated, parallel gathering of data to evaluate these new procedures is critical.

The application of technology to health and behavioral health services is not new and has a history of success, yet the COVID-19 pandemic has highlighted challenges and positive next steps in this arena. The rapid, widespread implementation of telehealth initially may have hindered the process of engaging families and ongoing therapeutic services. Notably, psychotherapy requires a foundation of trust and privacy, which was stated to be challenging to consistently develop and maintain via the telehealth platform. This may be especially true for therapists who have never utilized telehealth services prior to the pandemic. Many mental health professionals will likely need to gain a new skill set, access to telehealth-related therapeutic resources (e.g., therapeutic games), and planning time needed to successful engaging families and particularly young children. Further, telehealth services require family and provider access to technology (e.g., tablets, Wi-Fi, data), which are not available to all families or in every community. For instance, the Ultra-Orthodox (or Haredi) society represents 12 % of Israel’s population (Cahaner, Malach, & Choshen, 2018). From this group only 54 % of adults over the age of 20 have used computers in recent years compared to an average of over 80 % in the general population, and only 43 % had used the internet compared to 88 % overall (Malach & Cahaner, 2018). Yet despite these challenges, several participants noted that the widespread implementation of telehealth services actually improved engagement in therapy services for some families, making it easier to attend services. In addition, therapists are now afforded a concrete view into the homes of their clients, which ideally will allow them to tailor therapeutic interventions and homework assignments better.

Although the study includes several strengths, limitations warrant comment. First, the samples from the US and Israel did differ in participant size and composition. Notably, a greater proportion of the Israeli group were from therapeutic professions, while the US had a larger percentage of child welfare professionals. As such, it is likely that the participants’ responses cross-culturally may also be related to cross-professional differences. Further research on this topic, with keyed focus on specific professions is warranted. Second, the survey was provided electronically. Although electronic surveys are efficient ways to obtain information, they also can experience a low response rate. As such, the results are limited to those who self-selected into the study, and their experiences may differ from those who did not complete the survey. However, due to our recruitment strategy, we are unable to indicate how many individuals received the survey but declined to participate. Further, due to the small sample size we could not address ethnoreligious and cultural components which may affect dynamics and interventions during COVID-19 (e.g., lack of access to Internet in secluded religious groups).

4.1. Conclusions and recommendations

The COVID-19 pandemic has brought about concerns regarding consequences and impact on IFCSA. These consequences, both positive and negative, have emphasized the importance of the provision of adequate socioemotional and concrete, tangible supports for families. Policies should continue to support the basic needs of families with IFCSA. Future study on this topic should continue to weigh the costs and benefits of utilizing telehealth and tele-forensic/adapted interview services when in-person services are unavailable. In light of the findings, this study will form the basis for further research that examines how agencies handle resources if the potential for a deluge of reports once school reopens becomes a reality. Further, the impact of social isolation and economic stress should continue to be evaluated as the pandemic continues.