Caring For Child Survivors Of Sexual Abuse

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Caring for Child Survivorsof Sexual AbuseGuidelines for health and psychosocial serviceproviders in humanitarian settingsFirst Edition

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesCover Photo: UNICEF/Jill Connelly/Democratic Republic of the Congo, 2010 2012 by International Rescue CommitteeAll rights reserved.International Rescue CommitteeAgency Headquarters122 East 42nd StreetNew York, NY 10168U.S.A. 1 212 551 3000www.Rescue.orgFor more information about the Caring for Child Survivor’s Resources please contactthe IRC Women’s Protection and Empowerment Technical Unit at To download the CCS Guidelines electronically, please go to publication was funded in part by the Bill & Melinda Gates Foundation and the U.S.Department of State’s Bureau of Population, Refugees, and Migration (PRM). The findingsand conclusions contained within are those of the authors and do not necessarily reflectpositions or policies of our funders.

CARING FOR CHILD SURVIVORSOf Sexual Abuse GuidelinesAcknowledgementsThe Caring for Child Survivors (CCS) of Sexual Abuse Guidelines were developed to respond tothe gap in global guidance for health and psychosocial staff providing care and treatment to childsurvivors of sexual abuse in humanitarian setting. The CCS Guidelines are based on global researchand evidenced-based field practice, and bring a much-needed fresh and practical approach to helping child survivors, and their families, recover and heal from the oftentimes devastating impacts ofsexual abuse.On behalf of the IRC, I would like to extend a special word of appreciation to the U.S. Department ofState’s Bureau of Population, Refugees and Migration, the Bill & Melinda Gates Foundation and theUnited Nations Children’s Fund (UNICEF) for making the development of these guidelines possible.This generous support has allowed the IRC to develop a child-centered model of care and accompanying guidelines to support humanitarian field staff caring for child survivors of sexual abuse. I wouldlike to also recognize UNICEF for their role as technical partners in the CCS Initiative.I would like to extend a special thank you to Abigail Erikson, the principal author of these guidelines.Abigail’s extraordinary commitment, expertise and energy have been central to this effort and weare deeply grateful to all of her hard work. I would also like to thank members of the CCS Technicalreview panel. This panel of gender-based violence (GBV) and child protection experts were instrumental in ensuring the guidelines are rooted in best practice and global standards. Deep appreciationand thanks go to the following IRC experts: Laura Boone, Senior Technical Advisor, Child Protection;Eduardo Garcia Rolland, Technical Advisor, Child Protection; Dhammika Perera, Senior TechnicalAdvisor, Reproductive Health; Karin Wachter, Senior Technical Advisor, Women’s Protection andEmpowerment; Janel Smith, Clinical Care for Sexual Assault Survivors Specialist, and Eve Puffer,Technical Advisor, Research, Evaluation and Learning. In addition, Mendy Marsh, GBV EmergencySpecialist, UNICEF and Chen Reis, Clinical Associate Professor and Director of the HumanitarianAssistance Program at the University of Denver, provided key technical input and technical advice.A very special thank you goes to the IRC Women’s Protection and Empowerment Team in Thailandand the Community Wellbeing Initiative and Child Protection Teams in Ethiopia. The time and effortmade available by the IRC Field teams to pilot test the CCS tools and resources has been invaluableto the successful development of the CCS guidelines.We hope these guidelines will benefit child survivors in humanitarian settings throughout the world,as well as the individuals who help to provide for their care and treatment.Thank you,Heidi LehmannDirector, Women’s Protection and empowerment Technical unitInternational Rescue CommitteeCCS Guidelines Page 1

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesTable of ContentsIntroduction4Overview of the Caring for Child Survivors (CCS) ResourcesCCS Theory of ChangeUsing the CCS GuidelinesGlossary of TermsChapter One: Core Child Sexual Abuse Knowledge Competencies21Core Child Sexual Abuse Knowledge Competency AreasGuidelines for Assessing and Monitoring Core Knowledge CompetenciesChapter Two: Core Child-Friendly Attitude Competencies51Core Child-Friendly Attitude Competency AreasGuidelines for Assessing and Monitoring Core Attitude CompetenciesChapter Three: Core Skills: Engaging and Communicating withChild Survivors59Developing a Helping Relationship through Safe and Healing Communication StrategiesBest Practices for Communicating with Child SurvivorsGuidelines for Communicating with Children about their Experience of Sexual AbuseAddressing Common Communication ChallengesGuidelines for Assessing and Monitoring Core Communication Skill CompetenciesChapter Four: Guiding Principles and Key Issues87Guiding Principles for Working with Child Survivors of Sexual AbuseCaring for Child Survivors Key IssuesIssue 1: Mandatory Reporting RequirementsIssue 2: Confidentiality Protocols in Child CasesIssue 3: Ensuring the Best Interest of the Child: Balancing Roles in Decision-MakingChapter Five: Case Management for Child SurvivorsIntroduction to Case ManagementSteps of Case Management for Child Survivors of Sexual AbuseStep 1: Introduction and EngagementStep 2: Intake and AssessmentStep 3: Develop Case Goals and Action PlanStep 4: Implement the Case Action PlanStep 5: Case Follow-up and Monitoring ProgressStep 6: Case Closure and Evaluating ServiceStep 7: Service EvaluationPage 2 International Rescue Committee105

CARING FOR CHILD SURVIVORSOf Sexual Abuse GuidelinesChapter Six: Psychosocial Interventions for Child Survivors187Integrating Psychosocial Interventions into a Child and Family’s Care and TreatmentAssessing the Psychosocial Needs of Child SurvivorsGuidelines for Implementing Core Psychosocial InterventionsChapter Seven: Best Practices for Case Coordinationbetween Service Providers231Best Practice in Coordinating Child Case ResponseFinal Note to the Reader239CCS ToolsPlease note: related staff monitoring tools and/or sample case management forms areincluded at the end of each chapter. A list of the CCS tools and relevant page numbers areincluded below.CCS Knowledge Assessment Tool (CCS-KA)CCS Attitude ScaleCCS Communication Assessment Tool (CCS-CA)Child Needs Assessment and Case Action PlanChild Case Follow-Up FormChild Case Closure FormChild Client Satisfaction QuestionnaireCCS Case Management Skills Assessment Tool (CCS-CMA)CCS Case Management ChecklistChild and Family Psychosocial Needs Assessment Tool455783170172174175180183225Tools and other reference documents not specific to a particular chapter are includedat the end of the guidelines.Minimum Standards for Case ManagementGBVIMS Intake and Assessment Form240241CCS Guidelines Page 3

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesIntroductionOverview of the Caringfor Child Survivors (CCS)ResourcesGoalThe ultimate goal of theCaring for Child SurvivorsResources is to enableand empower staff inhumanitarian aid contexts to provide highquality care to childrenand families affected bysexual abuse.The International Rescue Committee (IRC), in partnership with the U.S.Department of State, the United Nations Children’s Fund (UNICEF) andthe Bill & Melinda Gates Foundation have dedicated resources towarddeveloping a program model of care1 and guidelines for implementing themodel of care for child survivors of sexual abuse across humanitarian settings. The purpose of developing these resources is to provide guidanceon how to:»» Build the capacity of health and psychosocial service providers on thefoundational (or “core”) knowledge, attitudes and skills to work withchild survivors of sexual abuse.»» Adapt case management for child survivors.»» Implement targeted psychosocial interventions.»» Improve coordinated care across multiple sectors and service providers.»» Monitor the quality of service provision.1Page 4 International Rescue CommitteeThe CCS Program Model is also referred to as the CCS Theory of Change. This references the logical framework developed to help child survivors recover and heal fromsexual abuse.

CARING FOR CHILD SURVIVORSOf Sexual Abuse GuidelinesThe Caring for Child Survivors (CCS) Resource Package is based on global research on childsexual abuse and evidence from field practice. The CCS Resource Package brings a muchneeded comprehensive and practical approach to helping child survivors and their familiesrecover and heal from the impacts of sexual abuse. The three main components are:»» Literature Review: An in-depth literature review of available evidence and promising practice to improve case management, psychosocial care, and clinical care for child survivorsof sexual abuse.2»» CCS Program Model: The logical model or “theory of change” that outlines the servicedelivery components necessary to help children recover and heal from sexual abuse.»» CCS Guidelines: The CCS Guidelines (this document) provide step-by-step guidance onhow to implement the main aspects of the CCS Program Model. The CCS Guidelines isthe “how-to” guide for instructing health and psychosocial field staff responding to children who have experienced sexual abuse. The CCS Guidelines include multiple tools formonitoring and evaluating the program model, such as: knowledge and skills competencyassessments and case management monitoring and evaluation tools.CCS Theory of Change andIntended OutcomesThe technical guidance outlined in this document comes from the CCS program model or“theory of change” outlined on the next page. The CCS theory of change posits that childrencan be supported in their recovery and healing from sexual abuse with child-specific, compassionate and appropriate care and treatment. The theory of change outlines the key elementsof care and treatment and the knowledge, skills and attitudes required for health and psychosocial service providers to be able to provide such care.2The CCS literature review is titled: Advancing the Field, Caring for Child Survivors of Sexual Abuse in Humanitarian Settings. A Review of Promising Practices to Improve Case Management, Psychosocial & Mental HealthInterventions, and Clinical Care for Child Survivors of Sexual Abuse. May 2010CCS Guidelines Page 5

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesCCS Theory of ChangeKey Elements of Care for Child Survivors of Sexual AbuseChild Survivors have Access to Child Centered CaseManagement ServicesCaseworkers have the knowledge, skills, attitudes and tools to provide childcentered case management.»» Understand and able to apply child sexual »» Understand and able to apply CCSabuse concepts in case management.Guiding Principles in case management.»» Possess child-friendly attitudes that»» Able to use child-friendly tools to aidcontribute to recovery and healing.effective case management services»» Able to communicate with child»» Able to appropriately engage caregiverssurvivors according to age andin the child’s care and treatment.developmental stage.»» Able to monitor activities using»» Able to adapt case managementestablished for child sexual abuse cases.Child Survivors have Access to Child Specialized Clinical Care &Treatment ServicesHealth Providers have the knowledge, skills, attitudes and tools to providespecialized medico-legal care for child survivors.»» Understand child growth and»» Able to adapt the medical exam anddevelopment and child sexualtreatment for child survivors.abuse concepts.»» Able to ensure safe and appropriate»» Able to communicate effectivelyreferrals and follow-up systems arewith child place.»» Understand and able to apply CCS»» Able to monitor activities usingGuiding Principles in case management.established tools.Health & Psychosocial Service Providers Coordinate Careaccording to Best PracticeService Providers have the knowledge, skills, attitudes and tools to use referralpathways, reporting agreements and information sharing protocols.»» Able to understand essentialprotocols exist.components to case coordination.»» Agreements and guidelines for»» Able to demonstrate best practice forinteracting with legal and reportingcoordinating child sexual abuse exist.»» Service provider agreements that»» Able to monitor activities usingoutline referral and information sharingestablished tools.Page 6 International Rescue Committee

CARING FOR CHILD SURVIVORSOf Sexual Abuse GuidelinesCaseworkersprovide appropriatecase managementto children andfamilies affected bysexual abuse.Health careproviders offer childspecialized medicalcare and treatment.Referral pathwaysand reporting agreements are developedand utilized properly.Info-sharing protocols are developedand utilized properly.Child survivors aresafe and have theirimmediate needs met.Caregivers engagepositively in theirchild’s healing process.Child survivorshave improved healthoutcomes andappropriateevidence collection.Childsurvivorsrecoverand healfromsexualabuseReferral systemsfunction and childcases are effectivelycoordinated betweenservice providers.CCS Guidelines Page 7

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesNote onLanguageThe term serviceprovider is used whenreferring to both healthand psychosocialprofessionals. The termcaseworker is usedwhen referencing anindividual tasked with theresponsibility to providecase management services to child survivors.The term caregiver isused to refer to the person and/or persons exercised day-to-day carefor a child. This includesbiological parents and/orother guardians responsible for the child’s careand well-being.Photo: Photographer Unknown/the IRCUsing the CCS GuidelinesWho can benefit from the CCS Guidelines?The primary target audience for the CCS Guidelines (referred to as “theguidelines” from now on) is staff who provide psychosocial, case managementand/or health services for survivors of gender-based violence (GBV) and/or children in humanitarian settings. United Nations and NGO protection andgender-related staff can also benefit from the guidelines and other components of the CCS Resource Package.What are the goals and aims of the CCS Guidelines?The goal is to provide staff with a user-friendly tool that offers best practiceguidance on caring for child survivors in humanitarian settings. The guidelinesaim to improve care for child survivors (and their non-offending family members), in order to help them recover and heal from abusive experiences. Theguidelines and accompanying tools will equip field staff with the necessaryknowledge, skills and attitudes to provide high-quality care to children andfamilies affected by sexual abuse.Page 8 International Rescue Committee

CARING FOR CHILD SURVIVORSOf Sexual Abuse GuidelinesOverview of the ChaptersThe guidelines walk readers through a step-by-step process for building capacity among healthand psychosocial service providers by focusing on the core knowledge, attitudes and skillsrequired for providing care to child survivors. Chapters 1–3 of the guidelines outline core competencies that apply to both health and psychosocial service providers. Chapters 4–6 are designedfor GBV and/or child protection program staff who deliver case management services to GBVsurvivors, including children. Chapter 7 provides concise guidance for coordinating care acrosshealth, child protection, GBV and other providers.»» Chapter 1: This chapter outlines the core child sexual abuse knowledge areas thatservice providers must have prior to working with children and families. The chapter walksthrough a set of core knowledge areas and introduces a supervision tool that can be usedto assess an individual staff member’s knowledge competency.»» Chapter 2: This chapter outlines the core child-friendly attitude competencies thatservice providers must have in order to work with children and families. The chapter walksthrough these core attitudes, including beliefs about child sexual abuse, and introduces asupervision tool for assessing attitude competencies.»» Chapter 3: This chapter outlines key principles of communication with child survivors,including instructions on how to communicate with children about the experience of sexualabuse. This section also explains verbal and non-verbal techniques that can be used tohelp children feel safer and more comfortable with expressing themselves.»» Chapter 4: This chapter introduces the reader to the guiding principles for workingwith child survivors and key issues that affect the delivery of care and treatment.It specifically addresses how to handle mandatory reporting for child abuse cases,confidentiality protocols and the roles of children and caregivers in decision-making.The discussion emphasizes the best interest of the child principle.»» Chapter 5: This chapter walks the reader through the step-by-step process of howto provide case management for child survivors and explains how to adapt casemanagement techniques for children of different ages. This chapter provides samplecase management forms for use in responding to cases of child sexual abuse andintroduces supervision tools for assessing case management competencies andevaluating applied practice.»» Chapter 6: This chapter introduces additional tools and interventions for staff to implementdirect psychosocial care interventions for child survivors and family members aspart of case management services. This chapter will help psychosocial staff build targeted,person focused psychosocial interventions for child survivors into their overall responseservices (e.g. case management or psychosocial services).»» Chapter 7: This chapter provides a concise overview of best practices related to childcase coordination across multiple service providers.CCS Guidelines Page 9

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesKey assumptions and parameters to the GuidelinesThe guidelines specifically address responding to cases of child sexual abuse—they are not general GBV or child protection response guidelines. It is necessary for field agencies implementingthese guidelines to have established response services, or at least the capacity to develop suchservices and/or be working with local partners providing services to survivors of gender-based violence or children facing broader protection concerns. Agencies and staff should already be trainedand able to demonstrate competency in:»» caring for survivors of gender-based violence3 and/or providing care andsupport to children with broader protection concerns, and»» basic case management and psychosocial care skills.Health staff should have also received training in clinical care for sexual assault survivors.4The following parameters to the guidelines should be noted:»» The guidelines are designed solely for the purpose of providing care and response services for child survivors of sexual abuse and their families. While aspects of the guidelinescan be applied to other forms of gender-based violence experienced by children (such asother forms of child abuse and exploitation) or to broader case management support, thespecific focus here is child sexual abuse.»» The guidelines provide step-by-step direction on how to provide case management andpsychosocial interventions for child survivors and their families. The guidelines do notaddress community-based interventions (such as integrating children into child-friendlyspaces or community-based interventions to combat social stigma and discrimination);however, they do offer suggestions for making appropriate referrals to agencies thatmight support these kinds of community-based interventions or provide these services.»» The guidelines are meant for children under the age of 18. However, approaches tocommunication and care outlined here will need to be adapted to a child’s age anddevelopmental stage. Age and developmental stage are taken into considerationthroughout the guidelines.34These guidelines should be used in conjunction with the Caring for Survivors of Sexual Violence in Emergencies training package developed by the Inter-Agency Standing Committee (IASC) Sub-Working Group onGender in Humanitarian Action with support from the Gender-Based Violence Area of Responsibility (GBVAoR) and/or other high quality GBV response training materials. In addition, the guidelines should be used withother standard guidelines for responding to GBV in humanitarian settings, such as the IASC Guidelines forPreventing and Responding to Gender-Based Violence in Humanitarian Contexts.The International Rescue Committee (IRC) and the University of California, Los Angeles (UCLA) Center forInternational Medicine. (2008). Clinical care for sexual assault survivors: A multimedia training tool, Facilitator’sguide. e 10 International Rescue Committee

CARING FOR CHILD SURVIVORSOf Sexual Abuse Guidelines»» The guidelines are designed for service providers working in humanitarian settings whereservices for survivors of GBV and/or children are in place, and agencies meet the minimum requirements for providing case management services.5 When referring to casemanagement services and/or caseworkers, the guidelines assume that the individuals areworking within agencies that meet the standards outlined in this document.»» The guidelines do not address treatment of perpetrators or prevention of sexual abuse,despite evidence showing that systemic interventions, raising awareness and preventionprograms create safer communities.»» The guidelines are not a training manual. Therefore, program coordinators and managerswill need to adapt the content to training curricula appropriate to specific culturesand contexts.Guide to Understanding IconsRead through the entire guidelines before deciding how best to apply the tools and guidelinesin your program. Readers will notice the following icons throughout the manual to help betternavigate this document.Sample ScriptToolHelpful Tip5Minimum standards for agencies providing case management can be found on page 240.CCS Guidelines Page 11

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesGlossary of TermsCommon terms and definitions used in thisdocument are defined below. These termsand definitions are not legal definitions andare not intended as such.6NoteThe IRC uses the term “children” to describeindividuals under the age of 18. Thesedefinitions fall in line with internationalconventions as summarized in the definitionof “child” below. The term “adolescent” isnot intended to replace the use of “children,”but instead provide an additional term todescribe specific ages, maturation and lifestages of individuals aged 10–19. The authorof this document understands that the terms“children” and “adolescent” take on differentmeanings in different contexts.Adolescence: defined as theperiod between ages 10 and 19 years old.It is a continuum of development in aperson’s physical, cognitive, behavioraland psychosocial spheres.Adolescent: Any person between theages of 10–19 years old.Adult: Any person 18 years and older.Assessment: The beginning stageof case management or psychosocial services in which information is gathered andevaluated for the purpose of making anappropriate decision about a course of action.Assessment prevents assumptions, createsgrounds for developing an appropriate plan ofaction, and helps identify survivor strengths.Attitude: Opinion, feeling or positionabout people, events, and/or things that isformed as a result of one’s beliefs. Attitudesinfluence behavior.Belief: An idea that is accepted as true. Itmay or may not be supported by facts. Beliefsmay stem from or be influenced by religion,education, culture and personal experience.Caregiver: This term describes theperson who is exercising day-to-day care fora child or children. He or she is a parent, relative, family friend or other guardian; it doesnot necessarily imply legal responsibility. Thismay apply to foster parents, including thosewho “adopt” a child spontaneously as well asthose who do so formally.Case Action Plan : The case6In an effort to ensure consistency, to the extentpossible, some definitions have been taken directlyfrom the IASC Guidelines on Gender-Based Violence Interventions in Humanitarian Settings. Otherdefinitions are sourced accordingly.Page 12 International Rescue Committeedocument that outlines the main needsof the client and goals and strategies formeeting their needs and improving theircurrent condition.

CARING FOR CHILD SURVIVORSOf Sexual Abuse GuidelinesCase Conference/Meeting :Case conferences are small meetings withappropriate service providers (e.g. alreadyinvolved in the child’s care) scheduled whenthe child’s needs are not being met in a timelyor appropriate way. The purpose of the caseconference is to gather the appropriate serviceproviders (and concerned support peoplein the child’s life as appropriate) to identifyor clarify ongoing issues regarding the childclients status. Case conferences providean opportunity to review activities includingprogress and barriers towards goals; to maproles and responsibilities; to resolve conflictsor strategize solutions; and to adjust currentservice; he or she will then arrange, sometimesprovide, coordinate, monitor, evaluate, andadvocate for a package of multiple services tomeet the specific client’s complex needs.8Case Supervision : The processwhereby a caseworker shares case work decisions, challenges and experience with anotherprofessional (generally a direct supervisor)who offers guidance, knowledge and support. Supervision helps caseworkers improvetheir case management skills and allowscaseworkers to share the burden of hearing and responding to clients’ problems andexperiences regarding violence; it also createsgeneral awareness of the care being provided.Case Documentation : InformationCaseworker : This term describes anrelated to the provision of case managementservices. Generally, this information includesdates of services; the specific service provider;a brief description of the situation and theclient’s responses to the subject matter; relevant action plans and follow-up appointmentinformation. Case documentation also includesdates and reason for closing the client’s case.7individual working within a service providing agency, who has been tasked with theresponsibility of providing case managementservices to clients. This means that caseworkers are trained appropriately on clientcentered case management; they are supervised by senior program staff and adhere to aspecific set of systems and guiding principlesdesigned to promote health, hope and healing for their clients. Caseworkers are alsocommonly referred to as social workers, caseholders, child protection workers, and GBVworkers, among others.Case Management: Social workbased case management is a systematicprocess, in which a trained and supervisedcaseworker assesses the needs of the clientand, when appropriate, assesses the client’s7In humanitarian settings, it is best practice to collectand store data in case files with non-identifying dataonly. For more information about the safe and ethicalcollecting, storing and usage of information, pleasego to Standards for Social Work Case Management. case mgmt.asp#intro.CCS Guidelines Page 13

InternationalCoreChild Sexual AbuseKnowledgeResCue CommitteeCompetenciesChild : Any person under the age of 18.9Children have evolving capacities dependingon their age and developmental stage.In working with children, it is critical tounderstand these stages, as it will determinethe method of communication with individualchildren. It will also allow the caseworker toestablish an individual child’s level of understanding and their ability to make decisionsabout their care. As a result, the caseworkerwill be able to make an informed decisionabout which method of intervention is mostappropriate for each individual child.The following definitions clarify the term “child”with regard to age/developmental stages forguiding interventions and treatment:»» Children 0–18, as per the CRC»» Young children 0–9»» Early adolescents 10–14»» Later adolescents 15–19Child and Youth development:Refers to the psychological, social, emotional,cognitive and physical changes that humanbeings undergo from birth to adulthood. Thechanges that take place—such as learning toclap, walk or talk, becoming empathic, andbeing able to think abstractly, to name justa few—are influenced by genetic as well asenvironmental factors. Many scholars haveidentified different “stages” of child and youthdevelopment which refer to the periods oftime or age ranges during which particularchanges are expected to take place. Theages associated with particular changes willvary across individuals, and as such, stages ofdevelopment are best understood on a continuum rather than a fixed timeline. Similarly,the changes occurring in children and youthtend to be processes of development ratherthan fixed events.10Child Survivor : A person under theage of 18 who has experienced any form ofgender-based violence.Child Survivor of SexualAbuse : A person under the age of 18 whohas experienced an act of sexual abuse.Child Sexual Abuse: There is noset definition of child sexual abuse. The WorldHealth Organization defines child sexualabuse as “the involvement of a child in sexualactivity that he or she does not fully comprehend, is unable to give informed consent to,or for which the child is not developmentallyprepared and cannot give consent, or thatviolates the laws or social taboos of society.Child sexual abuse is evidenced by t

» CCS guidelines: The CCS Guidelines (this document) provide step-by-step guidance on how to implement the main aspects of the CCS Program Model. The CCS Guidelines is the "how-to" guide for instructing health and psychosocial field staff responding to chil-dren who have experienced sexual abuse. The CCS Guidelines include multiple tools for

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