“And Then Cinderella Was Lying in My Bed”: Dissociation Displays in Forensic Interviews With Children Following Intrafamilial Child Sexual Abuse

Forensic Interviews With Children Following CSA

A heightened awareness of child maltreatment in the 1970s was followed by increased incidences of children in the legal system in the 1980s (Lambet al., 2011b). It is well established that the crime of child maltreatment is difficult to investigate. The children involved are commonly the sole source of information due to the frequent lack of evidence and the fact that the perpetrators are often closely linked to the victims (Malloy et al., 2011a). Addressing the characteristics of children as witnesses has been a focus for researchers who have identified a special set of traits among children, which have been found to have a profound effect on the ability of the children to retrieve and report on alleged incidents of maltreatment. These characteristics have been identified by an exhaustive examination of both lab and field studies and relate to the children’s cognitive, social, and emotional developmental abilities. Such findings are of particular importance for forensic child interviewers and are factors that interviewers need to be aware of. Indeed, several forensic guidelines have made efforts to consider children’s cognitive capabilities (e.g., Katz, 2016; Malloy et al., 2011a) and their emotional barriers during forensic interviews (e.g., Katz, 2015).

As in many other countries, Israel has recognized the need for specific and varied interventions in addressing CSA, one of which is the child forensic interview (Katz, 2016). The law in Israel (for further elaboration of the law please see Katz, 2016) recognizes the key role of child investigations and regulates them accordingly. This means it is understood that children play a decisive role in revealing and substantiating the abuse. The law further requires that children who are victims, witnesses, or even suspects in a criminal event are to be interrogated only by child forensic interviewers. Additionally, any information gleaned from this investigation is considered admissible evidence in a legal proceeding (London et al., 2005; McGuire & London, 2020).

There is a consensus in both research and practice that the ultimate goal of forensic interviews is to elicit a detailed and reliable testimony—a rich testimony (Lamb et al., 2011b). The richness of a testimony is assessed in regards to the number of legally relevant details provided by the child and represents a key indicator for assessing its legal reliability (Hershkowitz et al., 2006).

What Does Dissociation Have to Do With It?

A significant body of knowledge has been dedicated to exploring the multifacetedbiopsychosocial reactions to traumatic experiences. Among the various reactions, dissociation has received extensive attention, reflecting one of the most cardinal, yet complex, responses. The fundamental component of dissociation is a structured separation of typically integrated mental processes, mainly referring to thoughts, emotions, bodily experiences, memory, and/or identity (Spiegel & Cardeña, 1991). Findings have demonstrated that children exposed to CSA manifest high rates of dissociation (Macfie et al., 2001) and that CSA is commonly acknowledged as a critical event that is recognized in the etiology of dissociative symptoms and disorders in adults (Hartt & Waller, 2002; Swannell et al., 2012; Thomas, 2005; Vonderlin et al., 2018).

Dissociative reactions to trauma are commonly divided into three main time frames. The first occurs during the traumatic incident itself and a short time thereafter, referred to as peritraumatic dissociation (Marmar et al., 1998). During a traumatic experience, dissociation is thought to serve as a protective mechanism, aimed at shielding the individual from the accompanying sense of unbearable fear and pain (Spiegel, 1988). The evolutionary objective of dissociation has been denoted to enable survival during potentially imminent situations of bodily encounters, such as skin contact, the presence of body fluids, or when bodily integrity is injured or invaded (Schauer & Elbert, 2015).

The second time frame of dissociative responses to trauma is considered acute post-traumatic stress reaction/disorder, which may occur after three days and up to one month following the traumatic incident (American Psychiatric Association, 2013). A third possible time frame refers to chronic post-traumatic stress reactions, which denotes symptoms that are present for more than one month following the traumatic event. Chronic dissociative symptoms may be linked to several post-traumatic psychopathologies, including post-traumatic stress symptoms/disorder (PTSD), pediatric PTSD (in children younger than 6), dissociative disorders (American Psychiatric Association, 2013), complex post-traumatic stress disorder (CPTSD), and developmental trauma disorder (Ford et al., 2018). Acute and chronic dissociative symptomatology mainly refers to alterations in the sense of reality of one’s surroundings (derealization), self (depersonalization), inability to remember trauma-related information (sometimes reflecting dissociative amnesia), and intrusive experiences in which the person feels or acts as if the traumatic experience is reoccurring, often expressed in flashbacks (American Psychiatric Association, 2013). Among children, dissociative symptoms may also be reflected in repeated reactivation of the traumatic experience during play. Dissociative symptoms are often allocated as “positive, ” referring to an unbidden disruption of continuity in subjective experiences, or “negative, ” reflecting an inability to access information that is usually accessible (American Psychiatric Association, 2013). Notably, these three phases of peritraumatic, acute, and chronic post-traumatic reactions may be fused in cases of recurring exposure to trauma, as is often the case in CSA (Van der Kolk, 2017).

Manifestations of peritraumatic, acute as well as chronic dissociative responses and symptoms could affect the forensic interview in several ways. First, peritraumatic dissociative responses may be expressed by the children when describing the abusive incident/s during the interview. The fragmented experience of peritraumatic dissociation may impose barriers to the verbal narration of the abuse, as well as attention difficulties when describing it, often leading to incoherent and perforated testimonies (Kaplow et al., 2008). Peritraumatic dissociation may also lead to the report of bizarre, improbable, and fantastic descriptions that are embedded in the description of the abusive incident (Everson, 1997). Furthermore, thinking and talking about the traumatic experiences in the forensic interview may function as trauma reminders, thus potentially triggering acute and chronic dissociative symptoms. Thus, throughout the interview, children may display various manifestations of dissociation, presumably involving flashbacks, dissociative amnesia, or any expressionof discontinuity or fragmentation concerning the CSA experience. This may impede their ability to comply with the interview (Brand et al., 2016).

It is important to acknowledge that peri- and post-traumatic dissociative responses could jeopardize the production of testimony that meets all of the legal system’s requirements, if not addressed properly (Brand et al., 2017). Brown (2009), for example, has argued that dissociative reactions to trauma may be confused as malingering. Although some findings have shown that dissociation was not correlated with memory performance in the forensic assessment of alleged abuse (Eisen et al., 2002), other findings have demonstrated that, among children who showed high dissociative symptoms, the higher theirpost-traumatic symptomatology, the greater the inaccuracy of the reported information (Chae et al., 2011). These mixed findings, therefore, indicate that dissociation may occur and affect the forensic process. Unfortunately, to the best of our knowledge, the display and manifestations of peri- and post-traumatic symptomatology within forensic interviews have yet tobe tested.

The Current Study

The current study was designed to draw attention to the ways in which dissociation is displayed during forensic interviews following alleged intra familial child sexual abuse (IFCSA). IFCSA is the most common form of CSA, with particularly severe short- and long-term consequences. The fact that IFCSA occurs in the domestic setting highlights its far-reaching consequences for the children (McElvaney & Culhane, 2017). As IFCSA is embedded within a complex family and community context, it is therefore crucial to explorethe various aspects and impacts of this phenomenon.

A thorough thematic analysis, focusing on the various manifestations of dissociation, was carried out on 42 forensic interviews with children aged 4-14. The research questions of the current study are: What displays of dissociation can be identified in the children’s narratives throughout their forensic interviews (a) as they occurred during the reported abusive incident/s? and/or (b) as they occurred during the forensic interviews?

From an empirical standpoint, the majority of dissociation indications during CSA are derived from adults’ reports of experiences that occurred years earlier (e.g., Hetzel & McCanne, 2005; Nijenhuis et al., 2001; Thompson-Hollands et al., 2017). Forensic interviews with children subsequent to CSA very often take place a short time after the traumatic incident/s. Additionally, forensic interviews are structured in a way that encourages the child to use her or his own words to describe the experiences of CSA (Katz, 2015; Malloy et al., 2011a). The child’s words are systemically documented so that they are not distorted for legal purposes or objectives (Katz, 2015). As such, forensic interviews reflect a unique opportunity to capture vivid expressions of peritraumatic dissociative responses to CSA.

Sample

The sample consisted of 42 forensic interviews with Israeli children (29 girls), aged 4-14, with an average age of 9 years old, who were alleged victims of sexual abuse by a family member (parents: 30, siblings: 6, grandparents: 6). All of the cases of IFCSA consisted of multiple incidents and had descriptions of severe abuse, including rape.

Procedure

The 42 interviews were selected out of a total of 5,200 forensic interviews, with 1,400 forensic interviews relating to a perpetrator who was family member, conducted with alleged victims of sexual abuse in Israel in 2015. Only forensic interviews that met the following inclusion criteria were included in the current study’s sample: (1) The child was interviewed following a report of IFCSA; (2) the interview was the first forensic interview to be conducted with the child; (3) the child disclosed the abuse during the interview; (4) the child’s first language was Hebrew; (5) the child did not exhibit any developmental disabilities; and (6) all interviews included additional evidence (e.g., suspect admission, medical examination) suggesting a high probability that the abuse took place. The forensic interviews were carried out by the Service for Forensic Interviews in Israel after a complaint of sexual abuse. The forensic interviews with the children are one part of the overall investigative process, and it is important to note that the determination of whether the abuse took place or not is not the mandate of the forensic interviewer.

Interviews: The NICHD Investigative Interview Protocol

The interviews were conducted by seven trained forensic interviewers who shared similar professional backgrounds (i.e., a degree in social work and at least 18 months of experience as a child forensic interviewer). All interviews followed the National Institute of Child Health and Human Development (NICHD) protocol (for elaboration please see Katz, 2015), a requirement for child forensic interviews in Israel. The use of these guidelines allowed us to standardize the interview structure and adhere to best practice.

The NICHD protocol is a set of structured practical guidelines for forensic interviewers aiming to cover all phases of the investigative interview. The protocol has been found to elicit rich testimonies from children of all ages in response to free-recall invitations (Lamb et al., 2011a). It has been implemented in the United States, Israel, Sweden, the UK, and Canada. Follow-up studies have systematically indicated significant improvements in the quality of investigative interviews (Lamb et al., 2011b).

The protocol includes three phases. In the initial introductory phase, the interviewer becomes acquainted with the child, explains the ground rules, emphasizes the need to tell the truth, and encourages the child to say “I don’t know” when appropriate. The second phase consists of establishing a supportive relationship and rapport, while simultaneously introducing the interviewing techniques. When the child appears to be relaxed and comfortable, the interviewer proceeds to train the child’s episodic memory, using a neutral experience to help the child become familiar with the interviewer’s questioning style (i.e., emphasizing open-ended questions).

In the final phase, the primary focus of the interview is the incident of abuse. Interviewers are instructed to use open-ended questions as often as possible. Open-ended questions include initial invitations (e.g., “Tell me everything that happened to you from the beginning to the end”), follow-up invitations (e.g., “And then what happened?”), and cued invitations (e.g., “You mentioned the belt; tell me everything you can about that”). Interviewers then employ direct questions (e.g., “When did this happen?”), only after the open-ended questions appear to have exhausted the child’s recollection. Option-posing questions (e.g., “Did he hit you on the head?”) are asked only when essential forensic information is unavailable and only towards the end of the interview. Interviewers do not ask suggestive questions (e.g., “He made you bleed, right?”). At the interview’s conclusion, to help the children relax, interviewers are instructed to shift the focus of the conversation to neutral topics (e.g., “What are you going to do after the interview?”) (Lamb et al., 2011a; Malloy et al., 2011b).

Data Analysis

It is important to state that, given the strict ethical restrictions, the transcripts of the forensic interviews cannot be uploaded to any analysis system. Therefore, the data analysis was done manually by the authors of the manuscript and two other members of their research team. It should also be noted that the transcripts were provided to the research team by the Service for Forensic Interviews in Israel.

The interviews underwent several interrelated stages of qualitative thematic analysis (Braun & Clarke, 2006). First, each member of the research team (including the authors and two others) thoroughly read the transcripts of the forensic interviews. Then, the researchers identified preliminary ideas. The authors read the first ten interviews repeatedly, breaking each down into small textual segments that represented discrete units of meaning. Based on this, the identified codes were then grouped into initial themes. As the authors continued reading, some codes were removed or revised and other codes and categories were added. In the third stage, themes and subthemes were reviewed, classified, and reclassified, as required (Strauss & Corbin, 1998). Finally, the themes were refined and named and interrelationships were suggested (Braun & Clarke, 2006). During this stage, the authors also referred back to the transcripts to retrieve any further information necessaryto develop the categories (Maykut & More house, 1994). Based on the coding scheme that was generated from the first ten interviews, one author together with the additional two members of the research team analyzed all of the 42 manuscripts. In each case of disagreement, the four research team members resolved the identified issues through discussion.

Trustworthiness was achieved by audit trails and peer debriefing (Lincoln & Guba, 1990; Morse, 2015). The audit trail consisted of documenting how raw data were collected and analyzed, and participants’ direct quotes were attached to all interpretations (Bowen, 2009). The authors also kept personal journals to maintain awareness of influences on their interpretations (Jootun et al., 2009).

Ethical Approval

As the study was based on files containing highly personal information, the authors made an effort to meet the highest ethical standards. To ensure privacy and anonymity, the interviews were provided to the authors without names or identifying features of the children, parents, or other people and places involved in the incidents. The study was approved by the Research Board of the Ministry of Welfare in Israel, the Service of Children’s Forensic Interviews in Israel, and the Ethics Committee of Tel Aviv University. Therefore, given the strict ethical guidelines, none of the identifying information from the forensic interviews can be presented along with the demographic details of the children.

“I Could Not Feel Anything”: Displays of Dissociative Depersonalization/Derealization During the Incidents of the Abuse

When delving into the children’s narratives, with respect to the actual incidents of abuse, a display of dissociation can be evident. In particular, out of the 42 forensic interviews, this display of dissociative depersonalization/derealization during the incidents of the abuse was evident in 40 transcripts.

In the following narrative, a child referred to the way her grandfather was on top of her while describing everything on the wall but nothing from his specific actions: “We were both lying there on the bed, this is the room of my uncle so the walls there are decorated with many paintings that he used to draw… there were different colors on the walls. … I don’t know how he touched me, I just know that it was heavy at the beginning… .”Another child described: “I remember him touching me but I could not feel anything.”

A further display of dissociation from the children was their response to the abuse. Some of the children described that during the abuse they recalled stories from their nurseries: “Well, he sat with me and touched me, and then I thought of the story that I love from the nursery. I love the girl there, I wanted to be her friend.”Or they force themselves to sleep so that it will be less painful: “He started touching me and I closed my eyes and knew that it is time for me to sleep now.”; “He touched me and I felt like I was going to die from how painful it was… so I forced myself to fall asleep, to not move, because that was the only way to survive.”These narratives highlight the experiences of dissociation as communicated by the children to the forensic interviewers.

“… And Then Cinderella Was Lying in My Bed”: Displays of Fantasy Depersonalization and Derealization During the Incidents of the Abuse

In 28 of the forensic interviews, particularly among the younger children aged 4-5 (n=20), there were displays of fantasy elements in their narratives. For example, a 4-year-old child described that the perpetrator had done magic with a yellow wand: “He did abracadabra and it was in my weewee.” Then she continued and said that something came out of the “weewee”: “A blue heart came out.”

In another forensic interview, a 4.5-year-old child described their father calling them to lie with him on the bed and then said“ So I got on the bed and then Cinderella was lying in my bed and there were sparklers and magic.”

It is important to address that displays of fantasy could be found among older children as well, with a slightly different expression. For example, a 9-year-old child told the forensic interviewer: “I felt like I was a kind of Avatar, not that I was imagining this but just feeling like I am not myself, someone else.”

“Sometimes I remember and sometimes I do not”: Displays of Dissociative Amnesia During the Forensic Interview.

In all of the 42 forensic interviews, children tried to cooperate with the forensic interviewers and provide them with appropriate responses to their questions. However, all of the children communicated to the forensic interviewers that it was difficult for them to fully remember what had happened to them. They struggled to explain how it could be that they were able to recall some details but not others. The following quote illustrates this:

Interviewer: “So you told me that he got inside your room and that he touched you on your bed. What happened right after he got inside your room?”

Child: “Well I… I don’t really, I mean he was on me in bed but I don’t remember everything, like I remember only part of what happened but I don’t know why.”

In another interview, the child was struggling to provide more details and said “Sometimes I remember and sometimes I do not but I don’t know why it is, it is just like this, weird.”

The following dynamic shows the struggle to remember parts of the incidents:

I: “You said that your grandfather touched your tummy. Tell me more about it.”

C: “He touched but then I don’t remember. I told mommy that I don’t know but I remember only some of what happened but more things happened but I don’t remember them.”

Given that the incidents of the abuse were repeated, the children conveyed their difficulties in describing each one of the events separately. The following narrative demonstrates this difficulty: “I cannot remember one specific time. It is like it happened many times but it is like vague, like I remember only parts of things. It is not like a story that I can tell you, only parts that I do not understand.”

These examples illustrate the children’s attempts to be competent interviews in the forensic interviews. However, this comes alongside their struggles to recall the details of the incidents of the abuse, while also communicating these difficulties to the forensic interviewers in their own idiosyncratic ways.

“My Head Is Burning in Pain”: Displays of Dissociative Reactions Triggered During the Forensic Interviews

During the forensic interviews, there were numerous examples of reactivated post-traumatic reactions when the children were asked various questions regarding the incidents of the abuse such as digressions in the narratives, asking to leave the interview, and complaints of physical pain. These displays were evident in 38 forensic interviews.

Displays of digression were characterized by the children’s attempts to recall the abusive incidents and communicate it to the forensic interviewers but with sudden transitions to an irrelevant topic, detached from their narrative, as seen in the following example: “… and then he entered my room and looked at me and wow what a beautiful butterfly I see on the wall can you see this?”In another interview: “He took off my pants and can you see these lights? Is it purple or blue?”

Another reaction was to request to leave the room where the interview was taking place. This was mainly shown in requests to go drink water or go to the toilet, requests that were echoed in their responses to the actual abuse they described and occurred as the child was seemingly about to report on the abusive acts. For example, “Dad was calling me to come and sit next to him on the sofa and I tried to go to the toilet and I waited there but after 10 minutes he was still there on the sofa waiting for me. … I have to go to the toilet.”

Many children (n=30) described pain while discussing their incidents of abuse. The majority of the complaints of pain were in their head and tummy, with some children complaining about pain in their bones. The following examples illustrate this: “He always wanted me to sit with him and watch movies. … my head is cracking from pain… ”Another child said “He touched me and hugged me. My tummy is really in pain. It is hard for me to breathe.”Again, another child: “I remember that he was sleeping with me almost every night. … my legs and arms are in pain like inside pain like in this, how is it called? I think bones?”

Peritraumatic Dissociative Manifestations

The findings of this study revealed several main manifestations of dissociation that took place during incidents of IFCSA and the probable protective role in subjectivity and surviving the abuse (Gentile et al., 2014; Rabeyron & Caussie, 2016). Particularly, children described experiences of a disrupted sense of self and reality, i.e., depersonalization and derealization, as seen in a fragmented sensory experience during the incident of the abuse. Such manifestations were described by the children as an inability to feel their body, sometimes combined with a vivid memory of a specific visual input (e.g., paintings on the wall), or forcing oneself to sleep during the incident. In line with these testimonies, considerable findings have revealed that individuals exposed to CSA reported peritraumatic psychic and soma to form dissociation (Nijenhuis et al., 2001). Although some findings have indicated that peritraumatic depersonalization and derealization are implicated in reduced post-traumatic symptomatology (Shilony & Grossman, 1993), othershave found the opposite, unveiling the propensity of peritraumatic dissociative reactions in future mental healthmorbidity (Hagenaars & Hagenaars, 2020; Hagenaars et al., 2007; McNally, 2003).

One unique dissociative manifestation uncovered by the children’s testimonies was fantasy or imaginative dissociative depersonalization and/or derealization. Such a phenomenon was previously described more than two decades ago by Everson (1997), who identified the report of bizarre, improbable, and fantasy content provided by children during forensic interviews. Several explanations have been suggested regarding these phenomena, ranging from coping mechanisms and cognitive immaturity to a perpetrator’s attempt to confuse, discredit, or threaten the child (Everson, 1997). Although theory often focuses on imagination and play as core developmental components (Gilmore, 2011; Tessier et al., 2016; Thibodeau et al., 2016), empirical examinations of peritraumatic fantasy dissociation among children exposed to abuse are scarce. From a developmental perspective, the ability to employ fantasy content by children reflects an adaptive capability, an essential component of play (Russ & Fehr, 2013). However, trauma is suggested to disrupt these metaphoric and pretend-play capabilities (Haen, 2020; Terr, 2008) by impeding the ability to differentiate real life from fantasy (Carrick et al., 2010). Thus, the distinction between reality and fantasy or imagination is blurred. Such disruptions are often seen in children’s tendency to reenact the traumatic content in play (Terr, 2008) and/or display several post-traumatic play expressions, including restricted, aggressive, mechanistic, or repetitive (Chazan et al., 2016). The current findings are in line with these prior understandings, revealing yet another form of the restricted capability to differentiate between reality and fantasy. In particular, the current study indicates that this restricted capability is also evident in the inclusion of defensive fantasy dissociation when facing an unbearable reality.

Indirect attention concerning this phenomenon has also been seen through the lens of fantasy proneness, referring to the tendency to be extensively involved in fantasy and daydreaming (Wilson & Barber, 1982). Such propensities have been documented among individuals who have experienced child abuse and are closely linked to post-traumatic symptomatology and dissociative symptoms (Giesbrecht & Merckelbach, 2006; van der Boom et al., 2010). Fantasy proneness has also been suggested to be linked to memory biassusceptibility (Geraerts et al., 2005; Merckelbach et al., 2000), thus raising suspicionin regards to fantasy content in forensic settings. However, the current findings revealed that fantasy dissociative manifestations occur during the traumatic event itself, which is remarkably different from fantasy proneness and therefore should not be confused as such. Taken together, more research is needed to uncover the presence and role of imaginative and fantasy content within forensic settings.

Dissociative Manifestations as Expressed During the Forensic Interview

The current findings reported that some of the children described not being able to remember all of the details that happened to them during the abuse. This phenomenon may reflect dissociative amnesia, which is described as impaired autobiographical memory in the absence of structural brain damage (Markowitsch, 2003). Although there is an absence of structural damage, some brain functions have been proposed to correlate with dissociative amnesia (Brand et al., 2009; Staniloiu & Markowitsch, 2014). In the framework of child abuse, findings have long demonstrated the pertinency of dissociative amnesia among CSA survivors (Briere & Conte, 1993; Widom & Morris, 1997). An inability to remember parts or the entirety of what happened brings about significant challenges in the forensic context. This may be confused with an unwillingness to disclose the abuse (McNally, 2007) orthe susceptibility to false memory implantation. These findings, therefore, call for the need to include a clinical assessmentfor possible dissociative amnesia in forensic settings, as well as the development of useful methods to overcome it.

The phenomenology and manifestations of dissociation during forensic interviews are inherently linked to the unique characteristics of the memory processes of traumatic experiences. It has been proposed that highly stressful situations tend to be implicated in the breakdown of the language-based memory system and are, therefore, coded and stored as implicit sensory inputs (Brewin, 2011; Van der Kolk, 1994). As such, highly stressful experiences are often coded as fragmented somatosensory sensations, lacking proper assimilation with autobiographical (explicit) memory. Consequently, the intentional retrieval of traumatic memories is often deficient and difficult to verbally report (Brewin et al., 1996), frequently resulting in incoherent, “broken, ” or perforated testimonies. Additionally, the retrieval of traumatic experiences generally occurs in a “bottom-up” direction, as seen in the involuntary, intense, and fragmented somatosensory reexperiencing of the traumatic event (Foa et al., 1989; Hellawell & Brewin, 2004; Van Der Kolk, 2014). These substrates reflect flashbacks, which are often triggered by trauma reminders (Foa et al., 1989; Hellawell & Brewin, 2004; Van Der Kolk, 2014), and may occur during forensic interviews.

Indeed, the children’s testimonies unveiled additional manifestations of dissociative responses that occurred during the forensic interview, presumably activated by speaking about their traumatic experience. These responses may reflect dissociative flashbacks, which are considered one of the core post-traumatic stress symptoms (Jones et al., 2003). Flashbacks are emotion-laden memories (Bremner et al., 1995) that consist of vivid somatosensory trauma-related content (Brewin, 2011; Whalley et al., 2013). Such distinctive memory-related experiences may be triggered either by internal or external cues involving neural activity that distinguishes them from ordinary autobiographical memories (Brewin, 2015). Considering the sensory and involuntary nature of flashbacks, their content may be difficult to describe in words, particularly while they occur. Concurrently, the children do not “tell” the interviewer that they are experiencing a flashback, however, it may be apparent in their behavior.

Notably, while describing the abusive incident, several children disrupted their description of the incident by reporting a sudden experience of intense pain, either in their head, abdomen, hands, and/or legs. Although traumatic experiences, including CSA, may very often involve pain, empirical examinations of pain flashbacks are rare. A few studies have, nevertheless, exposed the phenomenon of pain flashbacks (Macdonald et al., 2018; Salomons et al., 2004; Schreiber & Galai-Gat, 1993; Whalley et al., 2007) and emphasized its occurrence and relevance for the study of post-traumatic reactions. To the best of our knowledge, the current study uncovered the first probable indication of pain flashbacks in forensic settings with children. This findingreveals the need to further understand its occurrence and the way it intervenes in the forensic procedure.

Clinical and Policy Implications

The current study illustrated the importance of examining children’s trauma displays during forensic interviews. Several forensic guidelines have been proposed that assimilate the understanding of peri- and post-traumatic reactions (Strand, 2019). However, to the best of our knowledge, these have yet to be empirically tested and implemented with children. The current study stresses the need to dedicate future efforts to the dissemination and evaluation of these reactions. Moreover, previous studies have demonstrated how multisession interviews can be beneficial (e.g., Duron & Remko, 2018), which should be further explored in this field.

The current findings hold several directions for practice that should be investigated further for their potential relevancy. First, it is recommended that as part of the forensic investigation, if assessed to be relevant by the forensic interviewers, children undergo a clinical developmental and mental assessment, including but not limited to post-traumatic symptomatology. Such screening should be conducted with the child as well as the parent or other keycaregiver. As proposed by Tedeschi and Billick (2017), screening procedures may indicate the level of post-traumatic symptomatology, which should be taken into consideration and thereby facilitate the forensic procedure.

Second, it is recommended that forensic practitioners develop and implementnew strategies regarding post-traumatic symptomatology within the forensic procedure. For example, considering that peri- and post-traumatic dissociation is often implicated in a difficulty to verbally report, recent findings have indicated that the action of writing traumatic memories several times may increase the coherence of the account (Vrana et al., 2019). Therefore, one possible way to overcome dissociative reactions to trauma is to include reporting in writing. New strategies may also take into consideration, or even rely on, the triggering effect of talking about the traumatic experience. Third, it is suggested that dissociative manifestations, if properly recognized and articulated, may be used as valid indications that the child suffers from a post-traumatic reaction, potentially indicating that they were exposed to trauma. Finally, considering that dissociative content and experiences are often implicit/nonverbal, it is recommended that the legal system develop new strategies to evaluate and confirm child abuse exposure based on the understanding of how trauma is manifested and perhaps best exemplified in nonverbal reactions.