Child Welfare: Increased Guidance and Collaboration Needed to Improve DOD's Tracking and Response to Child Abuse

With more than 1.2 million school-age military dependents worldwide, per DOD, the department's organizations work to prevent, respond to, and resolve incidents of child abuse. Incidents of child abuse, including child-on-child abuse, can cause a range of emotional and physical trauma for military families, ultimately affecting servicemember performance.

GAO was asked to review how DOD addresses incidents of child abuse and child-on-child abuse occurring on a military installation or involving military dependents. This report examines, among other things, the extent to which DOD has (1) visibility over such reported incidents, and (2) developed and implemented policies and procedures to respond to and resolve these incidents. GAO reviewed relevant policies and guidance; interviewed officials at a nongeneralizable sample of seven military installations; analyzed program data; interviewed parents of children affected by abuse; and interviewed DOD, service, and civilian officials, including at children's advocacy centers.

The Department of Defense (DOD) has limited visibility over reported incidents of child abuse—physical, sexual, or emotional abuse, or neglect by a caregiver—and child-on-child abuse due to standalone databases, information sharing challenges, and installation discretion. From fiscal years 2014 through 2018, the military services recorded more than 69,000 reported incidents of child abuse (see figure). However, personnel at all seven installations in GAO's review stated that they use discretion to determine which incidents to present to the Incident Determination Committee (IDC)—the installation-based committee responsible for reviewing reports and determining whether they meet DOD's criteria for abuse (an act of abuse and an actual or potential impact, e.g., spanking that left a welt). Per DOD guidance, every reported incident must be presented to the IDC unless there is no possibility that it could meet any of the criteria for abuse. However, personnel described incidents they had screened out that, per DOD guidance, should have been presented to the IDC. Without the services developing a process to monitor how incidents are screened at installations, DOD does not know the total number of reported child abuse incidents across the department.

While DOD has expanded its child abuse policies and procedures to include child-on-child sexual abuse, gaps exist. For example, DOD standardized the IDC process in 2016, but the new structure does not include medical personnel with expertise, contrary to best practices for substantiating child abuse allegations. Without expanding the IDC membership to include medical personnel, members may not have all of the relevant information needed to make fully informed decisions, potentially affecting confidence in the efficacy of the committee's decisions. GAO also found that the availability of certified pediatric sexual assault forensic examiners across DOD is limited—according to DOD officials, there are only 11 in comparison to 1,448 incidents of child sexual abuse that met DOD's criteria for abuse from fiscal years 2014 through 2018. Without processes that help ensure timely access to certified pediatric examiners, child victims of sexual abuse overseas may not receive exams in time for evidence to be collected for use in prosecution, increasing the stress and trauma of affected victims.

GAO is making 23 recommendations, including that the military services develop a process to monitor how reported incidents are screened at installations, that DOD expand the membership of the IDC to include medical personnel, and that DOD establish processes that help ensure timely access to certified pediatric examiners overseas. DOD concurred with 16, partially concurred with six, and did not concur with one of GAO's recommendations, which GAO continues to believe are valid, as discussed in the report.

With more than 1.2 million school-age military dependents worldwide,  according to the Department of Defense (DOD), the department has  responsibilities related to the prevention, response to, and resolution of  incidents of child abuse. DOD policy defines child abuse as the physical,  sexual, or emotional abuse, or neglect of a child by a parent, guardian,  foster parent, or caregiver. Incidents of child abuse, including child-on- child abuse, can cause a range of emotional and physical trauma for  military families, ultimately affecting servicemember performance and  readiness.

Since 2018, a number of media reports have highlighted challenges  regarding DOD’s response to incidents of child-on-child sexual abuse  occurring on military installations in the United States and overseas,  including within DOD Education Activity (DODEA) schools. DODEA  operates 163 schools in 11 countries, 7 states, Guam, and Puerto Rico  that collectively serve more than 70,000 children of active duty military  and DOD civilian families. DOD’s efforts related to child-on-child abuse  are currently focused on problematic sexual behavior in children and  youth, which is defined in policy as behaviors that involve sexual body  parts in a manner that deviates from normative or typical sexual behavior  and that are developmentally inappropriate or potentially harmful to the  individuals initiating or impacted by the behavior. Amid these media reports, you asked us to assess how DOD addresses incidents of child  abuse, including child-on-child abuse, occurring on military installations or  involving military dependents. This report assesses the extent to which  DOD (1) has visibility over such reported incidents, (2) has developed and  implemented policies and procedures to respond to and resolve these  incidents, and (3) collaborates with other governmental and  nongovernmental organizations to address these incidents.

For our first objective, we analyzed data from the three primary  organizations that DOD officials identified as having responsibility for  tracking these incidents. Our review included data on any abuse of a child  (emotional, physical, or sexual abuse, or neglect) by an adult and child- on-child abuse—any physical or sexual abuse of a child (under the age of  18) by another child. First, we analyzed data from the Army, the Navy,  the Marine Corps, and the Air Force’s Family Advocacy Programs  (FAP)—which, among other things, provide trauma-informed assessment,  rehabilitation, and treatment to persons who are involved in alleged  incidents of child abuse—on all reported incidents of child abuse for fiscal  years 2014 through 2018. We selected this timeframe to evaluate trends  over 5 years, and fiscal year 2018 was the most recent year for which  complete data were available at the time of our review. Specifically, we  analyzed the data to determine the number of reported incidents of child  abuse by service and the percentage of those that met DOD’s criteria for  child abuse, as well as to describe the characteristics of these incidents.  To assess the reliability of the service FAPs’ child abuse data, we  reviewed related documentation; assessed the data for errors, omissions,  and inconsistencies; and interviewed officials. We determined that the  data were sufficiently reliable to describe trends in reported incidents of  child abuse across the services and characteristics of such incidents from  fiscal years 2014 through 2018.

Second, we analyzed data from the military criminal investigative  organizations—the Army Criminal Investigation Command, the Naval  Criminal Investigative Service, and the Air Force Office of Special  Investigations—for the same time period for all investigations with a child  victim. Specifically, we analyzed the data to identify trends in the number of investigations over the past 5 fiscal years and to identify key  characteristics of the investigations. To assess the reliability of the military  criminal investigative organizations’ child victim investigation data, we  assessed the data for errors, omissions, and inconsistencies, and we  interviewed officials. We determined that the data were sufficiently  reliable to describe trends in child victim investigations across the  services and the characteristics of such investigations from fiscal years  2014 through 2018.

Third, we analyzed three sources of DODEA data: (1) child abuse reports  from school years 2014-2015 through 2017-2018, (2) serious incident  reports from school years 2013-2014 through 2017-2018, and (3) student  misconduct records from school years 2016-2017 through 2017-2018.  We selected this timeframe to evaluate serious incident report trends over  5 years, and school year 2017-2018 was the most recent year for which  complete data were available at the time of our review. We analyzed  DODEA’s child abuse reports and serious incident reports to identify  trends in the number and type of reports as well as to describe their  characteristics. To assess the reliability of DODEA’s child abuse reports  and serious incident reports, we reviewed related documentation;  assessed the data for errors, omissions, and inconsistencies; and  interviewed officials. We determined that the data were sufficiently  reliable to describe trends in and characteristics of child abuse reports  from school years 2014-2015 through 2017-2018 and serious incident  reports from school years 2013-2014 through 2017-2018, as well as to  compare serious incident reports to DODEA student misconduct records  from school years 2016-2017 through 2017-2018.

We also conducted an analysis of DODEA’s student misconduct records  for school years 2016-2017 and 2017-2018 to determine the number of  student misconduct records that school administrators, using DODEA’s  guidance, could have reasonably categorized as a violation of law or  sexual event and filed a serious incident report. We selected these 2  school years for the analysis because DODEA’s updated serious incident  reporting guidance was issued in August 2016 and was in place for both  school years. We compared the number of student misconduct records  for which we determined school administrators, using the guidance, could  have reasonably filed a serious incident report with the number of serious  incidents recorded by DODEA for the same time period to determine the  extent of DODEA’s visibility into serious incidents. We discussed the  student misconduct records and our analysis with DODEA officials.

Further, we interviewed relevant DOD and service officials at the  headquarters level and at a nongeneralizable sample of seven military  installations to identify how DOD tracks reported incidents of child abuse  from the time of a report to an ultimate adjudication, including how  information is communicated within and across the services. We selected  at least one installation per service as well as two joint installations, and  selected locations based on the number of reported child abuse incidents  and the number of investigated child-on-child abuse incidents, as well as  other factors. Specifically, we selected installations that had a high  number of reported incidents of child abuse, a high number of child-on- child abuse investigations—or both—from fiscal years 2014 through 2018  in order to maximize the possibility we would interview officials,  responders, and care providers who had responded to reported incidents  of child abuse. Other selection factors included a mix of types of  legislative jurisdiction, at least some installations with DODEA schools, a  high number of DODEA serious incident reports, and a mix of geographic  locations in the United States and overseas. We compared information  from our data analyses and interviews to DOD guidance; GAO-identified  practices for developing and maintaining a reliable schedule; GAO- identified leading practices for results-oriented management; and  Standards for Internal Control in the Federal Government related to  quality information, designing control activities, and monitoring activities.

For our second objective, we reviewed relevant DOD and service policies,  guidance, reports, and memoranda on child abuse, juvenile misconduct,  and problematic sexual behavior in children and youth. We also  conducted work at the previously mentioned nongeneralizable sample of  seven military installations in the United States and overseas where we  interviewed a variety of personnel responsible for tracking, responding to,  and resolving these incidents. To obtain the perspectives of parents and  guardians of children who have been affected by abuse (either by an  adult or another child) on military installations or while they were military  dependents, we interviewed, using a structured questionnaire, 20 parents  and guardians by phone. These parents and guardians volunteered to  speak with us about their perspectives on available resources and  assistance, case communication, and the investigative and adjudicative  processes. We compared the information from the selected installations  and interviews to GAO-developed practices to enhance and sustain  collaboration in interagency groups, Department of Justice (DOJ) best  practices for sexual assault forensic examination kits, and Standards for  Internal Control in the Federal Government related to quality  information.

For our third objective, we reviewed written agreements in place with  civilian organizations at the five nongeneralizable installations located in  the United States in our review, such as agreements with local civilian law  enforcement and state child welfare agencies that pertain to how  incidents of child abuse on the installation are to be addressed. We also  interviewed relevant officials from civilian organizations near the five U.S.  installations in our review, such as state and local child welfare agencies,  law enforcement organizations, prosecuting attorneys’ offices, and  Children’s Advocacy Centers (CAC) to determine the extent of their  collaboration with the military and any related challenges. In addition,  we interviewed DOJ officials regarding the prosecution of juvenile crimes  committed on overseas installations and on some U.S. installations.  Further, we contacted officials from the National Children’s Alliance,  which accredits CACs, about its efforts with DOD to improve collaboration  between the military and CACs. We compared the agreements and  information obtained through interviews with DOJ Principles of Federal  Prosecution, GAO-developed key considerations for interagency  collaborative mechanisms, and Standards for Internal Control in the  Federal Government related to quality information. Our scope and  methodology is described in detail in appendix I.

We conducted this performance audit from January 2019 to February  2020 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

DOD Roles and Responsibilities Related to Child Abuse

There are a number of organizations within DOD with responsibility for  preventing, responding to, and resolving incidents of child abuse,  including child-on-child abuse, as described below.

Under Secretary of Defense for Personnel and Readiness. The Under  Secretary of Defense for Personnel and Readiness collaborates with  DOD component heads to establish programs and guidance to implement  the FAP, among other things; it also programs, budgets, and allocates  funds and other resources for the FAP. The Assistant Secretary of  Defense for Manpower and Reserve Affairs, under the authority of the  Under Secretary of Defense for Personnel and Readiness, provides  policy, direction, and oversight to the FAP. The Assistant Secretary of  Defense for Manpower and Reserve Affairs, through the Deputy Assistant  Secretary of Defense for Military Community and Family Policy, is also  responsible for collaborating with service Secretaries to monitor  compliance with FAP standards. The Defense State Liaison Office,  located within the Office of the Deputy Assistant Secretary of Defense for  Military Community and Family Policy, is responsible for assisting with the  passage of state bills that affect key issues within the department, such  as the reporting of child abuse.

DOD Family Advocacy Program. DOD FAP serves as the policy  proponent for, and a key element of, DOD’s coordinated community  response system to prevent and respond to reports of child abuse,  domestic abuse, and problematic sexual behavior in children and youth in  military families. The FAP, among other things, provides trauma- informed assessment, rehabilitation, and treatment to persons who are  involved in alleged incidents of child abuse, domestic abuse, and  problematic sexual behavior in children and youth who are eligible to  receive treatment in a military treatment facility. To execute these  responsibilities, DOD funds over 2,000 positions in the department to  deliver FAP services, including credentialed and licensed clinical  providers. The department prescribes uniform standards for all service  FAPs through DOD Manual 6400.01, Volume 1, FAP Standards. DOD  uses these standards to promote public awareness; aid in prevention,  early identification, reporting, and coordinated, comprehensive  intervention and assessment; and to support victims of child abuse and  domestic abuse. DOD revised these standards in July 2019 to include the  same support and services for children exhibiting or affected by  problematic sexual behavior.

Military Service Family Advocacy Programs. Each military department  Secretary is responsible for developing service-wide FAP policy that  addresses any unique requirements for their respective installation FAPs.  The department Secretaries are also responsible for requiring that all  installation personnel receive the appropriate training to implement the  FAP standards. In addition, each service has a FAP headquarters entity  that develops and issues implementing guidance for the installation FAPs  for which they provide oversight. At the installations, commanders are to  establish an installation Family Advocacy Committee with a chairperson  that serves as the policy implementing, coordinating, and advisory body  to address child abuse and domestic abuse at the installation.

Military Criminal Investigative Organizations and Military Police. The  Department of Defense Inspector General establishes policy, provides  guidance, and monitors and evaluates program performance for all DOD  activities relating to criminal investigations and military law enforcement  programs, including coordination with DOJ. Military law enforcement  organizations include both military police and military criminal  investigative organizations. Each military department has established a  military criminal investigative organization that may initiate investigations  on incidents with a DOD nexus, such as if a crime occurred on a military  installation or involved military personnel or dependents. The military  departments’ military criminal investigative organizations are the

Naval Criminal Investigative Service, and

Air Force Office of Special Investigations.

Each military criminal investigative organization provides an element of  DOD’s special victim investigation and prosecution capability. DOD  defines special victims as adults or children who are sexually assaulted or  suffer aggravated assault with grievous bodily harm. A special victim  investigation and prosecution designation allows the military criminal  investigative organizations to assign specially trained investigators who  work collaboratively with other relevant trained personnel, such as Judge  Advocates and FAP managers, to provide services to the victim. While  military criminal investigative organizations can investigate any crime with  a DOD nexus—within their investigative purview—officials from each  organization stated that they primarily investigate serious felony-level  offenses and any type of sexual offense. Military police that provide  services at military installations primarily serve as first responders to  incidents and will notify a military criminal investigative organization for  more serious incidents requiring an investigation, according to service  officials.

DOD Office of the General Counsel and Service Judge Advocates.  The DOD Office of General Counsel provides advice to the Secretary of  Defense regarding all legal matters and services performed within, or  involving, DOD. The DOD Office of General Counsel also provides for the  coordination of significant legal issues, including litigation involving DOD  and other matters before DOJ. Each military department also has a Judge  Advocate General’s Corps that establishes legal offices (Offices of the  Staff Judge Advocate) which, among other things, serve as prosecutors  and defense counsel at courts-martial; provide legal assistance to eligible  personnel on personal, civil, and legal matters; advise commanders on  military justice and disciplinary matters; and provide legal advice to  military investigative agencies. In addition, any person identified as the  victim of an offense under the Uniform Code of Military Justice (or in  violation of the law of another jurisdiction if any portion of the investigation  is conducted primarily by the DOD components) is to be notified of their  rights under DOD’s Victim and Witness Assistance Program, informed  about the military justice process, and provided other services to support  the victim or witness and their family.

DOD Education Activity. DODEA operates as a DOD field activity under  the Office of the Under Secretary of Defense for Personnel and  Readiness. It is a federally-operated school system that is responsible for  planning, directing, and managing prekindergarten through 12th grade  educational programs for DOD. All DODEA personnel are designated as  mandatory reporters of child abuse and are required to participate in the  early identification of child abuse and the protection of children, including  the prompt reporting of alleged child abuse or any information that gives  reason to suspect child abuse.

FAP is responsible for several child abuse prevention programs across  the services. For example, the New Parent Support Program offers  intensive home visiting services on a voluntary basis to expectant parents  and parents with young children. Officials target the program toward  families who display some indicators of being at risk for child abuse or  who have been assessed and determined as at risk for child abuse. All  FAP personnel are mandated reporters to state child welfare service  agencies for all allegations of child abuse.

In addition, the service FAPs, at every military installation where families  are located, work with the other entities within the coordinated community  response, including civilian social services agencies and law  enforcement, to provide comprehensive prevention and response to  maltreatment. According to service FAP officials, while each service FAP  has a domestic abuse victim advocate program that serves domestic  abuse victims as well as non-offending parents in child abuse incidents, specific prevention efforts vary across installations and services. For  example, the Air Force FAP is taking steps to track the effectiveness of  FAP treatment programs to strengthen prevention efforts. Through the  Navy FAP’s victim advocate program, non-offending parents are  connected with resources from initial referral to case closure—or until the  non-offending parent no longer desires services—that include potential  prevention techniques, such as establishing a strong support system. The  Marine Corps initiated evaluation of prevention programs and uses  evidence-informed curricula to provide parenting education and support,  according to Marine Corps officials. The Army has begun to  operationalize combined parent-child cognitive behavior therapy to  address the needs of children and families at risk for child physical abuse  through child interventions, parent strategies to address child trauma, and  family interventions. At one Army installation, a FAP official described a  puppet show aimed at teaching children about appropriate and  inappropriate behaviors as part of prevention efforts related to  problematic sexual behavior in children and youth.

Other DOD organizations also have roles related to prevention. For  example, child development centers located on installations have a  number of child abuse prevention measures, including visual access  throughout activity rooms used for care, closed circuit television,  identification checks and badges for all visitors, and a system to indicate  which staff members are cleared to be alone with children, such as a  system of colored smocks. In addition, all personnel on military  installations who work with children, including those at DODEA schools,  child development centers, and child and youth centers, must pass a  background check as a condition of employment, among other things.

Child Abuse Incident Determination Process

Each military installation with a FAP has an Incident Determination  Committee (IDC) that reviews reported incidents of child abuse and  domestic abuse to determine whether they meet DOD’s criteria for  abuse. Per DOD guidance, every reported incident of abuse or neglect  must be presented to the IDC unless there is no possibility that the  incident could meet any of the criteria for abuse or neglect. Physical  abuse, emotional abuse, and neglect each have two primary associated  criteria: (a) an act or failure to act, and (b) physical injury or harm, or the  reasonable potential for physical injury or harm; psychological harm, or  the reasonable potential for psychological harm; or stress-related somatic  symptoms resulting from such act or failure to act. Any act of child  sexual abuse that is found to have occurred under part (a) is  automatically considered to have had a significant impact on the child,  which is the criterion for part (b); therefore, the IDC only considers part (a)  for incidents of child sexual abuse, and if the IDC determines the act  occurred, then the incident is found to have met criteria.

Voting members of the IDC include: the deputy to the installation  commander (Chair); the senior noncommissioned officer advisor to the  installation commander; representatives from the servicemember’s  command, the Staff Judge Advocate’s office, and military police; and the  FAP manager or FAP supervisor of clinical services. According to DOD  policy, the IDC may request that additional personnel, such as medical  personnel and military criminal investigative organizations, attend the IDC  when necessary to provide input on incidents and to answer any  questions about the results of a medical examination or an investigation.  IDC members review what is known about the incident, and then the  voting members vote to determine if an incident meets each of DOD’s  criteria for abuse. The final incident determination is made by a simple  majority vote, and the IDC Chair serves as the tiebreaker in the event of a  tie. The IDC’s decision is communicated to the servicemember via the  servicemember’s command. IDC determinations may be reconsidered.  The appeal request and response processes vary by service.

In August 2016, DOD issued guidance standardizing the IDC process  across the services. According to DOD officials, prior to this, each service  had a similar but distinct process for determining whether abuse  occurred. According to a DOD report, the IDC is to be a clinical, not a  disciplinary, process. The IDC is separate and distinct from any law  enforcement or military criminal investigative organization process.

Each incident that is presented to the IDC is also discussed at a clinical  case staff meeting, which is made up of personnel from the FAP, among  others. During the clinical case staff meeting—which can occur before or  after the IDC makes its determination, according to DOD officials— attendees generate clinical recommendations for support services and  treatment for victims and offenders of child abuse who are eligible for  treatment at a military medical treatment facility, and ongoing coordinated  case management. DOD FAP officials stated that treatment is not  dependent on an IDC’s determination, meaning that the FAP may still  provide support services to the family even if the IDC finds that a reported  incident does not meet DOD’s criteria for abuse.

DOJ Roles and Responsibilities in Addressing DOD-Related Incidents of Child Abuse

The Executive Office for United States Attorneys provides general  executive assistance and supervision to the Offices of the United States  Attorneys, including evaluating their performance, making appropriate  reports and inspections, and taking corrective action when needed. The  Executive Office for United States Attorneys also serves as a liaison  between DOJ and the 93 United States Attorneys located across the 50  states, the District of Columbia, and some U.S. territories. United States  Attorneys serve as the nation’s principal litigators and work under the  direction of the Attorney General to prosecute crimes, including some  crimes that occur on some military installations. When cases from military  installations are referred to a United States Attorney’s office for  prosecution, they can be accepted, referred, or declined. The case can be  declined for prosecution for several reasons: (1) it may not constitute a  federal offense, (2) there is insufficient evidence to obtain a conviction, (3)  prosecution would not serve a substantial federal interest, (4) the  individual may be prosecuted in another jurisdiction, or (5) there is  another adequate noncriminal alternative to prosecution.

DOJ’s Criminal Division comprises multiple sections, including the Child  Exploitation and Obscenity Section and the Human Rights and Special  Prosecutions Section, both of which have responsibility for resolving  crimes occurring on overseas military installations. The mission of the  Child Exploitation and Obscenity Section is to protect child welfare and  communities by enforcing federal criminal statutes relating to the  exploitation of children and obscenity. The Human Rights and Special  Prosecutions Section primarily investigates and prosecutes cases against  human rights violators and other international criminals.

The Office of Juvenile Justice and Delinquency Prevention within DOJ’s  Office of Justice Programs provides national leadership, coordination, and  resources to prevent and respond to juvenile delinquency and  victimization. The Office supports the efforts of states, tribes, and  communities to develop and implement effective and equitable juvenile  justice systems that enhance public safety, ensure youth are held  appropriately accountable to both crime victims and communities, and  empower youth to live productive, law-abiding lives.

Community Partner Roles and Responsibilities

In addition to DOD and DOJ, there are also community partners that  assist in responding to and resolving incidents of child abuse, including  child-on-child abuse. Depending on the military installation, there may be  local memorandums of agreement or understanding between the  installation and community partners, such as CACs, child welfare  agencies, and civilian law enforcement that help guide the response to  and reporting of these incidents.

The National Children’s Alliance and Children’s Advocacy Centers.  The National Children’s Alliance is the national association and  accrediting body for a network of approximately 900 CACs with locations  in all 50 states and the District of Columbia. CACs provide a child-focused  environment to conduct child forensic interviews and medical exams,  which are then reviewed by a multi-disciplinary team that includes  medical personnel, law enforcement, mental health personnel, legal  personnel, victim advocates, and state child welfare agencies. The  purpose of the multi-disciplinary team is to determine how to best support  the child, such as through therapy, courtroom preparation, and victim  advocacy.

State and local child welfare agencies and civilian law enforcement.  Each state or locality has a public child welfare agency that is responsible  for receiving and investigating reports of child abuse, as well as  assessing the needs of children and their families. This could include  removing a child from an abusive home or providing support services to  families in need. These agencies are governed by state laws that define  child protection roles and processes. The administrative framework for  child welfare services and programs vary by state, but all are responsible  for compliance with state and applicable federal requirements. For  example, states that accept federal funding under the Child Abuse  Prevention and Treatment Act must meet the statutory requirements of  the Act. Civilian law enforcement organizations are also key to ensuring  the welfare of children. In general, civilian law enforcement organizations  act as first responders to incidents and may provide a variety of services  from reporting the abuse to the appropriate child welfare agency to  conducting an investigation of the incident.

Military Installation Jurisdictions and the Adjudication of Criminal Offenses

As of 2018, DOD occupied varying legislative jurisdictions throughout the  26.9 million acres of land at 4,775 sites worldwide for which it is  responsible. Military installations may consist of one or more sites. In  the United States, military installations have one of four types of  legislative jurisdiction—or, depending on the installation, multiple types of  jurisdiction—that, among other things, helps determine the proper  adjudication venue for any criminal offenses committed on the property of  the installation. The four types of jurisdiction are described below.

Exclusive federal jurisdiction gives the federal government sole  authority to adjudicate criminal misconduct. Exclusive federal  jurisdiction exists when the federal government elected to reserve  authority at the time the real property was granted to the state, or  when the state transferred real property to the federal government  and failed to reserve jurisdictional authority as part of the transfer.

Concurrent jurisdiction applies when both the state and the federal  governments retain all authority to adjudicate criminal misconduct. In  the event of a conflict, the federal government prevails under the  Supremacy Clause of the Constitution.

Partial jurisdiction applies when both the state and the federal  government have some legislative authority, but neither one has  absolute power. The sharing of authority is not exclusive to  adjudication of criminal misconduct and federal supremacy applies in  the event of a conflict.

Proprietary jurisdiction applies to instances where the federal  government has virtually no legislative authority. The only federal laws  that apply are those that do not rely upon federal jurisdiction, such as  espionage, bank robbery, tax fraud, and counterfeiting; the federal  government maintains immunity and supremacy for inherently  governmental functions. An installation commander can exclude  civilians from the area pursuant to his or her inherent authority.

The installation’s jurisdiction as well as the status of the alleged offender  (civilian or servicemember) determines which venue will adjudicate the  incident. For example, if a servicemember commits a crime in exclusive  federal jurisdiction, the adjudication would likely fall under the Uniform  Code of Military Justice. If a civilian commits a crime in exclusive federal  jurisdiction, he or she may be prosecuted under federal law through the  appropriate United States Attorney’s Office. However, if a civilian commits  a crime in concurrent or proprietary jurisdiction, he or she may be  prosecuted by the state. The age of the accused is also an important  consideration because the intent of federal laws concerning juveniles is to  help ensure that state and local authorities will deal with juvenile  offenders whenever possible.

Exclusive federal jurisdiction may be relinquished in part or completely to  a state, and this action is referred to as the retrocession of jurisdiction.  The conference report accompanying the John S. McCain National  Defense Authorization Act for Fiscal Year 2019 included a provision for  the Secretaries of the military departments to seek to relinquish  jurisdiction, such that the state, commonwealth, territory, or possession  would have concurrent jurisdiction over offenses committed on military  installations by individuals not subject to the Uniform Code of Military  Justice, such as civilian dependents and children. The conference  report also directed the Secretaries of the military departments to report  to the defense committees on these efforts 15 months after the  enactment of the Act. In June 2019, the Acting Deputy Secretary of  Defense issued a memorandum directing each military department to  seek to establish concurrent jurisdiction with the respective states for  offenses committed by juveniles in areas on military installations that are  currently exclusive federal jurisdiction. This action seeks to provide  ways for the department to address actions by children in areas of  exclusive federal jurisdiction that may constitute a crime, such as some  instances of problematic sexual behavior in children and youth, since,  absent unusual circumstances, children and other civilians are not subject  to the Uniform Code of Military Justice. According to Army and  department officials, states—whose juvenile courts are rehabilitative in  nature—are much better equipped to deal with suspected crimes  committed by children than the federal government, which does not have  a juvenile justice system. These officials also noted that federal  prosecution is usually declined for such cases.

There are various laws and agreements in place regarding crimes  committed on U.S. military installations or involving servicemembers or  military dependents overseas. These laws include U.S. criminal laws that  may be applied extraterritorially, the Military Extraterritorial Jurisdiction  Act, the Uniform Code of Military Justice, and host nation laws. Whether  a particular law provides extraterritorial jurisdiction over such crimes  depends on the specific facts of the incident, such as the nature and  location of the alleged crime, the status of the alleged offender  (servicemember or civilian), and the nationalities of the alleged offender  and the victim. Status of forces agreements between the United States  and the host nation may also clarify how these circumstances should be  considered in determining venue.

Several Issues Limit DOD’s Visibility over Reported Incidents of Child Abuse and Child-on-Child Abuse

Three primary issues limit DOD’s visibility over reported incidents of child  abuse and child-on-child abuse—standalone databases, information  sharing challenges, and installation discretion. The military services use  standalone databases to track the reporting, response to, and resolution  of each reported incident of child abuse, which limits the department’s  visibility over these incidents. While DOD is developing a new database  to track problematic sexual behavior in children and youth, it has not yet  made key decisions about its development and implementation, which  could further affect visibility. In addition, challenges related to information  sharing limit visibility over child abuse incidents within and across the  military services. Further, Family Advocacy Program (FAP) installation  personnel are given considerable discretion in deciding how reported  incidents of child abuse are tracked and reported, as are DODEA school  personnel with regard to incidents of child-on-child abuse, which also  hinders the department’s visibility over these incidents.

Standalone Databases Limit DOD’s Visibility over Reported Incidents and Key Decisions Related to a New Database Have Not Yet Been Made

Standalone Service Databases Limit the Department’s Visibility over Both the Extent to Which Children Have Been Affected by Abuse and Incident Outcomes

Each military service maintains multiple standalone databases that  separately track the reporting, response to, and resolution of each  reported incident of child abuse, which limits DOD’s visibility over the  extent to which children have been affected by abuse on military  installations or as military dependents and its visibility over incident  outcomes. Depending on the reported incident, information regarding the  alleged abuse may be retained in multiple databases or only one  database. Specifically, each service’s FAP has a database—referred to  as the “central registry”—where it tracks the total number of reported  incidents of child abuse (by a parent or someone in a caregiving role) and  detailed information, such as information about the offender, victim, and  type of abuse, for incidents that met DOD’s criteria for abuse. Incidents  of abuse where the alleged offender was not in a caregiving role are not  tracked in the FAPs’ central registries and would only be tracked as  incidents of abuse if they were investigated by military law enforcement.  Information associated with investigations of these incidents by any  military criminal investigative organization is tracked in a separate  database maintained by each investigative organization. If the alleged  offender was a servicemember, information related to the adjudication or  case resolution is tracked in the relevant service’s military justice  database maintained by the services’ legal offices. Figure 1 shows the  department’s databases for tracking the abuse of children and how they  differ depending on the circumstances of the incident.

Because of DOD’s multiple standalone data systems, it is difficult to know  the extent to which children have been affected by abuse on military  installations or as military dependents. From fiscal years 2014 through  2018, the military service FAPs’ central registries recorded more than  69,000 reported incidents of child abuse, of which 48 percent met DOD’s  criteria for abuse. Over this same time period, the military criminal  investigative organizations conducted approximately 9,500 investigations  involving a child victim, some but not all of which may have also been  recorded in the service FAPs’ central registries. Figures 2 and 3 show  the number of incidents of child abuse reported to the military service  FAPs and the number of military investigations involving a child victim  from fiscal years 2014 through 2018, respectively.

However, the number of incidents tracked by both organizations cannot  simply be added together because, as previously discussed, there is  some overlap between them. For example, an incident of child sexual  abuse inflicted by a servicemember parent or a teacher would likely be in  both databases. Moreover, neither the service FAPs nor the military  criminal investigative organizations individually track all reported incidents  of abuse. Specifically, the FAP only tracks information related to abuse  inflicted by a parent, guardian, or someone in a caregiving role. It does  not capture incidents of abuse inflicted by, for example, a neighbor who  was not babysitting at the time of the incident. While the services’ military  criminal investigative organizations track any abuse of a child that rises to  their level of investigation, such as a felony or sexual offense—regardless  of the relationship between the alleged offender and the victim—they only  investigate certain crimes. For example, an incident of child neglect would  likely only be in the FAP’s central registry because incidents of neglect do  not typically rise to the level of a military criminal investigative  organization investigation. Similarly, an August 2019 report by the  Defense Health Board found that it is difficult to establish the true  incidence of child abuse across the department due to challenges  associated with the underreporting of cases and unreliable capture of  data.

Standalone databases also limit DOD’s visibility over incident outcomes.  Depending on the reported incident of abuse—for example, child sexual  abuse inflicted by a servicemember parent—to get the most complete  picture of how the incident was reported, responded to, and resolved,  service officials would need to query three databases: the FAP, military  criminal investigative organization, and military justice databases. Navy  legal officials stated that a centralized database for all child abuse  incidents—that tracks the FAP’s determination about whether the incident  met DOD’s criteria for abuse, the investigation, and resolution—would be  beneficial because it is currently very difficult to track an incident from the  initial report to its final outcome in order to easily determine what  happened in a particular case. These officials further stated that such a  database would benefit commanders’ oversight of cases for which they  are responsible.

The John S. McCain National Defense Authorization Act for Fiscal Year  2019 included a provision directing DOD to establish and maintain a  centralized database on each incident of problematic sexual behavior in  children and youth reviewed by an installation FAP. Specifically, per the  statute, for each substantiated and unsubstantiated incident of  problematic sexual behavior, the database is to track a description of the  allegation, whether or not a FAP review of the case has been completed,  the status and results of any related law enforcement investigation, and  the nature of any action taken. Officials responsible for the development  of the database—which is supposed to begin in fiscal year 2020—stated  that it will maintain information related solely to cases of problematic  sexual behavior and will not include other types of child-on-child abuse,  such as physical assaults not of a sexual nature. Additionally, these  officials stated that they do not have plans to expand the scope of the  database to include any adult-on-child inflicted abuse.

As a result, even once the centralized database on problematic sexual  behavior in children and youth is implemented, DOD will still lack a  centralized mechanism to track the reporting, response to, and resolution  of other incidents of abuse involving children that were reported to the  FAP or investigated by a military law enforcement organization— specifically, any abuse or neglect inflicted by an adult or physical abuse  inflicted by another child. DOD officials responsible for the development  of the database stated that they do not plan to expand the scope of the  centralized database because they do not want to conflate the processes  for responding to incidents of adult-inflicted child abuse and incidents of  problematic sexual behavior. While the response process differs between  incidents of adult-inflicted child abuse and incidents of problematic sexual  behavior, DOD officials acknowledged that the organizations involved in  the response process and the primary data sources are the same.

Additionally, DOD FAP officials stated the scope of the centralized  database was defined in statute and that they foresee additional privacy  and data-safeguarding issues if they were to expand its scope. While the  statute indicated what must be included in the database, it did not limit the  scope of the database to those required elements. DOD not only lacks  visibility over incidents of problematic sexual behavior, but over any  reported abuse of a child and could therefore benefit from a centralized  tracking mechanism for all such incidents. With regard to privacy and  data-safeguarding concerns, according to DOD, data-safeguarding  precautions were taken when developing the Defense Sexual Assault  Incident Database, which the department successfully implemented.  While the Defense Sexual Assault Incident Database does not contain  information pertaining to children, it contains sensitive information that the  department has taken steps to protect. Specifically, according to DOD,  the Defense Sexual Assault Incident Database is reviewed annually to  ensure all security controls are maintained and it is secured using  physical, technical, and administrative controls, such as role-based  permissions, to maintain the privacy of personal information. DOD FAP  officials also expressed concerns about maintaining information about  both adults and children in the centralized database. However,  information about both adults and children is included in the service  FAPs’ central registries and the military criminal investigative  organizations’ databases. DOD officials responsible for developing the  database noted that the department already plans to take precautions  when developing the database due to the collection and retention of  information about children.

Standards for Internal Control in the Federal Government states that  management should use quality information to achieve the entity’s  objectives. Specifically, quality information is appropriate, current,  complete, accurate, accessible, and provided on a timely basis. In  addition, management should design control activities to achieve  objectives, such as clearly documenting significant events in a manner  that allows the documentation to be readily available for examination.  Without a centralized database that tracks all incidents of abuse involving  children that were reported to the FAP or investigated by a military law  enforcement organization, DOD and Congress will not know the extent to  which children have been affected by abuse on military installations or as  military dependents, or how such incidents have been responded to and  resolved—making it difficult to identify and address trends that could lead  to further prevention efforts.

DOD Has Not Yet Made Key Decisions Related to the Development of Its Database to Track Problematic Sexual Behavior

While DOD is in the early stages of developing a centralized database to  track incidents of problematic sexual behavior in children and youth, it has  not yet made key decisions about its development and implementation,  which could further affect visibility over such incidents. Specifically, DOD  has not yet identified all information requirements, developed a plan for  how it will use the data it collects, or established a schedule for  development and implementation. DOD officials responsible for  developing the database stated that they are still in the process of  selecting a vendor to develop the system and that once a contract has  been awarded and is underway, they can make such decisions. Our prior  work has found that inadequate acquisition planning, including poorly  defined requirements and unrealistic cost estimates, can increase the risk  that the government may receive services that cost more than  anticipated, are delivered late, and are of unacceptable quality. Given  that DOD officials stated they plan to select a vendor in early fiscal year  2020 and move quickly with development—expecting to complete the  bulk of it in fiscal year 2020—it is an appropriate time to make these  decisions.

First, DOD has not yet identified all of the information it will track in the  database. DOD officials responsible for the development of the  centralized database stated that they have not yet identified all of the  information the database will track—other than the information required  by statute and some information related to the response process— because they are still in the early stages of the development process.  However, as previously discussed, DOD officials expect to complete the  bulk of the development this fiscal year. In November 2006, we found that  establishing a valid need and translating that into a service acquisition  requirement is essential for obtaining the right outcome. Without this, an  organization increases the risk that it will pay too much for the services  provided, acquire services that do not meet its needs, or enter too quickly  into a sensitive arrangement that exposes the organization to financial,  performance, or other risks. Additionally, Standards for Internal Control  in the Federal Government states that management should use quality  information to achieve the entity’s objectives, which includes identifying  information requirements that consider the expectations of both internal  and external users. As DOD progresses in its development of the  centralized database, identifying and defining the elements that each  responsible organization, such as the FAP and military law enforcement,  must track would help to ensure that the data collected are useful,  accurate, and complete, and that the data collected ultimately increase  the department’s visibility over these incidents.

Second, DOD has not yet determined how it will use the data it collects  from the database to increase visibility. DOD officials stated that because  they have not yet finalized the information requirements for the database,  they have not yet developed a plan for how the collected data will be  used. GAO-identified leading practices for results-oriented management  have shown that data-driven decision making leads to better results.

Further, agencies can use performance information to identify problems  or weaknesses in programs, to try to identify factors causing the  problems, and to modify a service or process to try to address problems.  As DOD progresses in the development of its database, developing a  plan for data-driven decision making—that details how the department will  use the data to help inform program development and increase visibility— would help DOD to assess its processes and procedures for responding  to and resolving incidents of problematic sexual behavior in children and  youth, identify any needed changes, and modify them as appropriate.

Finally, DOD has not yet established a completion date for the database  or developed a schedule to guide its development and implementation.  According to DOD officials responsible for the development of the  database, while they do not have a planned completion date for the  database or any associated milestones, they plan to select a vendor for  the development in early fiscal year 2020 and they anticipate the majority  of the development will take place the same year. These officials stated  that they have not yet set a completion date, in part, because of the  sensitivity of the information being collected and because the department  does not have a comparable database that collects and maintains  information on children. In addition, while these officials stated that they  had identified resources for the development of the database through  fiscal year 2020, they had not yet identified funding for future years.

GAO-identified practices for developing and maintaining a reliable  schedule include: (1) capturing all key activities, (2) sequencing all key  activities, (3) assigning resources to all key activities, (4) integrating all  key activities horizontally and vertically, (5) establishing the duration of all  key activities, (6) establishing the critical path for all key activities, (7)  identifying float—the amount of time a task can slip before affecting the  critical path—between key activities, (8) conducting a schedule risk  analysis, and (9) updating the schedule using logic and durations to  determine the dates for all key activities. Given that DOD is in the early  stages of development, establishing a reliable schedule for the  development and implementation of the centralized database—including  key activities and the timeframes and resources needed to execute  them—would provide the means to gauge progress, identify and address  potential problems, and promote accountability. Until the database is  implemented, DOD will continue to have limited visibility over incidents of  problematic sexual behavior in children and youth.

Information Sharing Challenges Limit Visibility over Child Abuse Incidents within and across the Military Services

Information Sharing Challenges Limit Visibility within Each Military Service

Information sharing challenges limit visibility within each military service— specifically, as it relates to required notifications between a service’s  installation FAP office and military law enforcement about reported  incidents of child abuse inflicted by a parent or someone in a caregiving  role. DOD policy states that the Secretaries of the military departments  are to ensure that installation commanders or service-equivalent senior  commanders ensure that the installation FAPs immediately report any  allegations of child abuse and any criminal allegations to the appropriate  law enforcement authority. Similarly, service guidance states that  military law enforcement is responsible for notifying the installation FAP  office of reported or suspected incidents of child abuse.

However, officials at four installations in our review described notification  challenges between these organizations. For example, officials at one  installation described a child abuse incident that had been investigated by  military law enforcement for 2 to 3 months, but the investigating  organization had not notified the installation’s FAP office. Legal officials at  another installation stated that over the past year, there had been five  incidents of child abuse that were reported to the installation FAP office,  but that the FAP had not reported to military law enforcement. These  officials stated that the lack of notifications can be frustrating for  commanders who need complete information about these incidents to  determine whether they need to take any action.

In addition, DODEA policy states that, among other things, DODEA  personnel are to promptly report all suspected or alleged incidents of child  abuse to the installation FAP office and the relevant child welfare agency,  if available. The policy does not require them to also report the  suspected abuse to law enforcement, but the FAP is to report the incident  to law enforcement. However, a senior DODEA official stated that one of  its regions has instituted a procedure for all child abuse incidents to be  reported to the FAP and law enforcement because the region had  experienced challenges with the FAP not consistently notifying law  enforcement.

The extent of these notification challenges is unknown because service  FAP and military law enforcement officials stated that they do not  document in their central registries or military criminal investigative  organization databases whether each notified the other. Service FAP and  military law enforcement officials stated that they can add fields to their  databases to track new information if provided with the direction and  resources to do so. Officials from these organizations also noted that any  notification to the other entity may instead be documented in any case  notes or in the case file. However, in April 2019, the DOD Office of  Inspector General evaluated military law enforcement incident reports and  found similar notification challenges related to FAP and military law  enforcement notifications for domestic violence incidents. Specifically,  the DOD Office of Inspector General evaluated 212 military law  enforcement domestic violence reports in which a FAP notification was  required and for 23 percent of the incidents (49 incidents) the military law  enforcement organization had not notified the FAP as required.

Standards for Internal Control in the Federal Government states that  management should internally communicate information to achieve the  entity’s objectives. For example, information is communicated down,  across, and up reporting lines to all levels of the entity. In addition, the  oversight body receives quality information that flows up the reporting  lines from management and personnel.

Without directing the service FAPs and military law enforcement  organizations to document in their respective databases the date that  they notified each other, these entities’ headquarters will remain limited in  their oversight abilities to ensure that these notifications occur and to take  appropriate actions in response. Even if notifications are documented in  case files, there is no mechanism for the headquarters entities to  efficiently determine whether a notification was made. Without ensuring  that notifications are made to both organizations, which play critical roles  in addressing incidents of child abuse, it is possible that an incident may  not be fully assessed by the FAP or investigated by military law  enforcement. Notification delays could result in at-risk children remaining  in an unsafe environment or could delay time-critical portions of an  investigation, such as forensic interviews or sexual assault exams.

Information Sharing Challenges Limit Visibility across the Military Services

Information sharing challenges limit visibility across the military services,  specifically as it relates to sharing child abuse incident determinations.  Installation officials stated that the lead service for any installation is  responsible for the installation’s FAP. They stated that even though the  Incident Determination Committee (IDC) will hear cases about the other  services’ members and dependents, all information is recorded in the lead  service’s central registry. For example, if an Air Force servicemember is  involved in a reported incident of child abuse while on an Army  installation, the Army FAP will record information about the incident in its  central registry. Of the Air Force FAP’s more than 3,000 reported  incidents that met criteria for child abuse from fiscal years 2014 through  2018 and had a servicemember offender, 22 percent of those offenders  were from one of the other three services. For the Army, the Navy, and  the Marine Corps, 2 percent, 9 percent, and 5 percent, respectively, of  their records were associated with servicemembers from another service.  Table 1 shows the number of child abuse incidents that met DOD’s  criteria for child abuse and involved a servicemember offender from fiscal  years 2014 through 2018, by the service that recorded the incident and  servicemember affiliation.

Since FAP personnel at the installations do not share access to the other  service’s central registries or the DOD Central Registry, according to  DOD FAP officials, they have established a process to share information  about child abuse allegations and determinations across the services. Per  DOD guidance, the service FAPs are to submit data from their central  registries on a quarterly basis for consolidation into DOD’s Central  Registry. According to DOD FAP officials, after the service FAPs submit  their data, the Defense Manpower and Data Center reviews the data and  identifies any child abuse incidents that met DOD’s criteria for abuse and  were recorded by a service FAP that is not the service to which the  servicemember is assigned. According to these officials, the Center then  forwards those relevant incidents to the services to which the  servicemembers are assigned with the expectation that they will  incorporate them into their central registries. According to Air Force,  Navy, and Marine Corps FAP officials, they regularly incorporate the data  received from the Center into their central registries so that they can be  searched by FAP personnel at the installations.

However, DOD does not have guidance that describes how the service  FAPs should receive information from the Center about child abuse  allegations and determinations that involve their personnel, but were  recorded by another service’s installation FAP, or how they should  incorporate such information into their central registries once received.  Further, according to DOD FAP officials, DOD does not have a process to  monitor that the service FAPs are consistently incorporating the  information they receive from the Center into their central registries.  Standards for Internal Control in the Federal Government states that  management should internally communicate information to achieve the  entity’s objectives. In addition, management should implement control  activities through policies and establish and operate monitoring activities  and evaluate the results. Specifically, ongoing monitoring is built into the  entity’s operations, performed continually, and responsive to change.

For example, one of the required fields in the service FAPs’ central  registries is whether the offender was previously known to the service’s  central registry—meaning that the offender was involved in a previous  incident of child abuse or domestic abuse that was presented to the  service FAP and was determined to meet DOD’s criteria for abuse.  However, if the incident of abuse occurred on another service’s  installation, and was therefore recorded in that other service’s central  registry—and the service to which the servicemember is assigned was  either not informed or did not input the information into its central  registry—the servicemember’s FAP may not be aware of the prior case  and therefore may not record the offender as previously known. Issuing  guidance that describes the process through which the service FAPs are  to receive and incorporate information into their central registries  regarding child abuse allegations and determinations involving their  servicemembers and dependents—that also includes a mechanism to  monitor that the process is consistently occurring—would provide better  assurance that the services have complete and up-to-date information  about their personnel and their dependents, which ultimately affects their  visibility over such incidents.

Discretion by FAP and School Personnel in How Incidents of Child Abuse and Child-on-Child Abuse Are Tracked and Reported Further Hinders DOD’s Visibility

FAP Discretion in Screening Reported Incidents Hinders Overall Visibility

FAP personnel at all seven installations in our review stated that they  screen reported incidents of child abuse to determine whether to present  them to the IDC. DOD guidance states that every reported incident of  child abuse must be presented to the IDC for a determination unless  there is no possibility that the incident could meet any of the criteria for  child abuse or neglect. However, installation personnel described  reported incidents of child abuse that had been screened out that, per  DOD guidance, should have been presented to the IDC. For example,  FAP officials at one installation stated that they screen out reports of  spanking by a parent if there is no mark. Since DOD’s list of actions  considered to be nonaccidental physical force includes spanking, it meets  at least one of DOD’s criteria for child abuse and should be presented to  the IDC for a determination. The IDC would then determine whether there  was a significant impact on the child, such as a welt or a more than  superficial bruise, or the reasonable potential for a more than  inconsequential physical injury or fear reaction—to determine whether the  reported incident meets all of DOD’s criteria for child physical abuse.  Officials from three of the services’ FAPs stated that if spanking is used  as a discipline technique—without information of injury or potential for  injury or psychological harm—then it should not be opened as an incident  and presented to the IDC. However, this is in conflict with DOD guidance  as confirmed by DOD FAP officials.

At another installation, child development center officials described an  incident where a staff member was speaking harshly with a child. These  officials stated that the supervisor at the center considered the action to  be child abuse—berating the child, which per DOD guidance is an act of  emotional abuse—and contacted the installation FAP. However, they  stated that the FAP personnel that received the report stated, without any  assessment of the incident, that it was not emotional abuse and that the  center should handle it administratively. According to center officials, the  incident was never presented to the IDC, but they considered the incident  to be significant enough that the center terminated the staff member’s  employment. FAP officials at a different installation stated that the  medical clinics were not previously reporting suspected abuse to the FAP,  but are now doing so. Because of this change, the FAP personnel said  they believe the clinics are over-reporting, which has led to the FAP  personnel screening out some of the clinic’s reported incidents of  suspected child abuse.

Two of the parents of children affected by abuse that we interviewed  discussed incidents that were reported to the FAP, but that the FAP did  not initially present to the IDC. According to one parent, one incident of  child abuse was presented to an IDC at a different installation after the  parent contacted the FAP at that installation for advice more than 2 years  after the initial report of abuse. According to the other parent, the other  incident of child sexual abuse was only presented to the IDC following  congressional involvement.

FAP personnel at one installation described the process of determining  whether a reported incident should be presented to an IDC as a clinical  judgement call and noted that they screen out about one-third of reported  incidents of child abuse annually. FAP personnel at another installation  stated that, as of summer 2019, they had received about 50 reported  incidents of child abuse since the start of the calendar year and that they  had screened out the majority of them. While installation FAP personnel  also described reported incidents of abuse that should be screened out  as child abuse per DOD guidance—such as abuse where the alleged  offender was not a parent, guardian, or someone in a caregiving role,  which is outside of the FAP’s purview—it is unclear how many of the  reported incidents that they have screened out should have been  presented to the IDC per the guidance.

Incidents that are not presented to the IDC are not recorded in the  relevant service FAP’s central registry and therefore are not captured in  DOD’s consolidated Central Registry, which the department uses to  prepare its statutorily required annual reports to Congress on child abuse  and domestic abuse. As a result, the actual total number of reported  incidents of child abuse across the department—which according to our  previously discussed analysis totaled more than 69,000 from fiscal years  2014 through 2018—may be higher. As previously discussed, the  Defense Health Board’s August 2019 report noted that it is difficult to  establish the true incidence of child abuse across the department due to  challenges associated with the underreporting of cases and unreliable  capture of data and that as a result, it is difficult to measure and monitor  the scope of the problem.

When we discussed with DOD FAP officials what the installations we  visited told us about how they screen reported incidents of child abuse,  officials expressed concerns about these installations not adhering to  DOD guidance. However, as previously discussed, the service FAPs are  responsible for overseeing installation FAPs. According to service FAP  officials, oversight of the screening process is primarily handled by  personnel at each installation. Air Force FAP officials stated that the FAP  personnel making these screening determinations have to meet certain  education requirements. Standards for Internal Control in the Federal  Government states that management should establish and operate  monitoring activities and evaluate the results. Without each military  service developing a process to monitor how reported incidents of child  abuse are screened at installations, the services cannot be sure that  incidents are being presented to the IDC in a consistent manner. Further,  installation FAPs may continue to screen out reported incidents of child  abuse, in contradiction of DOD guidance, therefore excluding them from  being documented in DOD’s Central Registry. As a result, DOD does not  know and cannot accurately report on the total number of reported  incidents of child abuse across the department. In addition to other known  underreporting, without such initiatives, DOD is further limiting its visibility  over incidents and hindering its ability to ensure appropriate responses to  incidents.

School Discretion in Reporting Serious Incidents Hinders DODEA Leadership Visibility

According to our analysis of DODEA data, DOD schools may not be  reporting all serious incidents of child-on-child abuse, which hinders  DODEA leadership visibility. From school years 2013-2014 through  2017-2018, across its 163 schools, DODEA reported a total of 167  serious incidents involving either an alleged violation of law or an alleged  sexual event—on average, one serious incident per school over the 5- year period. The types of reported serious incidents included a student  reporting that they were raped by two students in the school parking lot, a  student stabbing another student in the finger with a plastic fork and  drawing blood, and a wide range of other conduct. There was a slight  decrease in the number of serious incidents reported from school years  2013-2014 to 2014-2015, but since school year 2014-2015, the number of  serious incidents reported each year increased from a low of 22, to 55 in  school year 2017-2018. DODEA officials attribute the increased reporting,  in part, to the issuance of additional reporting guidance in August 2016.  Figure 4 shows the number of serious incidents involving either an  alleged violation of law or an alleged sexual event reported by DODEA  from school years 2013-2014 through 2017-2018.

According to DODEA officials, all serious incident reports are reviewed by  DODEA headquarters to ensure that the schools took the appropriate  actions needed to protect students and to ensure that incidents are  correctly categorized. These officials stated that the reports also help to  increase visibility at the headquarters level about the types of incidents  occurring in DODEA schools and where additional resources may be  needed. In addition, DODEA officials stated that they retain serious  incident reports for 5 years, which allows them to track serious conduct  issues when students transfer schools.

While the reporting of serious incidents has increased, our analysis of  DODEA student misconduct records found that schools’ reporting of  these incidents was incomplete. Specifically, our analysis identified 216  student misconduct records for school years 2016-2017 and 2017-2018  that school administrators, following DODEA guidance, could have  reasonably classified as serious incidents. The types of incidents  described in the student misconduct records included, among other  things, the use of physical force by a student on another student that  resulted in an injury; a student touching another student’s groin, breasts,  or buttocks without consent; and verbal and behavioral sexual  harassment. However, for this time period—for which DODEA reported  the highest number of serious incidents from school years 2013-2014  through 2017-2018—DODEA only reported 89 serious incidents. In  addition, DODEA officials stated that prior to August 2018, up to one-third  of schools were not recording student misconduct in the student  information system because they were not required to do so and, as a  result, we were not able to review any misconduct records for those  schools.

Challenges related to the reporting of serious incidents were also  highlighted in our interviews with parents and DODEA school  administrators. Specifically, two of the parents of children affected by  child-on-child sexual abuse that we interviewed discussed incidents that  occurred within DODEA schools. They both stated that they received  information about the incidents as part of Freedom of Information Act  requests and that the schools had not reported the abuse as serious  incidents. For one of these incidents, we identified a corresponding  DODEA child abuse report, but not a serious incident report. Per DODEA  guidance, the incident should have been categorized as a serious  incident (but not as child abuse) because the offender was a student— child abuse reports are only to be filed if the alleged offender was an  individual responsible for the child’s welfare, such as a parent or a  teacher.

In addition, at one installation in our review, FAP personnel discussed a  recent sexual assault within a DODEA school. When we discussed this  incident with a senior DODEA official who is to be notified of all serious  incidents reported in the region in which the school is located, the official  was unaware of the incident because it was not categorized as a sexual  assault in the serious incident report and another senior official for the  region had handled it directly. Further, administrators at one of the  DODEA schools we visited stated that the reporting guidelines are not  fully clear and that they often call the superintendent’s office for advice on  what to report and how to report it.

Standards for Internal Control in the Federal Government states that  management should internally communicate the necessary quality  information to achieve the entity’s objectives. Specifically, management  communicates quality information down and across reporting lines to  enable personnel to perform key roles in achieving objectives. However,  DODEA’s guidance affords school administrators discretion in what to  report because it does not explicitly define what types of serious incidents  must be reported. While the guidance identifies and defines a number of  incidents that could be reported as serious incidents, and provides  detailed examples—like a student intentionally exposing their genitals or  a student posting naked or suggestive photos of another student online— the guidance does not mandate that these incidents be reported.  Specifically, the guidance states that the lists of events, activities, and  paraphernalia described in the guidance as serious incidents are  illustrative only and do not identify every incident that may be  inappropriate, nor require that each incident result in a serious incident  report.

While DODEA officials noted that both reporting and their visibility over  serious incidents has been improving, they acknowledged that  administrators may not be reporting all serious incidents described in the  guidance because, in part, it may be easier for them to resolve some  incidents—such as students jokingly slapping each other on the  buttocks—at the school level instead of filing a serious incident report.  These officials stated that they are optimistic a new reporting database for  serious incidents that they implemented in August of 2019 will streamline  the process for administrators and increase reporting. In addition, in  February 2019, DODEA issued guidance related to the reporting of and  response to prohibited sexual, sex-based, and other related abusive  misconduct, which DODEA officials told us they believe will reduce  discretion in how alleged child-on-child sexual abuse is recognized and  reported.

While the new reporting system and guidance related to child-on-child  sexual abuse are positive steps, without additional guidance that clarifies  the types of incidents—including non-sexual incidents—that must be  reported as “serious incidents,” DODEA may continue to lack full visibility  into the extent to which serious incidents are occurring. As a result,  systemic issues within a particular school or district may never be  reported to DODEA leadership and any additional resources that a school  or district needs to prevent future incidents may not be identified. Further,  when a student transfers schools, the new school may be unaware of  serious conduct issues that were not properly documented, raising safety  concerns for the school and installation.

DOD Has Expanded Policies and Procedures on Child Abuse to Address Child-on-Child Abuse, but Gaps Exist in Processes for Responding to and Resolving Incidents of Abuse

DOD and the military services have taken steps to expand child abuse  policies and procedures to address child-on-child abuse in response to  Congress, but gaps exist in the processes for responding to and resolving  incidents of abuse. Specifically, the services may lack pertinent  stakeholder perspectives on the IDC after DOD policy changed the  permanent voting membership of the committee. In addition, families of  child abuse victims may receive inconsistent levels of information  following a report of child abuse, which can cause confusion and prevent  them from receiving available services. Further, service guidance  regarding the extent of commander authority to remove children from  unsafe homes overseas is unclear. Finally, the availability of certified  pediatric sexual assault forensic examiners is limited, especially  overseas.

DOD Has Taken Steps to Expand Child Abuse Policies and Procedures to Address Child-on-Child Abuse

In accordance with provisions in the John S. McCain National Defense  Authorization Act for Fiscal Year 2019, DOD and the military services  have taken steps to augment existing child abuse policies and procedures  to also include child-on-child abuse, specifically the incidence of  problematic sexual behavior in children and youth. The statute required,  among other things, that the Secretary of Defense establish a policy,  applicable across all military installations, to respond to allegations of  problematic sexual behavior in children and youth on military  installations. The purpose of the policy is to ensure a consistent,  standardized response to such allegations across the department. In May  2019, DOD issued a revised FAP instruction that establishes policy, assigns responsibilities, and prescribes procedures for the FAP specific to  child abuse, domestic abuse, and problematic sexual behavior in children  and youth. In addition, in July 2019, DOD revised the FAP standards to  implement policy, assign responsibilities, and provide procedures for  addressing problematic sexual behavior in children and youth in military  communities. As of October 2019, the military services had not yet  issued their updated FAP policies to incorporate the new department- wide policy and standards, but the policies were under development,  according to DOD FAP officials.

Prior to the issuance of DOD’s updated FAP policy, the Army issued a  broader policy on major juvenile misconduct in March 2019. The policy  addresses the command response to juvenile misconduct and the referral  of juvenile cases to civilian authorities. For Army installations in the  United States with areas of exclusive federal jurisdiction, the policy directs  such commands to seek to establish concurrent jurisdiction of juvenile  criminal offenses. In instances where establishing concurrent jurisdiction  is not feasible or recommended, the policy directs commanders to pursue  memoranda of agreement with local prosecution authorities that address  the referral of juvenile cases to the local juvenile court system for state  review and state determination of appropriate disposition. Army officials  stated that the Army policy covers more than incidents of problematic  sexual behavior in children and youth because the challenges involving  children on Army installations are broader than problematic sexual  behavior and encompass other types of misconduct, such as fights,  vandalism, and shoplifting. Officials from the other services stated that  their policies, which are under development, will focus on problematic  sexual behavior because that was what was required per statute.

In addition, DOD has taken steps to implement a training program for  personnel at installations that focuses on problematic sexual behavior in  children and youth. Specifically, DOD and DOJ’s Office of Juvenile  Justice and Delinquency Prevention entered into an interagency  agreement in July 2019 to expand the scope of DOJ’s cooperative  agreement with the University of Oklahoma. According to DOD officials,  this agreement includes providing training and technical assistance in  support of DOD’s response to problematic sexual behavior in children and  youth. The 3-year interagency agreement provides $1.5 million in  funding, and according to DOD officials, the funding will be used to  develop and implement targeted training on problematic sexual behavior  in children and youth for FAP personnel at the installations. According to  DOJ officials, other efforts include a DOJ and DOD working group on  child-on-child sexual abuse—focused on resolving jurisdictional issues,  as will be discussed in greater detail later in the report—and the  development of a centralized database for tracking incidents of  problematic sexual behavior in children and youth, as previously  discussed.

Further, DODEA has implemented a number of initiatives related to  serious student misconduct. These include the issuance of a standalone  sexual harassment policy and providing administrators with additional  guidance on reporting and responding to sexual activity within DODEA  schools, and the development and distribution of standardized language  regarding discrimination and sexual harassment for each school’s student  handbook. DODEA also created outreach materials for students on how  to recognize and respond to sexual harassment. DODEA has conducted  training for administrators on these topics. Other training initiatives  include training for all counselors, school psychologists, and nurses on  problematic sexual behavior in children and youth. As previously  discussed, DODEA also introduced a new reporting database for serious  incidents in August 2019 that is intended to simplify the serious incident  reporting process for administrators.

Installation Incident Determination Committees May Lack Pertinent Stakeholder Perspectives

In August 2016, DOD issued guidance to standardize the incident  determination process across the military services, which, among other  things, reshaped the permanent voting membership of the IDC. However,  the new structure may lack stakeholders with the requisite knowledge and  expertise to allow the IDC to make fully informed determinations. The  standardized process to determine whether an incident meets DOD’s  criteria for child abuse was informed by a collaboration between the Air  Force and New York University researchers, which yielded a decision- tree algorithm. The process was implemented by the Air Force and then  subsequently adopted by the Navy and the Marine Corps. According to  Army officials, the Army’s phased implementation of the IDC process was  ongoing as of October 2019.

As part of the standardization of the process in the 2016 guidance,  medical personnel were removed as permanent voting members of the  IDC, although they regularly participated in some of the services’ prior  incident determination processes, according to Army FAP officials. The  external researchers involved in the effort noted that they were primarily  involved in the decision-tree algorithm and not the composition of voting  members, which was an internal DOD decision. According to DOD, the  definitions in the decision-tree algorithm used to determine if an incident  meets criteria to be considered child abuse were robust enough that  experienced healthcare providers were not needed to determine if an  incident met DOD’s criteria for child abuse. In addition, DOD FAP officials  stated that participation in the IDC process by medical personnel could  take them away from their clinical duties and become burdensome since  the IDC at larger installations may meet weekly and for several hours.

DOD officials noted that medical personnel, and others, can still be invited  to participate in the IDC process as needed to provide information related  to specific incidents. While IDC members at four of the installations in our  review also noted that medical personnel can still be invited to share  relevant case information—in a nonvoting capacity—medical personnel  we spoke to at three of these installations noted that they are rarely  invited to participate. As a result, medical personnel at one installation we  visited stated that they have attempted to write their medical reports in  more lay terminology to bridge the gap and to help ensure that critical  information is properly relayed during the IDC meeting. Medical personnel  with expertise in child abuse stated that they would welcome the  opportunity to again participate in IDC meetings about which they have  specific knowledge, but that they are contacted to participate once every  2 years at the most. In addition, medical personnel at one of the  installations we visited had never heard of the IDC and were unaware of  its function.

During a number of our interviews and installation visits, medical  personnel frequently expressed concerns about the lack of medical  expertise in the IDC process. For example, medical personnel at three  installations we visited expressed concerns that the absence of medical  personnel on the IDC may prevent reported incidents of child abuse from  being fully understood. They noted that medical personnel—specifically,  pediatricians—have particular utility on the IDC because of the complexity  of some of the cases and the need to articulate how medical findings can  indicate whether an injury resulted from a nonaccidental use of force.  Medical personnel with expertise in child abuse stated that there is a  strong medical component to many child abuse cases and that FAP  clinicians may not have the requisite medical expertise needed to  appropriately interpret that information. Medical personnel also stated that  lacking this expertise could result in the IDC incorrectly voting that an  incident meets criteria for abuse or does not meet criteria. For example, a  pediatrician described one IDC meeting in which they were invited to  participate, as a nonvoting member, related to an incident that had  medical evidence that the pediatrician referred to as clearly presenting a  hallmark finding in child abuse—ear bruising patterns in a very young  child. However, the pediatrician stated that the IDC voted that the incident  did not meet DOD’s criteria for abuse before allowing medical personnel  to present information they had about the incident. According to this  pediatrician, after the vote, the IDC allowed the pediatrician to provide  information about the incident, but it did not alter the committee’s initial  determination.

At one of the IDC meetings we observed, IDC members discussed a case  that involved bruising. The IDC members noted that they wished that a  doctor had been present so that they could determine whether the  allegation had any merit. However, no medical personnel were present  and the IDC reached a determination without medical input. Members of  this IDC also discussed concerns about a downward trend across the  service in the number of cases meeting DOD’s criteria for abuse, which  they attributed to changes to the voting membership of the committee.

In addition, one of the parents that we spoke with described an incident  that met DOD’s criteria for child sexual abuse under the military service’s  prior incident determination process. However, the parent stated that after  the service implemented the new IDC process, the servicemember’s  command—which was added as a permanent voting member of the  IDC—requested that the determination be reconsidered. The parent  stated that the incident was again presented to the IDC and the  committee reversed the initial determination, concluding that the incident  did not meet DOD’s criteria for child sexual abuse. The parent expressed  concerns that the removal of medical personnel from the IDC process  played a significant role in the reversal of the determination.

Further, at one installation in our review, after the installation  implemented the new IDC process, officials set up a separate pre-IDC  process to discuss the same cases with medical personnel and others to  ensure that they include their perspectives in the determination process.  Installation officials stated that they felt the need to establish this  redundant process because participation and discussion are more limited  under the IDC process and there was an identified gap.

In August 2019, the Defense Health Board recommended that DOD  reconsider requiring at least one comprehensive pediatric medical health  care provider to be a member of all IDCs. However, DOD FAP officials  stated that they have no plans to reassess or expand the voting  membership based on this recommendation or the concerns expressed  by medical personnel across the military services. They stated that there  are other meaningful ways in which medical personnel can participate in  the IDC process, but that they should not be voting members because  their competing clinical responsibilities may lead to a lack of continuity on  the IDC and they might not have any direct knowledge of the incidents  being discussed. However, as previously discussed, medical personnel  are not being regularly invited to participate and, when they are, the  information they present may not be considered as part of the voting  process. In addition, medical personnel at one installation we visited  noted that even if they were regularly invited to participate, since they are  not permanent voting members, other clinic responsibilities may take  precedence.

A 2018 Department of Health and Human Services guide for child  protective caseworkers noted that involving teams with a diversity of  skillsets, including pediatricians, early in the child abuse determination  process can improve accurate and comprehensive assessments,  information sharing, and analysis of gathered information to support an  accurate substantiation decision. In addition, GAO-developed practices  to enhance and sustain collaboration in interagency groups note that it is  critical to involve nonfederal partners, key clients, and stakeholders in  decision-making. Further, in February 2014, we found that if collaborative  efforts do not consider the input of all relevant stakeholders, important  opportunities for achieving outcomes may be missed.

Without expanding the voting membership of the IDC to include medical  personnel, installation officials may not have all of the relevant information  to make a fully informed decision about whether an incident meets DOD’s  criteria for child abuse. The IDC may make different determinations  without the benefit of input from all relevant personnel, thus affecting  confidence in the efficacy of the process. Further, without expanding the  voting membership to include medical personnel, installations may  continue to develop concurrent or redundant processes in order to ensure  that all pertinent information about cases is shared.

Inconsistent Levels of Information Are Available to Victims’ Families Following a Reported Incident of Child Abuse

Victims’ families receive inconsistent levels of information related to the  response process and available services after an incident of child abuse  is reported. The process to respond to and address incidents of child  abuse can be lengthy—the average investigation is more than 9  months—and the responding organization and the particular steps it takes  depend on variables including the type of abuse, the status of the alleged  offender, and the location of the incident. For example, as previously  discussed, military criminal investigative organizations primarily only  investigate serious felony-level offenses and any type of sexual offense.  According to military criminal investigative organization officials, cases  that do not meet this threshold may be investigated by other military law  enforcement investigators, such as military police or local civilian law  enforcement. Additionally, the FAP only reviews incidents of child abuse  where the alleged offender was a parent or someone in a caregiving role.

As a result, the FAP would not present incidents to the IDC where the  alleged offender was another child or an adult who was not in a  caregiving role, such as a neighbor who was not babysitting at the time of  the incident. Further, as previously discussed, the jurisdiction of the  installation where the incident took place determines which entity, such as  the state or the federal government, will adjudicate the incident. The  process can also differ based on the state and local laws where the  incident occurred. For example, according to some state child welfare  agencies, they are more likely than the FAP to accept cases of child-on- child abuse, and they review such cases to see if a lack of supervision or  other aspect of parental neglect is involved.

The legal services that victims are eligible to receive differ depending on  the status of the alleged offender and the victim, and the type of abuse  alleged. For example, for incidents of child sexual abuse with an alleged  servicemember offender, victims and their families are eligible for military- provided legal advice and assistance, even if the abuse occurred off the  installation. However, the status of the victim (that is, whether the victim is  the dependent of a military member or not) will impact the nature and  extent of the legal assistance that can be provided.

Of the 20 parents of children affected by abuse that we interviewed, nine  stated that they did not understand what to expect during the investigation  and resolution process and nine were not aware of all available services  and resources offered. Some parents noted that if they had better  understood the process and available services, they could have received  counseling and other services more quickly. Twelve parents highlighted  that a guide summarizing the process and available services would have  been helpful. For example, seven parents said that they did not receive  and were not offered any services by the military. Multiple respondents  also highlighted the lack of sufficient legal assistance. Specifically, five  parents stated that they would have liked legal assistance but none was  available, and seven parents stated that the legal services offered by the  military did not meet their needs. For example, one parent stated that  they requested a waiver to receive the services of a Special Victims’  Counsel, but the request was denied for reasons that are unclear.

Standards for Internal Control in the Federal Government states that  management should externally communicate the necessary quality  information to achieve the entity’s objectives. Specifically, management  communicates with and obtains quality information from external parties,  including the general public, and in this case victims’ families. However,  while each organization, such as the FAP, may provide information to  families relevant to that organization’s responsibilities and services, the  military services have not established efforts to comprehensively inform  victims’ families about how child abuse incidents are to be addressed by  each responsible organization, for example by consolidating information  to help families understand the process and the services available to  them. While DOD officials stated that they have plans to develop such a  guide for responding to incidents of problematic sexual behavior in  children and youth, they stated that they do not have plans to develop a  similar guide for responding to incidents of child abuse because  information is already available from a number of different sources.  However, the parents we spoke with had challenges locating this  information in a timely manner following an incident of child abuse and  highlighted the need for additional information in a consolidated format to  avoid confusion and to more easily receive necessary services.

Without each military service establishing efforts to comprehensively  inform victims’ families about how reported incidents of child abuse will be  addressed, affected families may be confused about the process and  where to go for information. In addition, they may not receive the services  that they are entitled to and need, such as a Special Victim Counsel or a  legal assistance attorney, because they do not know that these resources  are available. As a result, DOD may not be providing comprehensive  responses to reported incidents of child abuse.

Service Guidance Related to the Extent of Commander Authority to Remove Children from their Homes on Overseas Installations Is Unclear

The military services’ guidance regarding the extent of commander  authority to remove children from their homes on overseas installations is  unclear. Within the United States, state and local child welfare agencies  have the authority to remove children from unsafe homes. However,  officials at an overseas installation stated that there is no law that clearly  authorizes commanders to exercise this authority on overseas  installations, and there may be no local authorities to provide guidance or  services at overseas installations. Rather, service guidance grants  installation commanders the authority to remove children from unsafe  homes on a temporary basis. Guidance describing this authority is not  standardized across the services and installation officials overseas stated  that additional guidance would help clarify situations when a child can be  removed from an unsafe home.

For example, according to Army guidance, an installation commander  may authorize emergency placement care when abuse is substantiated  and when neither judicial authorization nor parental consent can be  obtained, and the removal is necessary to avoid risk of imminent death,  serious bodily harm, or serious mental or physical abuse. In addition,  commanders may take action in situations when medical protective  custody is not appropriate. Per Navy guidance, commanders can only use  this authority in situations where there is substantial reason to believe the  life or health of the child is in real and present danger. Air Force  guidance states that base security and unit leadership are responsible for  overseeing the appropriate removal or placement of children with  consultation and guidance from the FAP. Per Marine Corps guidance,  commanders may implement a child removal order—designed for short- term placement of a child into a place of safety. Individual installation  commanders are responsible for issuing a written policy setting forth the  procedures and criteria for the removal of child victims of abuse or other  children in the household when they are in danger of continued abuse or  life-threatening child abuse.

Officials at installations overseas stated that the decision to remove a  child from an abusive home can vary depending on the commander’s  comfort level in doing so. For example, officials at two installations  provided an example where a commander removed a child from the  home in a situation of suspected abuse, and then a parent requested an  Inspector General investigation questioning the commander’s authority to  do so. Installation officials stated that the complaint to the Inspector  General was not substantiated, but that the ambiguity of the guidance,  coupled with the possibility of a commander having his or her actions  reviewed by the Inspector General, could affect a commander’s  willingness to take action in similar cases. Medical personnel we spoke with highlighted examples where military hospitals overseas have  admitted child abuse victims for their safety in situations when installation  commanders did not take action to otherwise remove the child from the  home. In one example, an infant presenting with physical trauma  consistent with abuse was admitted to the hospital for 1 month until the  child could be returned to the United States and a state child welfare  agency could respond to ensure the child’s safety.

Installation officials overseas responsible for addressing incidents of child  abuse stated that they believe additional clarity regarding commander  authorities would help commanders in making a determination about  when to exercise their authority to remove an at-risk child from a home. In  comparison to the services’ guidance, some state child welfare agencies  have comprehensive checklists and decision matrices to help officials  make decisions regarding child removal. One child welfare agency we  visited provided a list with 14 specific safety factors, including descriptions  of each factor, and a list of 10 protecting interventions. Safety factors  include anything that may put a child in danger, for example, questionable  caretaker explanations for a child’s injuries, or the family not allowing the  child welfare agency access to the child. Protecting interventions include  actions such as the family making use of community agencies or services  as a safety resource, or the non-offending caretaker moving to a safe  environment with the child. There is no comparably detailed guidance for  military commanders.

Standards for Internal Control in the Federal Government states that  management should internally communicate the necessary quality  information to achieve objectives. Quality information is reported down  and across reporting lines to enable personnel to perform key roles in  achieving objectives. However, legal officials and medical personnel at  overseas installations stated that existing guidance regarding commander  authority to remove children from potentially unsafe homes in overseas  environments is unclear. For example, these medical officials stated that  terms like “real and present danger” are not well defined, and that there  may be no child welfare agency available overseas to provide guidance  or services. These officials also stated that this threshold may be too  high, and could result in children suffering moderate neglect or abuse  because it does not rise to the level of real and present danger. Without  clarifying and standardizing across the services, in guidance, the  circumstances under which commanders may exercise their authority to  remove children from potentially unsafe homes overseas, timely response  to incidents may be inhibited and children may be left in unsafe situations.  Commanders may also face adverse actions if their authority to remove a  child from the home is not well-defined and their decision comes under  legal scrutiny.

Availability of Certified Pediatric Sexual Assault Forensic Examiners Is Limited, Especially Overseas

The availability of certified pediatric sexual assault forensic examiners  across the military services is limited, especially overseas. Based on our  analysis, from fiscal years 2014 through 2018, for all four military  services, there were 1,448 incidents that met DOD’s criteria for child  sexual abuse and may have therefore necessitated a sexual assault  forensic exam. According to our analysis of FAP data over these 5 years,  the average age of the victims involved was 10. However, according to  Defense Health Agency officials, there are only four child abuse  pediatricians who are certified to perform pediatric sexual assault forensic  exams: two in the Navy, one in the Army, and one in the Air Force. In  addition, according to these officials, the Army has seven sexual assault  forensic examiners, initially certified to perform exams on adults, who  have completed a 40-hour pediatric course, for a total of 11 certified  pediatric examiners across the department. In comparison, according to  these officials, there are a total of 466 sexual assault forensic examiners  throughout the department who are certified to perform exams on  adults—161 are located overseas and 305 are located within the United  States.

As a result of this disparity between examiners certified to perform exams  on adults and those certified for children, children affected by sexual  abuse on military installations or as military dependents may lack access  to qualified pediatric sexual assault forensic examiners. This lack of  access on overseas installations—identified by medical personnel as a  significant concern—can prevent them from being examined in a timely  manner or may subject them to further trauma if they are first examined  by an untrained provider and have to be examined again.

When victims of sexual assault receive a forensic exam, the exam may  be provided by either a trained sexual assault forensic examiner—that is,  a medical provider who has received specialized training in properly  collecting and preserving forensic evidence—or a medical provider who  has not received such specialized training. Studies have shown that  exams performed by trained sexual assault forensic examiners may result  in shortened exam time, better quality health care delivered to victims,  higher quality forensic evidence collection, as well as better collaboration  with the legal system and higher prosecution rates.

Navy officials stated that pediatric sexual assault forensic examiners are  not a billeted position at any installation and Air Force officials stated that  there are no certified pediatric sexual assault forensic examiners billeted  to any installation in Japan—which hosts the largest number of active  duty U.S. servicemembers outside of the United States—due to  inconsistent demand. Medical personnel we spoke with described two  options to overcome the lack of certified pediatric examiners: call a  certified pediatric examiner in the United States to guide—via  telephone—a pediatrician on the overseas installation through the exam;  or medically evacuate the victim to the United States.

Although DOJ best practices for sexual assault exams note that  telemedicine can result in significant positive changes in the methods of  examination and evidence collection, medical personnel stated that it is  inferior to an in-person exam because the person conducting the exam is  not the actual certified examiner, which can open the exam findings up to  legal challenges. Medical personnel also stated that a child may need to  undergo multiple exams if the initial exam is not performed correctly,  which, as noted previously, can add to a victim’s trauma. Additionally,  medical personnel stated that there can be technical challenges with  getting the right equipment in place and training people who may quickly  transition to another installation. If telemedicine processes were to be  established at overseas installations, there are still only four child abuse  pediatricians across the department who can consult on the exams, and  they may not be available to consult on all cases.

Further, medical personnel noted that using telemedicine for pediatric  exams overseas may result in these exams being physically conducted  by someone with little to no experience conducting any type of genital  exam. This is because pediatricians in the military typically do not conduct  any genital exams on children, even basic or preventative exams. In the  event that a girl becomes pregnant, officials stated that she will be sent to  a military adult obstetrician, and the military pediatrician would not  conduct any of the relevant exams. These personnel also stated that the  military does not conduct routine cervical exams on women until they are  21 years of age, so pediatricians likely have no practical experience  conducting even standard exams. A 2018 Department of Health and  Human Services guide for child protective caseworkers noted that if  health care providers do not routinely examine the genitalia of young  children, they may mistake normal conditions for abuse or vice versa.  One parent that we spoke with about an incident of sexual abuse  overseas stated that the child’s pediatrician was not comfortable  conducting such an exam, but offered to take a cursory “peek” for  anything concerning. The parent declined the offer because they knew  the pediatrician was neither trained nor certified to perform such an exam.

Although medical personnel stated that a medical evacuation to the  United States for an exam is a potential option, medical evacuations are  challenging because they can take 5 to 6 days. However, the physical  evidence from a sexual assault should be collected as soon as possible  and ideally between 1 and 5 days after the assault, according to DOJ best  practices. Additionally, installation medical personnel noted that medical  evacuations can result in additional stress on the victim from travel,  increased complexity of legal and investigation processes, and travel  costs that may be greater than training local examiners.

DOD medical personnel stated that it can be challenging because in  some instances the children can only receive the exam at medical  facilities that have a memorandum of understanding in place with the  military because the exams are typically funded locally. For example,  these officials described an incident of child sexual abuse in Okinawa—a  remote location in Japan with no certified examiners. These personnel  noted that while a medical evacuation to Hawaii would seem like a good  solution—because there is a trained pediatrician there to conduct sexual  assault exams—the pediatrician in Hawaii can only examine children who  have been referred directly by Hawaii’s child welfare agency. These  personnel noted that the next best option is San Diego, where there is a  DOD child abuse pediatrician, but by the time the travel is arranged,  which can take days, the evidence might no longer be available. These  personnel suggested that instead of relying on medical evacuations or  telemedicine, better options to ensure that child victims get timely access  to care could include certifying pediatricians or adult sexual assault  forensic examiners as pediatric examiners during mandatory training or  establishing shared regional assets.

In the United States, child victims of sexual abuse may have more options  to receive pediatric sexual assault forensic exams. Specifically, pediatric  exams may be done at a local Children’s Advocacy Center (CAC) or  hospital. However, it is still challenging in the United States because CAC  coverage is not uniform across the country, and rural patients may have  to travel several hours to the closest center. For example, officials at one  CAC we visited noted that while they have a certified pediatric examiner,  this individual is only available once per week. One parent that we spoke  with stated that they had to drive their child 2 hours to the closest CAC to  receive an exam when stationed at an installation in the United States.  Two parents described delays in receiving an exam in the United States  after the incident was reported, which could have prevented quality  evidence from being collected.

DOJ protocols for sexual assault forensic exams state that these exams  should be performed by a healthcare professional specially trained in  collecting evidence relating to sexual assault cases, such as a sexual  assault nurse examiner or other appropriately trained medical  professional. In particular, female children who have not yet reached  puberty should only be examined by health care providers specifically  trained in pediatric sexual abuse. Further, related DOJ best practices  state that evidence should be collected as soon as possible, ideally  between 1 and 5 days post assault. However, DOD does not have  processes in place to help ensure that children who are sexually abused  overseas have timely access to certified pediatric sexual assault forensic  examiners. Without processes that help ensure timely access to certified  pediatric examiners overseas, child victims of sexual abuse may not  receive exams in time for the evidence to be collected for use in  prosecution. In addition, the difficulty and time associated with obtaining an exam could potentially increase the stress and trauma of affected  victims and their families. Further, because of the variation in resources  across military installations, child victims of sexual abuse may have  access to different levels of care depending on the geographic location of  the installation due to the lack of standardized availability of certified  pediatric examiners.

DOD Collaborates with Interagency Partners to Address Reported Incidents of Child Abuse and Child-on-Child Abuse, but Challenges Remain

DOD collaborates at various levels both inside and outside the  department to address reported incidents of child abuse and child-on- child abuse. However, improving communication and establishing  comprehensive agreements could enhance the information DOD receives  about these incidents as well as the resources available to both the  department and victims of abuse.

DOD Collaborates with States and Localities to Ensure It Is Notified When Servicemembers or Military Dependents Are Involved in Reported Incidents of Child Abuse Outside the Installation

DOD has successfully collaborated with a number of states to help  ensure it receives notification from state authorities when  servicemembers or military dependents are involved in reported incidents  of child abuse off a military installation. DOD is required to address child  abuse in military families. However, with approximately 70 percent of  active-duty military families living off military installations in the civilian  community, service officials do not always have visibility over these  incidents since they may first be reported to the relevant civilian  authorities instead of to the military.

The Defense State Liaison Office has highlighted the importance of state  statutes that require the collection and reporting of military affiliation to the  appropriate military authorities as part of state child abuse cases, and has  identified this as a key issue. According to a senior Defense State Liaison  Office official, the office has successfully collaborated with a number of  states on child abuse reporting measures to require or allow local  jurisdictions to report incidents of child abuse in military families to  relevant military service officials. According to DOD, at least half of the  states have no such requirements, but at least one is considering passing  a law to provide for the requirement. According to this senior Defense  State Liaison Office official, the effort will remain a key issue area for the  office through at least fiscal year 2020 in order to continue to focus efforts  on these remaining states.

In August 2019, the Defense Health Board noted that child abuse can be  difficult to quantify because of underreporting, and some studies suggest  a lower rate of incidents being reported to the FAP if the incidents are first  identified at a civilian facility. Therefore, it recommended, in the absence  of state legislation, that DOD ensure that all U.S. military installations  have memorandums of agreement in place with state child welfare  agencies for bilateral information sharing on child abuse cases. A senior  Defense State Liaison Office official stated that the office has sought  legislation because prior efforts to establish memorandums of agreement  were only focused on information sharing and did not specify procedures  for state and local child welfare agencies to use in determining whether a  family involved in an incident had a military connection. Additionally, the  official noted that a statutory basis is important because otherwise state  laws that limit who child welfare agencies can share information with  about child abuse cases may take precedence. For example, some states  have expressed concerns that sharing information about an alleged, but  not yet confirmed, incident of child abuse could be detrimental to a  servicemember’s career.

We found that the extent of collaboration between the military and other  state and local authorities (such as child welfare agencies) varied among  the installations in our review. For example, child welfare agency officials  in Virginia noted that state policies requiring that they notify the FAP  about cases with a military affiliation have increased the amount of  coordination between the state and the military. However, according to  FAP officials at one installation we visited in North Carolina—where  approximately 80 percent of dependent children live off the installation—it  was rare to receive notification from some counties for child abuse cases  with a military affiliation because, at the time of our visit, there was no  state policy requiring it. DOD’s continued focus on improving  collaboration with the states that have not yet established such a  requirement should help to increase the department’s visibility over  incidents occurring off the installation. It should also help to ensure that  military families obtain the available FAP services for which they are  eligible.

DOD and DOJ Have Taken Some Actions to Increase Collaboration

DOD and DOJ have taken some actions to increase collaboration in  addressing the abuse of children on military installations. As previously  discussed, the conference report accompanying the John S. McCain  National Defense Authorization Act for Fiscal Year 2019 included a  provision for the service Secretaries to seek to relinquish jurisdiction over  offenses committed on military installations by individuals not subject to  the Uniform Code of Military Justice, such as civilians and children. In  response, according to DOJ officials, DOD and DOJ have, among other  things, established a joint working group to coordinate on issues related  to child-on-child sexual assault on military installations, including the  relinquishment of exclusive federal jurisdiction to the states. Both DOD  and DOJ officials agreed that the federal justice system is not well suited  to prosecuting juvenile offenses because it lacks a dedicated juvenile  justice system and that state courts, which aim to be rehabilitative in  nature, are better suited to adjudicate these cases. Specifically, DOJ’s  Justice Manual states that the intent of federal laws concerning juveniles  is to help ensure that state and local authorities will deal with juvenile  offenders whenever possible.

Working group officials stated that they are compiling a list of United  States Attorneys’ Offices and the military installations in their respective  districts from which they have received referrals, as well as the types of  jurisdictions at those installations. These efforts are designed to ultimately  result in a comprehensive chart detailing the precise jurisdictional status  of each military installation in the United States, which can then be used  to inform discussions with each state about the relinquishment of  exclusive federal jurisdiction. According to DOJ officials, the working  group is also developing templates of coordination documents, such as  letters and memoranda of understanding for outreach with the states.  Working group officials stated that the group has identified and is  attempting to address other issues, such as those regarding privacy  concerns related to information to be contained in DOD’s centralized  database for problematic sexual behavior in children and youth, which, as  previously discussed, is under development.

The difficulties of addressing child-on-child sexual assault are  exacerbated when the incident occurs overseas, where no U.S. state  authorities exist to assume jurisdiction. The Military Extraterritorial  Jurisdiction Act can be used to either prosecute child offenders as  adults—for certain violent or controlled substance violations—or to initiate  federal delinquency proceedings. However, as discussed, while both  DOD and DOJ officials stated that they prefer to refer children to state  courts, this is currently not possible when the incident occurs overseas.  Working group officials stated that this challenge is another issue being  actively discussed by the group in an effort to identify potential solutions.  For example, they stated that one idea under discussion relates to a  specific Virginia state law that asserts concurrent jurisdiction over federal  crimes committed by a child, to be assumed only if waived by the federal  court or the United States Attorney. The discussion centered on the idea  that the Virginia state law could potentially be applied extraterritorially.  Therefore, if a sexual assault were to occur on an installation with  exclusive federal jurisdiction in Virginia—or theoretically overseas where  the United States has jurisdiction—the Virginia courts could assert  jurisdiction as long as the relevant United States Attorney’s office has  waived jurisdiction. However, whether or not Virginia could use its courts  to address matters that occurred overseas and where the juvenile  offender is not a resident is not yet clear. Legal officials at one installation  who are involved in the working group efforts stated that they were  considering whether it was possible to have a single municipal court have  sole jurisdiction for any juvenile crimes occurring on overseas  installations. However, officials stated that the working group continues to  research and discuss these types of issues to improve collaboration  between the two departments and identify solutions to these important  issues.

DOJ Notices of Declination of Prosecution Do Not Typically Provide Adequate Detail About the Reasons to Inform Military Investigators

Service officials stated that while DOD is typically notified by DOJ when it  declines to prosecute the abuse of a child on a military installation, the  notification does not consistently include detailed reasons for why the  case was declined. Officials from the Army Criminal Investigation  Command—the military criminal investigative organization with the largest  number of cases—stated that they are not informed of the reasons for  case declinations because they have been told that the information is  considered an attorney work product. Officials from the other military  criminal investigative organizations stated that for some cases they do  receive reasons why they are declined. However, DOJ officials stated that  in cases where a United States Attorney does notify DOD of a declination  and the reason, it may be very vague, such as “insufficient evidence,” and  may not detail the insufficiencies.

DOJ officials stated that while a case may be declined for various  reasons, there are three primary reasons for declinations: (1) insufficiency  of the evidence (not enough admissible evidence to obtain and sustain a  conviction beyond a reasonable doubt); (2) the person is subject to  prosecution under another jurisdiction, such as in a state court system; or  (3) there is an adequate noncriminal alternative to criminal prosecution.  Officials within the Executive Office for United States Attorneys stated  that they were not aware of any standard letters used to notify DOD of  prosecutorial decisions and that the format and content of the notification  are office dependent.

According to DOJ officials, the investigating organization is to inform  victims of a declination of prosecution. However military law enforcement  officials from two services stated that the responsibility for informing  victims of a declination of prosecution would be dependent on the  circumstances of the individual case, such as whether formal charges had  been preferred and any discussion between the military criminal  investigative organization and United States Attorney. According to some  of the parents we spoke with, this process does not always result in a  timely notification of a prosecution declination—including the reasons for  the declination—to the victims or their families. For example, one parent  we spoke with highlighted the lack of information when they tried  repeatedly for nearly one year to contact the military investigators for a  case status update—while in the process of filing an information request  with DOJ—and were finally told that their child’s case had been declined  for prosecution with no additional information on the reasons for the  declination. Another parent stated that the Assistant United States  Attorney informed them that a child-on-child abuse case would not be  prosecuted due to a lack of strong evidence, specifically, a poor child  forensic interview conducted by the military criminal investigative  organization and the mishandling of electronic evidence.

DOJ has committed to assisting DOD in responding to incidents of child- on-child abuse through the working group, as discussed previously.  Additionally, DOJ has begun tracking referrals made to United States  Attorneys by DOD for child-on-child sexual offenses. Specifically, in  September 2018, the Director of the Executive Office for United States  Attorneys issued a memorandum that instructed all United States  Attorneys to begin tracking referrals of child-on-child sexual offenses from  the military. According to these data, between October 1, 2018 and  August 5, 2019, the military referred 63 of these cases to United States  Attorneys for prosecution. Two of these cases were accepted for  prosecution and 19 were declined—the remaining cases were either  referred to state or local authorities or were still pending. Per the  memorandum, this information is to be provided, on a monthly basis, to  the Office of the Deputy Attorney General, the lead DOJ office for the  working group.

DOJ’s Principles of Federal Prosecution recommends that whenever an  attorney declines to prosecute, the prosecutor should ensure the decision  and reasons are communicated to the investigating agency involved and  to any other interested agency. In addition, Standards for Internal  Control in the Federal Government states that management should  externally communicate the necessary quality information to achieve  objectives. Specifically, management selects appropriate methods of  communication, such as a written document—in hard copy or electronic  format—or a face-to-face meeting. Management periodically evaluates  the entity’s methods of communication so that the organization has the  appropriate tools to communicate quality information within and outside of  the entity on a timely basis. However, United States Attorneys are not  consistently communicating the reasons for declining to prosecute DOD  cases involving child victims to the military criminal investigative  organizations.

Without seeking avenues to improve communication between the military  criminal investigative organizations and United States Attorneys for  relevant cases involving child victims—to help ensure that investigators  are notified when prosecution is declined—investigators may not be  informed of the reasons why a case is declined, such as for investigative  deficiencies or weaknesses. As a result, DOD may be limited in its ability  to improve investigative processes or identify areas where additional  investigative training may be needed to improve future incident resolution.  Improving this communication through the ongoing DOD and DOJ  working group or by other means could also increase the information  DOD receives about incident outcomes. Additionally, victims and their  families may be better informed of their case disposition and the  reasoning behind that disposition.

The Military Services Do Not Consistently Make Use of Children’s Advocacy Center Resources Available for Child Victims of Abuse

Per the National Children’s Alliance, most military installations in the  United States with FAP services are located within 50 miles of a  Children’s Advocacy Center (CAC). However, military families may not  be able to access CAC services because, according to a 2019 study  conducted by the Alliance, only 7 percent of CACs with military  installations in their service area reported having a memorandum of  understanding, which is needed to authorize services associated with a  FAP referral. In addition, according to the Alliance’s 2019 study, while  66 percent of service FAP offices reported having a relationship with their  local CAC, 47 percent of those offices reported that contact with the local  CAC was infrequent. As shown in figure 5, there are CACs in each state.

CACs have considerable experience working with abused children.  Specifically, according to the National Children’s Alliance, in 2018 CACs  collectively served over 367,000 children, conducted over 260,000  forensic interviews, and completed over 91,000 medical exams and  treatments. Further, CACs provide a child-friendly environment to conduct  these interviews and exams, which are then reviewed by a  multidisciplinary team that includes medical, law enforcement, mental  health, and legal personnel, victim advocates, and state child welfare  agencies. The purpose of the multidisciplinary team is to determine how  to best support the child, such as through therapy, courtroom preparation,  and victim advocacy.

With regard to child forensic interviews, CACs work to minimize  retraumatization of a child by only conducting one comprehensive  interview of the child that is typically recorded and involves a team  viewing the interview from a separate room. The recorded interview can  then be shared with other interested parties with a need to know to  include doctors, police, lawyers, therapists, investigators, and judges.  This prevents the child from having to talk about the traumatic experience  repeatedly in environments where they may be uncomfortable, such as in  a police station where they may think they are in trouble.

Officials from the Naval Criminal Investigative Service stated that they  prefer to use CACs for child forensic interviews when available and where  agreements are in place. Both the Army and the Air Force’s military  criminal investigative organizations stated that, depending on the  circumstances of the case, they may make use of CACs when, for  example, agents qualified in child forensic interviews are unavailable. At  one U.S. installation we visited, military criminal investigators told us that  due to personnel transfers they sometimes do not have investigators  available who are qualified to conduct these interviews. Other military  criminal investigators with whom we spoke noted that the lack of  continuous training for military child forensic interviewers is challenging  because regular practice is needed to develop and maintain the skillset.  One investigator stated that even though they had not conducted a child  forensic interview in 4 years, they were still technically qualified to  conduct these interviews. Despite their ability to conduct the interviews,  we spoke to military criminal investigators who preferred to rely on child  forensic interviewers from the CACs who had more expertise because of  the volume of interviews that they conduct.

In September 2012, we found that agencies that articulate their  agreements in formal documents can strengthen their commitment to  working collaboratively. However, according to installation and CAC  officials, four of the U.S. installations that we visited either did not have a  formal agreement in place with the local CAC or noted that maintaining  the agreement was challenging because of the limits that military turnover  puts on their ability to build such partnerships. DOD has assigned the  responsibility to establish formal agreements with counterparts in the  community, such as CACs, within the Family Advocacy Committee at  each individual installation. However, given that only 7 percent of CACs  with a military installation in their area reported having such an agreement  in place according to the National Children’s Alliance’s 2019 study,  developing installation-level agreements with CACs has had limited  success.

In 2015, the Federal Bureau of Investigation established a nationwide  memorandum of understanding with the National Children’s Alliance to  use CACs to conduct forensic interviews. DOD FAP officials stated that a  similar agreement between the military services and the National  Children’s Alliance would benefit military families. In August 2019, the  National Children’s Alliance recommended the development of a national  memorandum of understanding between the National Children’s Alliance,  service FAPs, and military criminal investigative organizations within each  service. Similarly, in August 2019, a report by the Defense Health Board  recommended the development of memorandums of agreement with  external entities, such as the National Children’s Alliance and state child  welfare agencies.

DOD FAP and National Children’s Alliance officials noted that discussions  about establishing these types of agreements are not new and believed  that agreements would be most effective between the National Children’s  Alliance and each respective military service and military criminal  investigative organization versus at the installation level. As of February  2019, officials from three of the services indicated that while discussions  have been underway, none of these military services have an established  agreement, though the status of their efforts varies. For example, as of  September 2019, Air Force officials described the effort as being in its  infancy, with no established timeframes to achieve goals. Marine Corps  FAP officials stated that they were exploring the feasibility of establishing  an agreement with the National Children’s Alliance, and Navy FAP  officials stated that they were developing a draft agreement for services  and support to families impacted by problematic sexual behavior in  children and youth. However, given the need for services associated with  any type of abuse, such an agreement should not be restricted to  problematic sexual behavior.

The John S. McCain National Defense Authorization Act for Fiscal Year  2019 stated that the Secretaries of the military departments shall permit,  facilitate, and encourage multidisciplinary teams at the installations to  collaborate with appropriate civilian agencies for services to support child  abuse victims. A national memorandum of understanding could help to  break down some of the currently cited barriers to collaboration between  CACs and the military, and facilitate such a multidisciplinary approach to  addressing incidents of child abuse. For example, DOJ has provided  funding for CAC-military partnership pilot projects, which are aimed at  improving coordination between CACs and the military to address  reported incidents of child abuse. Information from current CAC-military  partnership pilot projects indicates that a common barrier to coordination  of services is continuity in staffing and leadership for their military  counterparts. A base commander’s assignment at a post is time limited,  as are some military investigative personnel. These frequent changes in  staffing and leadership can result in changes in leadership styles,  priorities, and methods of operation and can require a perpetual cycle of  building relationships and revising protocols with new counterparts.

Without a memorandum of understanding in place between each military  service and the National Children’s Alliance, the coordination between the  military services and the CACs will continue to be ad hoc and dependent  on the relationships of individuals at each installation. Further, without  such agreements, the military services may not be fully aware of CAC  services and thus may not effectively leverage their facilities or personnel  to help address incidents of child abuse involving military dependents.

While DOD has taken steps to address recent incidents of child-on-child  sexual abuse reported by the media—by establishing policies and  beginning to develop a centralized database for problematic sexual  behavior in children and youth—the department faces broader  challenges, related to visibility, process, and collaboration in addressing  the abuse of children. For example, DOD’s visibility over incident  outcomes and the extent to which children have been abused—by an  adult or another child—is limited by standalone databases, information- sharing challenges, and personnel discretion at the installation level. As  DOD develops a centralized database on problematic sexual behavior, it  could address some of these challenges by expanding the scope of the  database to include any abuse of a child, regardless of offender and type  of abuse, and making key decisions related to its development. Further,  additional guidance and processes are needed to help reduce  information-sharing challenges and installation-level discretion in the  tracking and reporting of these incidents. Until DOD resolves these  challenges, it will continue to have limited visibility over the extent to  which children have been affected by abuse on military installations or as  military dependents.

Additionally, the department faces gaps in its existing processes for  responding to and resolving incidents of child abuse that should be  addressed as it continues to develop processes related to problematic  sexual behavior in children and youth. For example, given concerns  expressed by medical personnel across the military services, DOD should  expand the voting membership of the IDC to include medical personnel to  ensure that stakeholders with pertinent knowledge and expertise are  included. It is critical that IDC determinations are made with all of the  relevant information available. Moreover, qualified medical personnel play  an essential role in responding to children who have been abused, such  as by conducting sexual assault exams. However, according to DOD  officials, there are only 11 certified pediatric sexual assault examiners  across the department. Without processes to ensure that children who  are sexually abused overseas have timely access to a qualified examiner,  child victims of sexual abuse may not receive exams in time for the  evidence to be collected for use in prosecution and may experience  additional stress and trauma. Until DOD addresses these process-related  challenges, among others, child victims and their families may not receive  the assistance, care, and services that they need.

Finally, while DOD has successfully collaborated with a number of states  to increase information sharing and with DOJ to address child-on-child  sexual offenses occurring on military installations, there are opportunities  for DOD to improve its collaboration with external partners to the benefit  of military families. For example, there are opportunities to improve  communication between the military criminal investigative organizations  and United States Attorneys to ensure that DOD is aware of declinations  of cases involving the abuse of children and why they were declined.  Such avenues could, among other things, help identify needed changes  to investigative processes or training. Further, there are opportunities to  facilitate awareness and increase the military services’ use of CAC  resources, such as through the establishment of a national agreement  between the National Children’s Alliance and each military service.  Ultimately, improving interagency collaboration could enhance DOD’s  visibility over these incidents and increase the resources available to both  the department and victims of abuse.

We are making a total of 23 recommendations, including 11 to the  Secretary of Defense, three to the Secretary of the Army, six to the  Secretary of the Navy, and three to the Secretary of the Air Force.

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should expand the scope of the department’s  centralized database on problematic sexual behavior in children and  youth, which is under development, to also track information on all  incidents involving the abuse of a child (physical, sexual, emotional, and  neglect) reported to the Family Advocacy Program or investigated by a  military law enforcement organization, regardless of whether the offender  was another child, an adult, or someone in a noncaregiving role at the  time of the incident. (Recommendation 1)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should, as part of the ongoing development of the  centralized database, identify and define the elements to be tracked by  each responsible organization, such as the Family Advocacy Program  and military law enforcement. (Recommendation 2)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should develop a plan for how it will use the data it  will collect in the centralized database to help ensure data-driven  decision-making is used to inform program efforts. (Recommendation 3)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should establish a reliable schedule for the  development and implementation of the centralized database on  problematic sexual behavior in children and youth that includes key  activities, the timeframes and resources needed to execute them, and  GAO-identified practices for developing and maintaining a reliable  schedule. (Recommendation 4)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should direct the service Family Advocacy  Programs and military law enforcement organizations to document in their  respective databases the date that they notified the other entity of a  reported incident of child abuse. (Recommendation 5)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should issue guidance that describes the process  through which the service Family Advocacy Programs are to receive and  incorporate information into their central registries regarding child abuse  allegations and determinations involving their servicemembers and  dependents that were recorded by another service’s installation Family  Advocacy Program. Such guidance should include a mechanism to  monitor that the process is occurring consistently. (Recommendation 6)

The Secretary of the Army should develop a process to monitor how  reported incidents of child abuse are screened at installations to help  ensure that all reported child abuse incidents that should be presented to  an Incident Determination Committee are consistently presented and  therefore tracked. (Recommendation 7)

The Secretary of the Navy should develop a process to monitor how  reported incidents of child abuse are screened at installations to help  ensure that all reported child abuse incidents that should be presented to  an Incident Determination Committee are consistently presented and  therefore tracked. (Recommendation 8)

The Secretary of the Navy should ensure that the Commandant of the  Marine Corps develops a process to monitor how reported incidents of  child abuse are screened at installations to help ensure that all reported  child abuse incidents that should be presented to an Incident  Determination Committee are consistently presented and therefore  tracked. (Recommendation 9)

The Secretary of the Air Force should develop a process to monitor how  reported incidents of child abuse are screened at installations to help  ensure that all reported child abuse incidents that should be presented to  an Incident Determination Committee are consistently presented and  therefore tracked. (Recommendation 10)

The Secretary of Defense should ensure that the Under Secretary of  Defense for Personnel and Readiness, in coordination with the Director of  the Department of Defense Education Activity, clarifies Department of  Defense Education Activity guidance to define what types of incidents  must be reported as “serious incidents” to help ensure that all serious  incidents of which Department of Defense Education Activity leadership  needs to be informed are accurately and consistently reported by school  administrators. (Recommendation 11)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should expand the voting membership of the  Incident Determination Committee to include medical personnel with the  requisite knowledge and experience. (Recommendation 12)

The Secretary of the Army should establish efforts to comprehensively  inform victims’ families about how reported incidents of child abuse will be  addressed following the report, such as a comprehensive guide that  explains the process the Family Advocacy Program and military law  enforcement organizations will follow, and available victim services.  (Recommendation 13)

The Secretary of the Navy should establish efforts to comprehensively  inform victims’ families about how reported incidents of child abuse will be  addressed following the report, such as a comprehensive guide that  explains the process the Family Advocacy Program and military law  enforcement organizations will follow, and available victim services.  (Recommendation 14)

The Secretary of the Navy should ensure that the Commandant of the  Marine Corps establishes efforts to comprehensively inform victims’  families about how reported incidents of child abuse will be addressed  following the report, such as a comprehensive guide that explains the  process the Family Advocacy Program and military law enforcement  organizations will follow, and available victim services. (Recommendation  15)

The Secretary of the Air Force should establish efforts to  comprehensively inform victims’ families about how reported incidents of  child abuse will be addressed following the report, such as a  comprehensive guide that explains the process the Family Advocacy  Program and military law enforcement organizations will follow, and  available victim services. (Recommendation 16)

The Secretary of Defense, in collaboration with the Secretaries of the  military departments, should clarify, in guidance, the circumstances under  which commanders may exercise their authority to remove a child from a  potentially unsafe home on an overseas installation. (Recommendation  17)

The Secretary of Defense should ensure that the Under Secretary of  Defense for Personnel and Readiness, in coordination with the Director of  the Defense Health Agency, establishes processes that help ensure  children who are sexually abused overseas have timely access to a  certified pediatric sexual assault forensic examiner to conduct the  examination. Initiatives could include certifying pediatricians or adult  sexual assault forensic examiners as pediatric examiners during  mandatory training or establishing shared regional assets.  (Recommendation 18)

The Secretary of Defense, in collaboration with the Deputy Attorney  General, should seek avenues to improve communication between the  military criminal investigative organizations and United States Attorneys  for relevant cases involving child victims to help ensure that investigators  are notified when prosecution is declined, including the reasons for the  declination when appropriate, such as details about any investigative  deficiencies. (Recommendation 19)

The Secretary of the Army should seek to develop a memorandum of  understanding with the National Children’s Alliance that makes children’s  advocacy center services available to all Army installations and thereby  increase awareness of those services across the department.  (Recommendation 20)

The Secretary of the Navy should continue to develop a memorandum of  understanding with the National Children’s Alliance that makes children’s  advocacy center services available to all Navy installations and thereby  increase awareness of those services across the department.  (Recommendation 21)

The Secretary of the Navy should ensure that the Commandant of the  Marine Corps continues to develop a memorandum of understanding with  the National Children’s Alliance that makes children’s advocacy center  services available to all Marine Corps installations and thereby increase  awareness of those services across the service. (Recommendation 22)

The Secretary of the Air Force should seek to develop a memorandum of  understanding with the National Children’s Alliance that makes children’s  advocacy center services available to all Air Force installations and  thereby increase awareness of those services across the department.  (Recommendation 23)

We provided a draft of this report to DOD for review and comment. In its  written comments, DOD concurred with 16 recommendations, partially  concurred with six recommendations, and did not concur with one  recommendation. DOD also provided technical comments (referred to as  enclosure 1 in its written comments), which we incorporated as  appropriate. DOD’s written comments are summarized below and  reprinted in appendix VI.

For the 16 recommendations with which DOD concurred, DOD’s written  comments discuss ongoing and planned efforts to implement our  recommendations, and in some cases provide target completion dates.

DOD did not concur with our first recommendation to expand the scope of  its centralized database on problematic sexual behavior in children and  youth to track information on all incidents involving the abuse of a child  reported to the FAP or investigated by a military law enforcement  organization. In its written comments, DOD stated concerns related to  privacy and protecting information collected and shared on the alleged  conduct of juveniles. DOD also cited a statutory requirement to not  disclose directly or indirectly certain juvenile records during the course of  juvenile delinquency proceedings and stated that it is the department’s  position that it is imperative to protect sensitive juvenile data with any  database. We agree that protecting sensitive juvenile data is imperative  and acknowledge in the report that privacy and data-safeguarding  precautions—such as role-based permissions and other physical,  technical, and administrative controls—will need to be taken, as they  were in the development of the Defense Sexual Assault Incident  Database.

In addition, as discussed in the report, the department already maintains  databases that include information about both adults and children, such  as the service FAPs’ central registries and the databases of the various  military criminal investigative organizations, which contain data on both  adult and juvenile offenders and victims. DOD does not assert that it  would be impossible to establish role-based permissions and the sorts of  physical, technical, and administrative controls that would protect the  privacy rights of individuals whose information appeared in a central  database like the one we recommend.  Moreover, the existence of other  DOD databases that incorporate such measures supports the notion that  it is possible to develop such a database in this situation. Doing so would  provide the information needed to track the extent to which children have  been affected by abuse and problematic sexual behavior, while  safeguarding the personal information of minors.

DOD’s written comments also stated that the report conflates three  separate and distinct constructs of behavior: juvenile misconduct,  problematic sexual behavior in children and youth, and child abuse and  neglect committed by adults. As described in our scope and methodology,  the scope of our review included child abuse inflicted by both adults and  children, which, according to DOD definitions, includes the three  categories of behavior noted above. As stated in our report, information is  tracked in multiple standalone databases, due, in part, to who inflicted the  abuse; as a result, it is difficult to know the extent to which children have  been affected by abuse on military installations or as military dependents.  In addition, while the response process differs between incidents of adult- inflicted child abuse and incidents of problematic sexual behavior, DOD  officials acknowledged that the organizations involved in the response  process and the primary data sources are the same. As we also noted,  officials stated that a centralized database for all child abuse incidents,  tracking the FAP’s determination about whether an incident met DOD’s  criteria for abuse, the investigation, and resolution, would be beneficial in  determining what happened in a particular case. These officials further  stated that such a database would benefit commanders’ oversight of  cases for which they are responsible. In addition, without a centralized  database that tracks all incidents of abuse involving children, DOD and  Congress do not know the extent to which children have been affected by  abuse on military installations or as military dependents, or how such  incidents have been responded to and resolved. This makes it difficult to  identify and address trends that could lead to further prevention efforts.  As such, we continue to believe that this recommendation is valid and  should be implemented.

DOD partially concurred with recommendation 5 to direct the service  FAPs and military law enforcement organizations to document in their  respective databases the date they notified the other entity of a reported  incident of child abuse. In its written comments, DOD stated that it will  analyze the efficiency, cost, and feasibility of recording the notification  date to law enforcement in FAP databases and that it plans to incorporate  a notification field as part of new data standards for DOD’s criminal justice  agencies. Similarly, DOD also partially concurred with recommendation 6  to issue guidance that describes the process through which the service  FAPs receive and incorporate information into their central registries  regarding child abuse allegations and determinations involving their  servicemembers and dependents that were recorded by another service’s  installation FAP, and that the guidance include a mechanism to monitor  that the process is occurring consistently. DOD stated that it will review  FAP data reporting policy to explore the potential to reference this  process in the scheduled reissuance of DOD policy in 2023. DOD further  stated that such information sharing is limited to reported incidents of  child abuse that were determined to have met DOD’s criteria for abuse  rather than all abuse allegations. We continue to believe that issuing  guidance that extends to both allegations and determinations would  provide better assurance that the services have complete and up-to-date  information about their personnel and their dependents, and increase  their visibility over incidents of child abuse.

DOD partially concurred with recommendation 12 to expand the voting  membership of the IDC to include medical personnel with the requisite  knowledge and experience. In its written comments, DOD agreed that the  inclusion and consideration of medical information in the determination  process is important, and stated that the current process includes medical  personnel as nonvoting members. DOD also stated that it will engage the  researchers who developed the IDC algorithm and process, as well as  other stakeholders—including the Defense Health Agency and the military  services—for collaborative input and guidance for a forthcoming revision  of the relevant DOD Manual. However, as discussed in the report,  medical personnel we spoke with at installations stated that they are not  always included in the process, and if they are, their medical expertise is  not always included as part of the final determination, contrary to best  practices for substantiating child abuse allegations. Further, if medical  personnel are not voting members, other clinical duties may take  precedence. Therefore, we continue to believe that this recommendation  is valid.

For recommendations 13, 14, and 16, the Army, the Navy, and the Air  Force concurred that they should establish efforts to comprehensively  inform victims’ families about how reported incidents of child abuse will be  addressed following the report, such as a comprehensive guide that  explains the process and available victim services. However, the Marine  Corps partially concurred with the related recommendation 15, stating  that it is out of scope for the FAP to explain the processes that law  enforcement organizations will follow. However, our recommendations  state only that the FAP and military law enforcement processes should be  effectively communicated to the families, not that the FAP would have to  determine or communicate the law enforcement processes to affected  families. Further, DOD’s written comments stated that Marine Corps  Order 1754.11 addresses the recommendation because it directs victim  advocates to be assigned to the non-offending parent of a victim of child  abuse who requests services. However, parents we spoke with indicated  that they were not aware of all available services and resources offered  by the military, and that a comprehensive guide outlining the process  would have helped them understand what was going to happen. For  these reasons, we continue to believe that the recommendation is valid.

For recommendations 20 through 23, DOD’s written comments stated  that the services concurred with the overall recommendation to seek to  establish memorandums of understanding with the National Children’s  Alliance that make children’s advocacy center services available to all  military installations and thereby increase awareness of those services  across the department. While the Marine Corps and the Air Force  concurred (recommendations 22 and 23), DOD noted that individual  service differences in organizational structure and process are reflected in  the nuances of their responses. For example, the Army partially  concurred with recommendation 20. DOD stated that the Army is working  with the National Children’s Alliance to develop a broad memorandum of  understanding to support partnerships between military installations and  local children’s advocacy centers. The agreement is intended to assist in  providing support services, education, and prevention services to military  families and investigations of child abuse and problematic sexual  behavior with a goal to finalize the agreement in fiscal year 2021. The  Army also plans to pursue local agreements with children’s advocacy  centers who may not participate in the broader service-wide agreement.  We believe that such local agreements, in addition to a broader  memorandum of understanding with the National Children’s Alliance,  would be beneficial and that these actions would meet the intent of our  recommendation.

Likewise, the Navy partially concurred with recommendation 21. DOD’s  written comments stated that the Navy seeks to develop memorandums  of understanding both broadly with the National Children’s Alliance, as  well as with local children’s advocacy centers who may not be accredited  through the National Children’s Alliance. Similar to the Army, we believe  that such local agreements would be beneficial in addition to a broader  agreement with the National Children’s Alliance and, that together, they  would meet the intent of our recommendation. DOD’s comments also  stated that the Navy’s planned agreement with the National Children’s  Alliance will outline services and support to families affected by  problematic sexual behavior. However, as previously discussed in this  report, we believe that such an agreement should not be restricted to  problematic sexual behavior given the need for services associated with  any type of abuse. As such, we continue to believe that the  recommendation is valid.

We are sending copies of this report to the appropriate congressional  committees, the Attorney General of the United States, the Secretary of  Defense, the Secretary of the Army, the Secretary of the Navy, the  Secretary of the Air Force, and the Commandant of the Marine Corps. In  addition, this report is available at no charge on the GAO website at  http://www.gao.gov.

If you or members of your staff have any questions regarding this report,  please contact me at (202) 512-3604 or farrellb@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be  found on the last page of this report. GAO staff who made significant  contributions to this report are listed in appendix VII.

Department of Defense (DOD) policy defines child abuse as the physical,  sexual, or emotional abuse, or neglect of a child by a parent, guardian,  foster parent, or caregiver. Our review included any abuse of a child  (emotional, physical, or sexual abuse, or neglect) by an adult regardless  of their caregiving status and child-on-child abuse—any physical or  sexual abuse of a child (under the age of 18) by another child.

To assess the extent to which DOD has visibility over reported incidents  of child abuse, including child-on-child abuse, occurring on military  installations or involving military dependents, we analyzed data from the  three primary organizations that DOD officials identified as having  responsibility for tracking these incidents: (1) the military services’ Family  Advocacy Programs (FAP), (2) the military criminal investigative  organizations, and (3) the DOD Education Activity (DODEA).

First, we analyzed FAP data from the Army, the Navy, the Marine Corps,  and the Air Force on all reported incidents of child abuse for fiscal years  2014 through 2018. We selected this timeframe to evaluate trends over 5  years, and fiscal year 2018 was the most recent year for which complete  data were available at the time of our review. Specifically, we analyzed  the data to determine the number of reported incidents of child abuse by  service and the percent of those that met DOD’s criteria for child abuse.  Because the services are required to track more detailed information  about incidents of child abuse that they determined met DOD’s criteria for  child abuse, we conducted a more detailed analysis of these incidents to  describe their characteristics, such as the status of the offender, the  relationship between the offender and the victim, the age of the victim,  and the type of abuse (emotional, physical, sexual, or neglect). To assess  the reliability of the service FAPs’ child abuse data, we reviewed related  documentation; assessed the data for errors, omissions, and  inconsistencies; and interviewed officials. We determined that the data  were sufficiently reliable to describe trends in reported incidents of child abuse across the services and characteristics of such incidents from  fiscal years 2014 through 2018.

Second, we analyzed data from the military criminal investigative  organizations—the Army Criminal Investigation Command, the Naval  Criminal Investigative Service, and the Air Force Office of Special  Investigations—for the same time period for all investigations with a child  victim. We also analyzed child victim investigation data from the U.S.  Marine Corps Criminal Investigation Division, a federal law enforcement  agency that also investigates some offenses involving child victims.  Specifically, we analyzed the data to identify trends in the number of  investigations over the past 5 fiscal years. We also analyzed the  investigation data to identify key characteristics of the investigations, such  as the status of the offender, relationship between the victim and  offender, and primary investigative agency. To assess the reliability of the  military criminal investigative organizations’ child victim investigation data,  as well as that of the U.S. Marine Corps Criminal Investigation Division,  we assessed the data for errors, omissions, and inconsistencies, and  interviewed officials. We determined that the data were sufficiently  reliable to describe trends in child victim investigations across the  services and the characteristics of such investigations from fiscal years  2014 through 2018.

Third, we analyzed three sources of DODEA data: (1) child abuse reports  from school years 2014-2015 through 2017-2018, (2) serious incident  reports from school years 2013-2014 through 2017-2018, and (3) student  misconduct records from school years 2016-2017 through 2017-2018. We  selected these timeframes to evaluate serious incident report trends over  5 years and to align with the FAP and investigation data; school year  2017-2018 was the most recent year for which complete data were  available at the time of our review. All DODEA records were redacted by  DODEA personnel to ensure the privacy of students and DODEA  personnel.

DODEA child abuse reports track information about incidents of  suspected or alleged child abuse or neglect. We analyzed DODEA’s  child abuse reports over 4 school years to identify trends in the number  and type of child abuse reports as well as to describe characteristics of  the reports. Specifically, we analyzed characteristics such as the  relationship between the victim and the offender, the location of the  reported abuse, and notifications by DODEA to external organizations,  such as the FAP. To assess the reliability of DODEA’s child abuse  reports, we reviewed related documentation; assessed the data for errors,  omissions, and inconsistencies; and interviewed officials. We determined  that the data were sufficiently reliable to describe trends in and  characteristics of child abuse reports from school years 2014-2015  through 2017-2018.

DODEA serious incident reports track information about alleged or  suspected serious incidents resulting in consequences greater than those  normally addressed through routine administrative actions. We analyzed  DODEA’s serious incident reports relating to child-on-child abuse— involving a violation of law or a sexual event—over the past 5 school  years to identify trends in the number and type of serious incident reports  as well as to describe characteristics of the reports. Specifically, we  analyzed the type of serious incident (assault/battery, child pornography,  nonconsensual sexual contact, etc.), whether police were notified,  whether the police investigated, and the type of school filing the report. To  assess the reliability of DODEA’s serious incident reports, we reviewed  related documentation; assessed the data for errors, omissions, and  inconsistencies; and interviewed officials. We determined that the data  were sufficiently reliable to describe trends in and characteristics of  serious incident reports from school years 2013-2014 through 2017-2018,  and to compare serious incident reports to DODEA student misconduct  records from school years 2016-2017 through 2017-2018.

DODEA’s student misconduct records are separate from child abuse  reports and serious incident reports—but may also be filed in relation to a  serious incident—and track information regarding disciplinary actions and  the triggering incident, such as an abusive or indecent act. We requested  and received all redacted DODEA student misconduct records over the  past 5 school years that involved at least one of 26 incident types that we  determined, through conversations with DODEA officials familiar with the  records, could relate to a child-on-child serious incident. We received  over 26,000 records, some of which related to the same incident, for  example, according to DODEA officials, when more than one student was  involved. For school years 2016-2017 and 2017-2018, we conducted a  content analysis of the student misconduct records, using DODEA’s  Serious Incident Reporting Procedures, to determine the number of  student misconduct records that school administrators, using that  guidance, could have reasonably categorized as a violation of law or  sexual event and filed a serious incident report. We selected these 2  school years for the analysis because DODEA’s updated serious incident  reporting guidance was issued in August 2016 and was in place for both  school years.

Because of the large number of DODEA student misconduct records, we  conducted our content analysis in two stages. We first conducted an  electronic search to identify potentially-relevant records and then  conducted a manual review of all potentially-relevant records. One of our  data analysts electronically searched the student misconduct record  descriptions for key terms that could potentially signify that the incident  was of a nature serious enough to warrant the filing of a serious incident  report, per DODEA guidance. We selected the search terms using the  DODEA guidance (e.g., assault, battery, and rape); additional terms that  may signify a medical or police response (e.g., nurse, ambulance, blood,  and police) because incidents resulting in an injury may be considered to  be serious incidents per the guidance; and terms for common social  media outlets (e.g., Facebook and Snapchat) because taking or sharing  nude photos of another student without their knowledge is an example of  a noncontact sexual act that should result in the filing of a serious incident  report. This search resulted in 2,619 student misconduct records—after  removing duplicate records—that we then manually reviewed. It is  possible that we did not identify some student misconduct records that  could have been categorized as serious incidents because we did not  include some search terms that would have identified more.

Two analysts independently reviewed each of the 2,619 student  misconduct records, using the DODEA guidance, and recorded their  determination that a record (a) could have been classified as a serious  incident report per DODEA’s guidance, (b) was unclear whether it could  be classified as a serious incident report, or (c) should not have been  classified as a serious incident report per DODEA’s guidance. For records  where the two analysts did not initially agree on a determination, they met  and discussed the records and reached a final determination. We then  compared the number of student misconduct records which we  determined school administrators, using the guidance, could have  reasonably categorized as a violation of law or sexual event and filed a  serious incident report with the number of serious incidents recorded by  DODEA for the same time period to determine the extent of DODEA’s  visibility into serious incidents. We discussed the student misconduct  records, the content analysis, and the comparison to serious incident  reports with DODEA officials.

Further, we interviewed relevant DOD and service officials at the  headquarters level and at a nongeneralizable sample of seven military  installations to identify how DOD tracks reported incidents of child abuse  from the time of a report to an ultimate adjudication, including how  information is communicated within and across the services. We selected  at least one installation per service as well as two joint installations, and  selected locations based on the number of reported child abuse incidents  and the number of investigated child-on-child abuse incidents over the  past 5 fiscal years, as well as other factors. Specifically, we selected  installations that over the past 5 fiscal years had a high number of  reported incidents of child abuse or a high number of child-on-child abuse  investigations—or both—in order to maximize the possibility we would  interview officials, responders, and care providers who had responded to  reported incidents of child abuse. Other selection factors included a mix  of types of legislative jurisdiction (such as exclusive and concurrent  jurisdiction), at least some installations with DODEA schools, a high  number of DODEA serious incident reports, and a mix of geographic  locations in the United States and overseas. Because we did not select  locations using a statistically representative sampling method, the  comments provided during our interviews with installation officials are  nongeneralizable and therefore cannot be projected across DOD or a  service, or any other installations. While the information obtained was not  generalizable, it provided perspectives from installation officials that have  assisted with the response to reported incidents of child abuse. We  compared information from our data analyses and interviews to DOD  guidance; GAO-identified practices for developing and maintaining a  reliable schedule; GAO-identified leading practices for results-oriented  management; and Standards for Internal Control in the Federal  Government related to quality information, control activities, and  monitoring activities.

To assess the extent to which DOD has developed and implemented  policies and procedures to respond to and resolve incidents of child  abuse, including child-on-child abuse, occurring on military installations or  involving military dependents, we reviewed relevant DOD and service  policies, guidance, reports, and memoranda on child abuse, juvenile  misconduct, and problematic sexual behavior in children and youth. We  also conducted work at a nongeneralizable sample of seven military  installations in the United States and overseas. At the installations, we  interviewed FAP personnel, medical and mental health personnel, military  law enforcement officials, legal personnel, Special Assistant United  States Attorneys, military criminal investigators, chaplains, child  development center personnel, school liaison officers, military family life  counselors, DODEA personnel, and commanders about how they  prevent, track, respond to, and resolve these incidents.

To obtain the perspectives of parents and guardians of children who have  been affected by abuse on military installations or while they were military  dependents (either by an adult or another child), we interviewed 20  parents and guardians by phone that volunteered to speak with us about  their perspectives on available resources and assistance, case  communication, and the investigative and adjudicative processes. To  develop the interview protocol for parents and guardians, we reviewed  DOD and service policies, interviewed DOD officials, and reviewed our  prior work related to sexual assault in the military. We also consulted  with a GAO mental health professional on the appropriateness of the  instrument as well as guidance on resources to offer participants if  relevant. A survey specialist helped to design the interview protocol,  another survey specialist reviewed it for methodological issues, and an  attorney reviewed it for legal terminology and any other issues. Prior to  interviewing parents and guardians, we pretested the interview protocol  with three analysts who had children and had experience as a military  servicemember or military dependent. We used the pretests to determine  whether: (1) the questions were clear, (2) the terms used were precise,  (3) respondents were able to provide information that we were seeking,  and (4) the questions were unbiased. We made changes to the content  and format of the interview protocol based on the results of our pretesting.

Further, each team member was trained on the interview protocol to  assure its consistent implementation across interviewers and participants.  Due to the sensitivity of the information being discussed, we took several  steps to help ensure a confidential and safe environment during the  phone interviews. All information provided was handled confidentially— callers’ names and contact information were not recorded in our notes  and we did not audio record the interviews. We conducted interviews from  June to September 2019. We took interview notes on paper and later  entered them into a Microsoft Word form. Data entry was verified by the  same analyst. The data were electronically extracted from the Word forms  into a comma-delimited file that was then imported into Excel for analysis.

We summarized the answers to questions about the characteristics of the  incidents discussed, such as whether the offender was a child or an adult,  the location of the incident, the military dependent status of the victim,  and the servicemember status of the offender. Quantitative data  analyses were conducted by one analyst and verified by a second  analyst. We also conducted a content analysis of the narrative information  to identify common themes related to items such as parents’ awareness  of available victim services, the clarity of the response process, and areas  for improvement. Two analysts reviewed the data collected from the  interviews and agreed on the themes into which callers’ comments would  be categorized. Standardized coding instructions were developed and  tested. One analyst reviewed all the callers’ narrative comments and  indicated in the spreadsheet if a theme was present or absent. A different  analyst reviewed the first analyst’s coding to see if they reached the same  determination. For records where the two analysts did not initially agree  on a determination, they met and discussed the records and reached a  final determination. The codes were then counted to assess how many  callers mentioned a given theme. Because we did not select participants  using a statistically representative sampling method, the perspectives  obtained are nongeneralizable and therefore cannot be projected across  DOD, a military service, or installation. While the information obtained  was not generalizable, it provided perspectives from parents and  guardians who were willing to discuss their experiences with the  reporting, response, and resolution processes.

Additionally, we observed each service’s Incident Determination  Committee (IDC) process—through which installations determine whether  an incident meets DOD’s criteria for child abuse—at a total of four  installations. We also attended a symposium hosted by the National  Center on Sexual Exploitation on problematic sexual behavior in children  and youth. We compared the information from the selected installations,  observations, and interviews to GAO-developed practices to enhance and  sustain collaboration in interagency groups, Department of Justice (DOJ)  best practices for sexual assault forensic examination kits, and Standards  for Internal Control in the Federal Government related to quality  information.

To assess the extent to which DOD collaborates with other governmental  and nongovernmental organizations to address incidents of child abuse,  including child-on-child abuse, occurring on military installations or  involving military dependents, we reviewed written agreements in place  with civilian organizations at the nongeneralizable sample of U.S.  installations in our review, such as agreements with local civilian law  enforcement and state and local child welfare agencies about how  incidents of child abuse on the installation are to be addressed. We also  interviewed relevant officials from civilian organizations near the five U.S.  installations in our review, such as state child welfare agencies, law  enforcement organizations, prosecuting attorneys offices, and children’s  advocacy centers (CAC) to determine the extent of their collaboration with  the military and any related challenges. In addition, we interviewed a  senior official from the Defense State Liaison Office regarding their  outreach to states to increase information sharing with state child welfare  agencies. Further, we interviewed DOJ officials regarding the prosecution  of juvenile crimes committed on overseas installations and on some U.S.  installations and its coordination with DOD to address these incidents.  Finally, we contacted officials from the National Children’s Alliance, which  accredits CACs, about its efforts with DOD to improve collaboration  between the military and CACs. We compared the agreements and  information obtained through interviews with DOJ Principles of Federal  Prosecution, GAO-developed key considerations for interagency  collaborative mechanisms, and Standards for Internal Control in the  Federal Government related to quality information.

Tables 2 and 3 present the DOD and non-DOD organizations we visited  or contacted during our review to address our three objectives.

We conducted this performance audit from January 2019 to February  2020 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

Appendix II: Questionnaire for Interviews with Parents and Guardians of Children Affected by Abuse on Military Installations or While They Were Military Dependents

To obtain the perspectives of parents and guardians of children affected  by abuse on military installations or while they were military dependents,  we interviewed parents and guardians who volunteered to speak with us  about their perspectives on available resources and assistance, case  communication, and the investigative and adjudicative processes. We  announced our interest in anonymously interviewing parents and  guardians of children affected by abuse on military installations or while  they were military dependents and provided a toll-free telephone number  and email address for volunteers to contact us. Department of Defense  Military Community and Family Policy officials, who are responsible for  Military OneSource—a 24/7 connection for military families to information,  answers and support—agreed to post our announcement on the Military  OneSource website. We also posted our announcement on our agency  social media platforms and disseminated it through officials at some of  the installations we visited. It was also featured in an article by a military- focused news outlet. Further details about our methodology for these  interviews can be found in appendix I. The interview questionnaire  follows.  1.  In what state are you currently located, or if you’re overseas, in what  2.  Are you currently, or were you previously, associated with a particular  military service, including as a military dependent?    Which service? ______________  3.  Are you calling about abuse that your child experienced, or a child for  whom you are a guardian experienced, or are you calling about  someone else’s child’s experience?

My child/a child for whom I am a guardian  Someone else’s experience                          Go to Question 4    End discussion  4.  In what year did the abuse occur?  (If multiple years, write the range.)  Year provided  5.  Was the abuse reported to any military or civilian government office?    Continue to “a” a.  In what year was the abuse first reported?    6.  Did the abuse occur on the property of a military installation, including  in military housing?  What installation was it? _______________  a.  Was the child who was affected by abuse a military dependent at  the time of the incident?  If “no” here and Q6 above is no, don’t know,      or prefer not to answer, End discussion  Don’t Know                               know, or prefer not to answer, End discussion    If “don’t know” here and Q6 above is no, don’t     If “prefer not to answer” here and Q6 above is      no, don’t know, or prefer not to answer,   7.  Did the abuse occur in a child care facility, a home, a DOD school, or  somewhere else?  Interviewer: Check all they mention  a.  (Skip if the abuse occurred on an installation and the installation  was provided in Q6)   In what state or country did the abuse occur?  8.  Was the individual who perpetrated the abuse a servicemember at the  time of the incident?  Continue to “a”    Continue to “a”    Continue to “a”  a.  Was the individual who perpetrated the abuse another child under  the age of 18 at the time of the incident?

Prefer not to answer  9.  Was the individual who perpetrated the abuse a parent, guardian,  foster parent, or someone in a caregiving role at the time of the  incident, including an older sibling babysitting, or a teacher, etc.?  10. What organization was the abuse first reported to? For example,   was it first reported to the Family Advocacy Program, military law  enforcement, military criminal investigators, civilian law enforcement,  the chain of command, Child Protective Services, or some other  organization?

Family Advocacy Program (FAP)  Continue to “a”

Military law enforcement (Security Forces, Military Police, Provost’s   Office, Master-at-Arms, etc.)    Continue to “a”

Military criminal investigators (CID, OSI, NCIS, Marine Corps CID)     Continue to “a”  Continue to “a”

Chain of Command (to include Commander, Unit, Wing, etc.)    Continue to “a”

Child Protective Services (CPS)  Skip to “b”

Chaplain  military or civilian government organization?  Did you or the chaplain report the abuse to any other    What office?    What office? _______ then continue to “a”

Was the abuse ever reported to a civilian Child Protective  Services agency?    Continue to “b”    Continue to “b”    Continue to “b”    Continue to “b”

Was the abuse ever reported to the Family Advocacy Program?    Continue to “c”    Continue to “c”    Continue to “c” c.

Had you ever heard of the Family Advocacy Program before this  interview?

Prefer not to answer  11. Are you aware that the Family Advocacy Program is responsible for  assessing and providing support services to military families affected  by child abuse?  12. (If child was abused by a parent/guardian/foster parent/someone in a  caregiving role—If Q9 = Yes) Were you notified by the Family  Advocacy Program about whether the incident was considered to be  child abuse, according to DOD criteria and policy?    Continue to “a”    Skip to “Response to Abuse” section    Skip to “Response to Abuse” section    Skip to “Response to Abuse” section  a.  Was the Family Advocacy Program’s process for assessing the  report of abuse and determining whether it met criteria to be  considered child abuse clear to you?  b.  Is there anything that the Family Advocacy Program could do to  clarify the process or make the process clearer?

III. Response to Abuse  13. Did the child or family receive any services from the military related to  the abuse, for example, psychological or legal counseling or medical  care?    Continue to “a”  a.  What services did the child or family receive from the military?  b.  What, if any, services provided by the military were particularly  helpful?  c.  What, if any, services were provided by the military but did not  meet your family’s needs?  i.

Why didn’t those services meet your family’s needs?  _________________________________________  d.  What, if anything, could be improved about the services you  received from the military, such as the services themselves, or the  ease of access or timeliness of the services provided?    14. Were there services that your child or family were offered by the  military, but that you did not receive, either because you did not need  them or because of some other factor?    Continue to “a”  a.  What type of services were offered but not received?  b.  Why did you not receive these services—for example, was it by  choice or was there some factor that prevented you from receiving  them?   _________________________________________  15. Did your child or family receive any services from civilian  organizations or providers related to the abuse, for example,  psychological or legal counseling or medical care?    Continue to “a”  a.  What services did your child or family receive from civilian  organizations or providers?  16. Were there any services—either through the military or a civilian  agency—that you think would have been helpful, but were not  available?    Continue to “a” a.  What services?  _________________________________________  IV. Investigation/Resolution of Abuse  17. Was the incident of abuse investigated by any law enforcement  organization, including military or civilian law enforcement? For  example, was the incident of abuse investigated by the military police,  a military investigative organization, civilian state or local law  enforcement, the Federal Bureau of Investigation, or some other law  enforcement organization?    Continue to “a”

Skip to “Miscellaneous Questions” section   Skip to “Miscellaneous Questions” section   Skip to “Miscellaneous Questions” section  a.  What law enforcement organization or organizations conducted an  investigation? If more than one law enforcement organization  conducted an investigation, please tell me all the organizations.

Military police (Security Forces, Military Police, Provost’s    Office, Marshal-at-Arms, etc)

Military investigative organization (CID, OSI, NCIS, Marine Corps  CID)  18. (If military conducted an investigation, see response to Q17a) What  type of information did you receive from the investigating military  organization during the course of the investigation, if any, such as  status updates by phone, e-mail, or letter?  _________________________________________  a.  Did you have a point of contact that you could reach out to at the  investigating military organization with any questions or for status  updates?  19. After the investigation ended, were you informed about the outcome  or informed of any next steps regarding any potential criminal or  administrative action against the individual that perpetrated the  abuse?    Continue to “a”    Continue to “a”  a.  Did you have a point of contact that you could reach out to with  any questions about the outcome of the investigation or next  steps?

Prefer not to answer  20. What, if anything, would you recommend that DOD or the military  services do to be more responsive to families of children who have  been affected by abuse on military installations or as military  dependents?  21. What, if anything, would you recommend DOD or the military services  do to help prevent child abuse or child-on-child abuse?  22. Is there anything related to child abuse on military installations or of  military dependents that we did not discuss but you think we should  be aware of?  23. One last question: Was there anyone else present with you during any  part of our conversation?

Appendix III: Characteristics of Incidents of Child Abuse Reported to the Military Services’ Family Advocacy Programs, Fiscal Years 2014-2018

Each military service’s Family Advocacy Program (FAP) has a  database—referred to as the “central registry”—where it tracks (1) reports  of abuse that did not meet the Department of Defense’s (DOD) criteria for  child abuse, about which no identifiable individual information is tracked;  and (2) information on reports of abuse that met DOD’s criteria for abuse,  which is linked to identifiable servicemembers, their family members, and  the alleged offenders. Per DOD guidance, the services are to track 46  data elements on all reported incidents of child abuse that met DOD’s  criteria for abuse. The service FAPs only track information in their central  registries related to child abuse where the offender was a parent,  guardian, foster parent, or someone in a caregiving role. The following  describes key characteristics of incidents of child abuse that met DOD’s  criteria for abuse as reported to the Army, the Navy, the Marine Corps,  and the Air Force FAPs from fiscal years 2014 through 2018.

Army FAP. Over the past 5 fiscal years, the Army FAP recorded 32,386  reported incidents of child abuse, of which 50 percent met DOD’s criteria  for child abuse. Of the incidents that met DOD’s criteria for abuse, 66  percent involved neglect, 20 percent involved physical abuse, 17 percent  involved emotional abuse, and 5 percent involved sexual abuse. The  majority of incidents (97 percent) were intrafamilial—meaning that the  victim and the offender were from the same family, such as a parent or  sibling—and 2 percent of the incidents were extrafamilial or external to  the family, such as a babysitter or a childcare provider. Half of the victims  and 52 percent of the offenders were male. In addition, a quarter of  offenders had prior FAP cases related to child abuse or domestic abuse  that met DOD’s criteria for abuse. Figure 6 depicts characteristics of  incidents reported to the Army FAP that met DOD’s criteria for child  abuse over the past 5 fiscal years.

Navy FAP. From fiscal years 2014 through 2018, the Navy FAP recorded  10,744 reported incidents of child abuse, of which 51 percent met DOD’s  criteria for child abuse. Of the incidents that met DOD’s criteria for abuse,  59 percent involved neglect, 33 percent involved physical abuse, 14  percent involved emotional abuse, and 6 percent involved sexual abuse.  The majority of incidents (96 percent) were intrafamilial and 4 percent of  the incidents were extrafamilial. Slightly over half of the victims and  offenders were male (52 percent). Additionally, since fiscal year 2017,  when the Navy began tracking whether offenders had prior FAP cases  related to child abuse or domestic abuse that met DOD’s criteria for  abuse, 1 percent of offenders had prior cases. Figure 7 depicts  characteristics of incidents reported to the Navy FAP that met DOD’s  criteria for child abuse over the past 5 fiscal years.

Marine Corps FAP. Over the past 5 fiscal years, the Marine Corps FAP  recorded 8,356 reported incidents of child abuse, of which 54 percent met  DOD’s criteria for child abuse. Of the incidents that met DOD’s criteria  for abuse, 62 percent involved neglect, 20 percent involved emotional  abuse, 15 percent involved physical abuse, and 2 percent involved sexual  abuse. The majority of incidents (96 percent) were intrafamilial and 4  percent of the incidents were extrafamilial. Slightly over half of the victims  and offenders were male (52 percent) and 7 percent of offenders had  prior FAP cases related to child abuse or domestic abuse that met DOD’s  criteria for abuse. Figure 8 depicts characteristics of incidents reported to  the Marine Corps FAP that met DOD’s criteria for child abuse over the  past 5 fiscal years.

Air Force FAP. From fiscal years 2014 through 2018, the Air Force FAP  recorded 17,836 reported incidents of child abuse, of which 41 percent  met DOD’s criteria for child abuse. Of the incidents that met DOD’s  criteria for abuse, 55 percent involved neglect, 25 percent involved  physical abuse, 22 percent involved emotional abuse, and 4 percent  involved sexual abuse. The majority of incidents (95 percent) were  intrafamilial and 4 percent of the incidents were extrafamilial. Slightly over  half of the victims and offenders were male (51 percent and 53 percent,  respectively). In addition, 0 percent of offenders had prior FAP cases  related to child abuse or domestic abuse that met DOD’s criteria for  abuse. Figure 9 depicts characteristics of incidents reported to the Air  Force FAP that met DOD’s criteria for child abuse over the past 5 fiscal  years.

Appendix IV: Characteristics of Military Criminal Investigative Organization Investigations Involving Child Victims, Fiscal Years 2014-2018

Each military criminal investigative organization—the Army Criminal  Investigation Command, the Naval Criminal Investigative Service, and the  Air Force Office of Special Investigations—maintains an investigative  case management system where it tracks information about the  investigation, such as the offense(s), victim(s), and alleged offender(s),  among other things. According to military criminal investigative  organization officials, they primarily investigate felony level crimes as well  as any type of sexual offense. The following are key characteristics of  investigations involving child victims investigated by each of the three  military criminal investigative organizations from fiscal years 2014 through  2018.

Army Criminal Investigation Command. Over the past 5 fiscal years,  the Army Criminal Investigation Command conducted or monitored 5,565  investigations involving a child victim. Some of those investigations  involved multiple victims, offenders, and offenses. Specifically, those  5,565 investigations included 6,535 victims, 5,965 alleged offenders, and  8,483 offenses. The Army Criminal Investigation Command was the  primary investigative organization for almost three-quarters of the  investigations (74 percent). For the rest of the investigations, the primary  investigative organization was another federal, state, or local civilian law  enforcement organization, such as the Federal Bureau of Investigation,  which conducted 4 percent of the investigations. Additionally, 42 percent  of the investigations involved an intrafamilial relationship—meaning that  the victim and the alleged offender were from the same family, such as a  parent or sibling—between at least one of the alleged offenders and  victims. Figure 10 depicts characteristics of the Army Criminal  Investigation Command’s investigations involving a child victim over the  past 5 fiscal years.

Naval Criminal Investigative Service. From fiscal years 2014 through  2018, the Naval Criminal Investigative Service conducted or monitored  1,513 investigations involving a child victim. Some of those investigations  involved multiple victims, offenders, and offenses. Specifically, those  1,513 investigations included 1,731 victims, 1,618 alleged offenders, and  1,812 offenses. The Naval Criminal Investigative Service was the primary  investigative organization for about half of the investigations (54 percent).  The remainder of the investigations were either joint with another law  enforcement organization or the Naval Criminal Investigative Service was  only monitoring the investigation. Additionally, 40 percent of the  investigations involved an intrafamilial relationship between at least one  of the alleged offenders and victims. Figure 11 depicts characteristics of  the Naval Criminal Investigative Service’s investigations involving a child  victim over the past 5 fiscal years.

Air Force Office of Special Investigations. Over the past 5 fiscal years,  the Air Force Office of Special Investigations conducted or monitored  1,304 investigations involving a child victim. Some of those investigations  involved multiple victims, offenders, and offenses. Specifically those  1,304 investigations included 1,549 victims, 1,384 alleged offenders, and  1,649 offenses—12 percent of investigations involved more than one  victim. In addition, 42 percent of investigations involved an intrafamilial  relationship between at least one of the alleged offenders and victims.  Figure 12 depicts characteristics of the Air Force Office of Special  Investigations’ investigations involving a child victim over the past 5 fiscal  years.

Appendix V: Characteristics of Department of Defense Education Activity Child Abuse Reports and Serious Incident Reports, School Years 2013-2014 through 2017-2018

The Department of Defense Education Activity (DODEA) tracks  suspected or alleged abuse of students through (1) child abuse reports,  and (2) serious incident reports.

Child abuse reports. DODEA guidance defines child abuse as the  physical injury, sexual maltreatment, emotional maltreatment, deprivation  of necessities, or combinations for a child by an individual responsible for  the child’s welfare under circumstances indicating that the child’s welfare  is harmed or threatened. The term encompasses both acts and omissions  on the part of the responsible person. Child abuse reports are to be  submitted on any incidents of suspected or alleged child abuse to  DODEA headquarters within 24 hours of the occurrence or notification of  the incident.

From school years 2014-2015 through 2017-2018, DODEA reported 254  suspected or alleged incidents of child abuse. Of DODEA’s 163 schools,  115 reported an incident of child abuse over these 4 school years.  Reported child abuse included a range of incidents, such as parents  leaving their children unattended, parents physically abusing their  children, teachers using physical force on students, and teachers  inappropriately touching students. The most common types of abuse  were physical abuse (51 percent of reported incidents), multiple types of  abuse (11 percent), and sexual abuse (9 percent). The majority of the  reported incidents involved the abuse of a child by a parent or guardian  (55 percent) or abuse by DODEA personnel (31 percent). Figure 13  depicts characteristics of incidents of child abuse reported by DODEA  over 4 school years.

Serious incident reports. DODEA guidance defines a serious incident  as an event or allegation that impacts school readiness, or the health,  safety, and security of DODEA-affiliated personnel, facilities, and property  resulting in consequences greater than those normally addressed through  routine administrative or preventive maintenance actions. Serious incident  reports are normally submitted by the school principal, assistant principal,  or designated administrative officer within 2 business days after the event  is brought to the attention of the first-line supervisor. DODEA has different  categories of serious incidents, such as drug and alcohol events, violation  of law events, sexual events, and security incidents. Serious child-on- child abuse incidents are reported as either violation of law events, such  as assault and battery or sexual events.

From school years 2013-2014 through 2017-2018, DODEA reported 167  serious incidents involving either an alleged violation of law or an alleged  sexual event. Only 74 of DODEA’s 163 schools reported such an  incident over the past 5 school years. Reported serious incidents included  a range of incidents, such as students posting nude photos and videos of  other students on social media, inappropriate touching on the school bus,  physical assaults, and rape. Of the serious incident reports we received,  the most common types were nonconsensual sexual contact (35 percent  of reported incidents), assault and battery (25 percent), rape (16 percent),  and child pornography (15 percent). The majority of the reported serious  incidents involved a single victim (68 percent), but 13 percent of the  incidents involved more than one victim and 20 percent did not specify a  victim. Figure 14 depicts characteristics of serious incidents involving an  alleged violation of law or an alleged sexual event reported by DODEA  over the past 5 school years.

According to DODEA officials, DODEA implemented a new database for  reporting serious incidents in August 2019. These officials noted that one  of the goals of the system is to make reporting more straightforward for  school administrators and to standardize serious incident reports across  schools. DODEA officials anticipate adding child abuse reports to the new  database in late calendar year 2019 or early 2020.

Appendix VI: Comments from the Department of Defense

Appendix VII: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Kimberly Mayo (Assistant  Director), Molly Callaghan (Analyst in Charge), Vincent M. Buquicchio,  Christopher Gezon, Grant Mallie, Joseph Neumeier, Kya Palomaki, Paul  Seely, Mike Silver, and Lillian M. Yob made significant contributions to  this report.

Military Justice: DOD and the Coast Guard Need to Improve Their  Capabilities to Assess Racial and Gender Disparities. GAO-19-344.  Washington, D.C.: May 30, 2019.

Children Affected by Trauma: Selected States Report Various  Approaches and Challenges to Supporting Children. GAO-19-388.  Washington, D.C.: April 24, 2019.

Sexual Violence: Actions Needed to Improve DOD’s Efforts to Address  the Continuum of Unwanted Sexual Behaviors. GAO-18-33. Washington,  D.C.: December 18, 2017.

Child Well-Being: Key Considerations for Policymakers, Including the  Need for a Federal Cross-Agency Priority Goal. GAO-18-41SP.  Washington, D.C.: November 9, 2017.

Military Personnel: DOD Has Processes for Operating and Managing Its  Sexual Assault Incident Database. GAO-17-99. Washington, D.C.:  January 10, 2017.

Sexual Violence Data: Actions Needed to Improve Clarity and Address  Differences Across Federal Data Collection Efforts. GAO-16-546.  Washington, D.C.: July 19, 2016.

Sexual Assault: Actions Needed to Improve DOD’s Prevention Strategy  and to Help Ensure It Is Effectively Implemented. GAO-16-61.  Washington, D.C.: November 4, 2015.

Youth Athletes: Sports Programs’ Guidance, Practices, and Policies to  Help Prevent and Respond to Sexual Abuse. GAO-15-418. Washington,  D.C.: May 29, 2015.

Military Personnel: Actions Needed to Address Sexual Assaults of Male  Servicemembers. GAO-15-284. Washington, D.C.: March 19, 2015.

Child Welfare: Federal Agencies Can Better Support State Efforts to  Prevent and Respond to Sexual Abuse by School Personnel. GAO-14-42.  Washington, D.C.: January 27, 2014.

Child Maltreatment: Strengthening National Data on Child Fatalities Could  Aid in Prevention. GAO-11-599. Washington, D.C.: July 7, 2011.

Military Justice: Oversight and Better Collaboration Needed for Sexual  Assault Investigations and Adjudications. GAO-11-579. Washington,  D.C.: June 22, 2011.

With more than 1.2 million school-age military dependents worldwide, the Defense Department works to prevent and respond to child abuse, including child-on-child abuse.

It’s difficult for DOD to track abuse cases from first report to final outcome because the organizations involved track different parts of the process and their databases don’t work together.

We also found that victims’ families get inconsistent information about the case response process. Some families we spoke to weren’t aware of all the resources available to them.

Our 23 recommendations include expanding DOD’s centralized database and better informing victims’ families.