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Definitions, Scope, and Effects of Child Sexual Abuse

Definitions

Most professionals are fairly certain they know what child sexual abuse is, and there is a fair amount of agreement about this. For example, today very few people would question the inclusion of sexual acts that do not involve penetration. Despite this level of consensus, it is important to define what sexual abuse is because there are variations in definitions across professional disciplines.

Child sexual abuse can be defined from legal and clinical perspectives. Both are important for appropriate and effective intervention. There is considerable overlap between these two types of definitions.

Statutory Definitions

There are two types of statutes in which definitions of sexual abuse can be found – child protection (civil) and criminal.

The purposes of these laws differ. Child protection statutes are concerned with sexual abuse as a condition from which children need to be protected. Thus, these laws include child sexual abuse as one of the forms of maltreatment that must be reported by designated professionals and investigated by child protection agencies. Courts may remove children from their homes in order to protect them from sexual abuse. Generally, child protection statutes apply only to situations in which offenders are the children's caretakers.

Criminal statutes prohibit certain sexual acts and specify the penalties. Generally, these laws include child sexual abuse as one of several sex crimes. Criminal statutes prohibit sex with a child, regardless of the adult's relationship to the child, although incest may be dealt with in a separate statute.

Definitions in child protection statutes are quite brief and often refer to State criminal laws for more elaborate definitions. In contrast, criminal statutes are frequently quite lengthy.

Child Protection Definitions

The Federal definition of child maltreatment is included in the Child Abuse Prevention and Treatment Act. Sexual abuse and exploitation is a subcategory of child abuse and neglect. The statute does not apply the maximum age of 18 for other types of maltreatment, but rather indicates that the age limit in the State law shall apply. Sexual abuse is further defined to include:

In order for States to qualify for funds allocated by the Federal Government, they must have child protection systems that meet certain criteria, including a definition of child maltreatment specifying sexual abuse.

Criminal Definitions

With the exception of situations involving Native American children, crimes committed on Federal property, interstate transport of minors for sexual purposes, and the shipment or possession of child pornography, State criminal statutes regulate child sexual abuse. Generally, the definitions of sexual abuse found in criminal statutes are very detailed. The penalties vary depending on:

Often types of sexual abuse are classified in terms of their degree (of severity), first degree being the most serious and fourth degree the least, and class (of felony), a class A felony being more serious than a class B or C, etc.

Clinical Definitions

Although clinical definitions of sexual abuse are related to statutes, the guiding principle is whether the encounter has a traumatic impact on the child. Not all sexual encounters experienced by children do. Traumatic impact is generally affected by the meaning of the act(s) to the child, which may change as the child progresses through developmental stages. The sexual abuse may not be "traumatic" but still leave the child with cognitive distortions or problematic beliefs; that is, it is "ok" to touch others because it feels good.

Differentiating Abusive From Nonabusive Sexual Acts

There are three factors that are useful in clinically differentiating abusive from nonabusive acts – power differential; knowledge differential; and gratification differential.

These three factors are likely to be interrelated. However, the presence of any one of these factors should raise concerns that the sexual encounter was abusive.

- Power can also derive from the larger size or more advanced capability of the offender, in which case the victim may be manipulated, physically intimidated, or forced to comply with the sexual activity. Power may also arise out of the offender's superior capability to psychologically manipulate the victim (which in turn may be related to the offender's role or superior size). The offender may bribe, cajole, or trick the victim into cooperation.

- Generally, the younger the child, the less able she/he is to appreciate the meaning and potential consequences of a sexual relationship, especially one with an adult. Usually, the maximum age for the person to be considered a victim (as opposed to a participant) is 16 or 18, but some researchers have used an age cutoff of 13 for boy victims.17 Apparently, the researchers felt that boys at age 13, perhaps unlike girls, were able to resist encounters with significantly older people and were, by then, involved in consensual sexual acts with significantly older people. However, clinicians report situations in which boys victimized after age 13 experience significant trauma from these sexual contacts.

- Situations in which retarded or emotionally disturbed persons participate in or are persuaded into sexual activity may well be exploitive, even though the victim is the same age or even older than the perpetrator.

- In this regard, some activities that involve children in which there is not a 5-year age differential may nevertheless be abusive. For example, an 11-year-old girl is instructed to fellate her 13-year-old brother. (This activity might also be abusive because there was a power differential between the two children based on his superior size.)

Sexual Acts

The sexual acts that will be described in this section are abusive clinically when the factors discussed in the previous section are present as the examples illustrate. The sexual acts will be listed in order of severity and intrusiveness, the least severe and intrusive being discussed first.

- Example: A coach told a team member he had a fine body, and they should find a time to explore one another's bodies. He told the boy he has done this with other team members, and they had enjoyed it.

Offender exposing intimate parts to the child, sometimes accompanied by masturbation.

- Example: A grandfather required that his 6-year-old granddaughter kneel in front of him and watch while he masturbated naked.

- Example: A stepfather made a hole in the bathroom wall. He watched his stepdaughter when she was toileting (and instructed her to watch him).

- Example: Mother and father had their 6- and 8-year-old daughters accompany them to viewings of adult pornographic movies at a neighbor's house.

- Example: Neighbor paid a 13-year-old emotionally disturbed girl $5 to undress and parade naked in front of him.

- Example: A father put his hand in his 4-year-old daughter's panties and fondled her vagina while the two of them watched "Sesame Street."

- Example: A mother encouraged her 10-year-old son to fondle her breasts while they were in bed together.

- Example: A father, lying in bed, had his clothed daughter sit on him and play "ride the horse."

- Example: A father used digital penetration with his daughter to "teach" her about sex.

- Example: An adolescent boy required a 10-year-old boy to put Vaseline on his finger and insert it into the adolescent's anus as initiation into a club.

- Example: A psychotic mother placed a candle in her daughter's vagina.

- Example: A babysitter had a 6-year-old boy penetrate her vaginally with a mop handle.

- Example: Several children who had attended the same day care center attempted to French kiss with their parents. They said that Miss Sally taught them to do this.

- Example: A mother required her 6-year-old daughter to suck her breasts (in the course of mutual genital fondling).

- Example: A father's girlfriend who was high on cocaine made the father's son lick her vagina as she sat on the toilet.

- Example: An adolescent, who had been reading pornography, told his 7-year-old cousin to close her eyes and open her mouth. She did and he put his penis in her mouth.

- Example: A mother overheard her son and a friend referring to their camp counselor as a "butt lick." The boys affirmed that the counselor had licked the anuses of two of their friends (and engaged in other sexual acts with them). An investigation substantiated this account.

- Example: A 7-year-old girl was placed in foster care by her father because she was incorrigible. She was observed numerous times "humping" her stuffed animals. In therapy she revealed that her father "humped" her. There was medical evidence of vaginal penetration.

- Example: Upon medical exam an 8-year-old boy was found to have evidence of chronic anal penetration. He reported that his father "put his dingdong in there" and allowed two of his friends to do likewise.

Circumstances of Sexual Acts

Professionals need to be aware that sexual acts with children can occur in a variety of circumstances. In this section, dyads, group sex, sex rings, sexual exploitation, and ritual abuse will be discussed. These circumstances do not necessarily represent discrete and separate phenomena.

- Child pornography can involve only one child, sometimes in lewd and lascivious poses or engaging in masturbatory behavior; of children together engaging in sexual activity; or of children and adults in sexual activity.

- It is important to remember that pictures that are not pornographic and are not illegally obscene can be very arousing to a pedophile. For example, an apparently innocent picture of a naked child in the bathtub or even a clothed child in a pose can be used by a pedophile for arousal.20

- Situations in which young children are prostituted are usually intrafamilial, although there are reports of child prostitution constituting one aspect of sexual abuse in some day care situations. Adolescent prostitution is more likely to occur in a sex ring (as mentioned above), at the hand of a pimp, in a brothel, or with the child operating independently. Boys are more likely to be independent operators, and girls are more likely to be in involved in situations in which others control their contact with clients

- As best can be determined, ritual sexual abuse is abuse that occurs in the context of a belief system that, among other tenets, involves sex with children. These belief systems are probably quite variable. Some may be highly articulated, others "half-baked." Some ritual abuse appears to involve a version of satanism that supports sex with children. However, it is often difficult to discern how much of a role ideology plays. That is, the offenders may engage in "ritual" acts because they are sadistic, because they are sexually aroused by them, or because they want to prevent disclosure, not because the acts are supported by an ideology. Because very few of these offenders confess, their motivation is virtually unknown.

- Often sexual abuse plays a secondary role in the victimization in ritual abuse, physical and psychological abuse dominating. The following is a nonexhaustive list of characteristics that may be present in cases of ritual abuse:

Most allegations of ritual abuse come from young children, reporting this type of abuse in day care, and from adults, who are often psychiatrically very disturbed and describe ritual abuse during their childhoods. Issues of credibility are raised with both groups. Moreover, accounts of ritual abuse are most disturbing, to both those recounting the abuse and those hearing it.

Scope of the Problem of Child Sexual Abuse

Clinicians and researchers working in sexual abuse believe that the problem is underreported. This belief is based on assumptions about sexual taboos and on research on adults sexually abused as children, the overwhelming majority of whom state that they did not report their victimization at the time of its occurrence. Moreover, it is probably true that situations involving female offenders as well as ones with boy victims are underidentified, in part because of societal perceptions about the gender of offenders and victims.

Estimates of the extent of sexual abuse come from three main sources – research on adults, who recount their experiences of sexual victimization as children; annual summaries of the accumulated reports of sexual abuse filed with child protection agencies; and two federally funded studies of child maltreatment entitled the National Incidence Studies. In addition, anecdotal information is supplied by some convicted/self-acknowledged offenders, who report sexually abusing scores and even hundreds of children before their arrest.

Prevalence of Child Sexual Abuse

Studies of the prevalence of sexual abuse are those involving adults that explore the extent to which persons experience sexual victimization during their childhoods. Findings are somewhat inconsistent for several reasons. First, data are gathered using a variety of methodologies: telephone interviews, face-to-face interviews, and written communications (i.e., questionnaires). Second, a study may focus entirely on sexual abuse, or sexual abuse may be one of many issues covered. Third, some studies are of special populations, such as psychiatric patients, incarcerated sex offenders, and college students, whereas others are surveys of the general population. Finally, the definition of sexual abuse varies from study to study. Dimensions on which definitions may differ are maximum age for a victim, the age difference required between victim and offender, whether or not noncontact acts are included, and whether the act is unwanted.

The factors just mentioned have the following effects on rates of sexual abuse reported. Face-to-face interviews, particularly when the interviewer and interviewee are matched on sex and race, and multiple questions about sexual abuse may result in higher rates of disclosure. However, it cannot be definitively stated that special populations such as prostitutes, drug addicts, or psychiatric populations have higher rates of sexual victimization than the general population, because some studies of the general population report quite high rates. Not surprisingly, when the definition is broader (e.g., inclusion of noncontact behaviors and "wanted" sexual acts) the rates go up.

Rates of victimization for females range from 6 to 62 percent, with most professionals estimating that between one in three and one in four women are sexually abused in some way during their childhoods. The rates for men are somewhat lower, ranging from 3 to 24 percent, with most professionals believing that 1 in 10 men and perhaps as many as 1 in 6 are sexually abused as children. As noted earlier, many believe that male victimization is more underreported than female, in part because of societal failure to identify the behavior as abusive. However, the boy himself may not define the behavior as sexual victimization but as sexual experience, especially if it involves a woman offender. Moreover, he may be less likely to disclose than a female victim, because he has been socialized not to talk about his problems. This reticence may be increased if the offender is a male, for he must overcome two taboos, having been the object of a sexual encounter with an adult and a male. Finally, he may not be as readily believed as a female victim.

The Incidence of Child Sexual Abuse

Incidence of a problem is defined as the number of reports during a given time frame, yearly in the case of sexual abuse. From 1976 to 1986, data were available on the number of sexual abuse cases reported per year to child protection agencies, as part of data collection on all types of maltreatment. These cases were registered with the National Center on Child Abuse and Neglect, and data were analyzed by the American Humane Association. Over that 10-year period, there was a dramatic increase in the number of reports of sexual abuse and in the proportion of all maltreatment cases represented by sexual abuse. In 1976, the number of sexual abuse cases was 6,000, which represented a rate of 0.86 per 10,000 children in the United States. By 1986, the number of reported cases was 132,000, a rate of 20.89 per 10,000 children. This represents a 22-fold increase. Moreover, whereas in 1976 sexual abuse cases were only 3 percent of all reports, by 1986, they comprised 15 percent of reports.32

Striking though these findings may be, their limitations must be appreciated. First, current data are not available. Second, cases included in this data set are limited to those that would warrant a CPS referral, generally cases in which the abuser is a caretaker or in which a caretaker fails to protect a child from sexual abuse. Thus, cases involving an extrafamilial abuser and a protective parent are not included. Third, the data only refer to reported cases. This means those cases that are unknown to professionals and those known but not reported are not included. Moreover, these are reports, not substantiations of sexual abuse. The national average substantiation rate is generally between 40 and 50 percent. Substantiation rates vary from State to State and among locations.

The National Incidence Studies (NIS-1 and NIS-2) provide additional data on the rates of child maltreatment, including sexual abuse. Information for these studies was collected in 1980 and 1986; thus, they do not provide annual incidence rates, as the Child Protection data do. In addition, these studies project a national rate of child maltreatment based on information from 29 counties, rather than using reports from all States. Nevertheless, these studies do allow for some analysis of trends because data were collected at two different time points. Moreover, one of the most important features of the NIS studies is that they gathered information on unreported as well as reported cases.

Differences between the first and second studies indicate there was a more than threefold increase in the number of identified cases of sexual maltreatment. An estimated 42,900 cases were identified by professionals in 1980 compared with 133,600 cases in 1986. These figures represent a rate of 7 cases per 10,000 children in 1980 and 21 cases per 10,000 in 1986. Despite the fact that the 1986 number and rate are quite close to the figures for suspected sexual abuse reported to child protection agencies in 1986, only about 51 percent of cases identified by professionals in the National Incidence Study were reported to child protective services (CPS). Furthermore, the proportion of cases identified but not reported to CPS did not change significantly between 1980 and 1986.

It is clear that available statistics on the prevalence and incidence of sexual abuse do not completely reflect the extent of the problem. However, they do provide a definite indication that the problem of sexual victimization is a significant one that deserves our attention and intervention.

The Effects of Sexual Abuse on its Victim

Concern about sexual abuse derives from more than merely the fact that it violates taboos and statutes. It comes principally from an appreciation of its effects on victims. In this section, the philosophical issue of why society is concerned about sexual abuse and documented effects will be discussed.

What's Wrong About Sex Between Adults and Children?

It is important for professionals, particularly if they dedicate a substantial part of their careers to intervening in sexual abuse situations, to distance themselves from their visceral reactions of disgust and outrage and rationally consider why sex between children and adults is so objectionable.

Organizations such as the North American Man Boy Love Association (NAMBLA) and the René Guyon Society challenge the assertion that sexual abuse is bad because of its effects on children. These organizations argue that what we label as harmful effects are not the effects of sexual abuse but the effects of societal condemnation of the behavior. Thus, children feel guilty about their involvement, suffer from "damaged goods syndrome," have low self-esteem, are depressed and suicidal, and experience helpless rage because society has stigmatized sex between adults and children. If society would cease to condemn the behavior, then children could enjoy guilt-free sexual encounters with adults. Such organizations also argue that we, as adults, are interfering with children's rights, specifically their right to control their own bodies and their sexual freedom, by making sex between children and adults unacceptable and illegal.

How can we respond to this argument? It is true that many of the effects of sexual abuse at least indirectly derive from how society views the activity. However, the impact also reflects the experience itself. The reader will recall the earlier discussion of differentiating abusive from nonabusive encounters on the basis of power, knowledge, and gratification.

Because the adult has more power, he/she has the capacity to impose the sexual behavior, which may be painful, intrusive, or overwhelming because of its novelty and sexual nature. This power may also be manifest in manipulation of the child into compliance. The child has little knowledge about the societal and personal implications of being involved in sex with an adult; in contrast, the adult has sophisticated knowledge of the significance of the encounter. The child's lack of power and knowledge means the child cannot give informed consent. Finally, although in some cases the adult may perceive him/herself providing pleasure to the child, the main object is the gratification of the adult. That is what is wrong about sex between adults and children.

The Impact of Sexual Abuse

Regardless of the underlying causes of the impact of sexual abuse, the problems are very real for victims and their families. A number of attempts have been made to conceptualize the effects of sexual abuse In addition, recent efforts to understand the impact of sexual abuse have gone beyond clinical impressions and case studies. They are based upon research findings, specifically controlled research in which sexually abused children are compared to a normal or nonsexually abused clinical population. There are close to 40 such studies to date.

Finkelhor, whose conceptualization of the traumatogenic effects of sexual abuse is the most widely employed, divides sequelae into four general categories, each having varied psychological and behavioral effects.

Our understanding of the impact of sexual abuse is frustrated by the wide variety of possible effects and the way research is conducted. Researchers do not necessarily choose to study the same effects, nor do they use the same methodology and instruments. Consequently, a particular symptom, such as substance abuse, may not be studied or may be examined using different techniques. Furthermore, although most studies find significant differences between sexually abused and nonabused children, the percentages of sexually abused children with a given symptom vary from study to study, and there is no symptom universally found in every victim. In addition, often lower proportions of sexually abused children exhibit a particular symptom than do nonabused clinical comparison groups. Finally, although some victims suffer pervasive and debilitating effects, others are found to be asymptomatic.

In addition, a variety of factors influence how sexual maltreatment impacts on an individual. These factors include the age of the victim (both at the time of the abuse and the time of assessment), the sex of the victim, the sex of the offender, the extent of the sexual abuse, the relationship between offender and victim, the reaction of others to knowledge of the sexual abuse, other life experiences, and the length of time between the abuse and information gathering. For example, the findings for child victims and adult survivors are somewhat different.

It is important for professionals to appreciate both the incomplete state of knowledge about the consequences of sexual abuse and the variability in effects. Such information can be helpful in recognizing the wide variance in symptoms of sexual abuse and can prevent excessive optimism or pessimism in predicting its impact.

 

* When children are victims, sexual comments are usually made in person. However obscene remarks may be made on the telephone or in notes and letters.

** Activities in parenthesis are not illustrative of the sexual act being defined.

*** Sexual contact can be either above or beneath clothing.

**** The offender may inflict oral sex upon the child or require the child to perform it on him/her or both.

***** These statistics from the revised second National Incidence Study reflect the revised definition of child abuse and neglect, which includes the combined total children who were demonstrably harmed and threatened with harm.

Techniques For The Child Interview And A Methodology For Substantiating Sexual Abuse

Because of the central role played by the child interview in substantiating sexual abuse, it is addressed in greater depth than some of the other aspects of child sexual abuse practice.

Introduction

As noted in the previous chapter, child interview data may be gathered in one or more interviews, depending on the particular child, the professional conducting the interview, and the safety of the child's living arrangement. The interviewer must initially spend time getting to know the child. This allows the interviewer to learn about the child's life circumstances and possible context of abuse and to ascertain the child's developmental level, modes of communication, the child's affective or emotional state(s), and overall functioning, including the child's competency. With young children, this part of the assessment usually involves play activity with some questions. With older children, the interviewer is likely to rely primarily on talking to the child and asking questions. At this point, questions are usually about the child's life in general and are neutral. They might include queries about the child, as well as her/his school, friends, and family.

Either before, during, or following this general discussion, the interviewer speaks to the child about why she/he is being seen and how the information the child gives will be used. If the interview is to be taped or there are people behind the one-way mirror, the child should be informed. This material is communicated at the child's developmental level and varies with the circumstances of the case.

Information elicited, statements recorded, and behavior observed during this initial phase of the interview often lead naturally into discussion of possible sexual abuse.

Techniques for Interviewing the Child

A variety of techniques can be used in trying to elicit information from the child. The focus here is on techniques most useful with young children. Appropriate questions and several types of media or props – anatomically explicit dolls, anatomical drawings, picture drawing, story telling, and the doll house – are discussed.

Although appropriate questions will be the first technique discussed, they are no more important than the media that will be described. In many cases, what children demonstrate with media is far more compelling than what they say. It is also somewhat artificial to treat questioning as a separate undertaking. Although questions can be used by themselves, as will become clear, questions are always asked in the process of using media, and the limited research suggests children communicate more accurately when questioned using props than when questioned without them.

It is a good practice to use more than one technique in eliciting information, even if it is only the combination of the use of anatomical dolls and questions. Some of these techniques, such as story telling, are rightfully the province of mental health professionals and should not be used by Child Protective Services (CPS) caseworkers and law enforcement personnel. However, the other techniques can be used by all professionals likely to interview children, provided they have adequate training in their use.

Use of Questions

It is prudent to avoid leading questions in case they might cause a false accusation and in order to preclude challenges to interviewing techniques. The interviewer should assume that the more open-ended the question, the greater confidence he/she should have in the child's responses. A continuum consisting of five types of questions, from most open-ended to most close-ended, is presented in the following discussion. This framework is fairly consistent with other clinical writing on questioning strategies. The types of questions are as follows:

General Questions

General questions are frequently used as opening questions when an adult comes in for assessment or treatment. For example, if an adult rape victim comes to a mental health professional, the therapist might begin by asking, "Tell me why you came to see me today." This question is likely to elicit an account of the rape.

Interviewers attempting to determine if a child has been sexually abused usually ask comparable general questions early in the interview. They might ask, "Did anyone tell you why you are coming to see me today?" With adolescents and late latency-aged children, general questions often produce some information about sexual abuse. Unfortunately, these general questions are less useful with young children. Typical responses from them are, "No," or "I don't remember" (despite the care the accompanying adult might have taken in preparing the child). Alternatively young children may acknowledge that they know why they are being interviewed but say they don't want to talk about it. The children may also give vague responses such as "to talk about the bad things" or "to say what Grandpa did." However, they may fail or refuse to elaborate. More directive questions are needed.

Focused Questions

Clinical experience suggests focused questions are optimal. They often elicit relevant information, but they are not leading. There are three types of focused questions:

Within each type, questions focused on daily routine and care activities may produce important information. For example, questions about bathing may elicit details about the body, the "helping" parent, and the abuse setting.

Questions focused on persons will include questions about the alleged offender. It is a good strategy to begin by asking questions that will not be difficult. Thus, focused questions might first be asked about siblings, then about the mother, and finally about the alleged offender. A series of focused questions about an alleged offender might be the following:

There are two types of focused questions about the possible circumstances of the sexual abuse that many interviewers use.

These questions are commonly used because often children are told that the sexual abuse is a special secret between themselves and the offender. Alternatively, offenders may induce children's cooperation or normalize the behavior by defining the victimization as a game.

However, there are other potentially productive focused questions related to the circumstances of the abuse. These questions are suggested by the information the interviewer gathers before seeing the child. Examples might be as follows:

Questions that focus on body parts are generally used in conjunction with anatomically explicit dolls or anatomical drawings. The interviewer has the child give names for the various body parts. Then focused questions can be asked. For example, the interviewer might ask the following questions with regard to the penis:

If the child responds, "It goes 'pee'," the interviewer might ask,

Comparable questions might be asked of a female victim about the vagina:

If the child responds that she touches it, the interviewer might ask:

If the child names someone, the evaluator might follow with:

In some cases or at certain points during an interview, children may not respond to focused questions, or they may reply, "I don't know," or "I don't remember." In these cases, more directive questions are necessary.

Multiple-Choice Questions

When information is not forthcoming with a focused question, the interviewer may resort to a multiple-choice question. There are several caveats for their use. First, young children may have difficulty with this format, and they will have more difficulty the more options given. Second, interviewers must be sure to include a correct response, so that the child is not given the choice between two or more incorrect responses. Thus, in a case in which the victim has affirmed that another child was there, but did not respond when asked who it was, the interviewer might ask, "Was it one of your friends or someone else?" in case it was someone the child did not know. Third, it is advisable to limit the use of multiple-choice questions to the circumstances of the sexual abuse and, if possible, not to use them to ask about the abuse itself. For example, the interviewer might ask:

The interviewer would avoid asking:

Yes-No Questions

Despite the fact that research indicates that even young children provide quite accurate information in response to yes-no questions,76 they are generally used in investigative interviews only when more open-ended questions are not productive, but the interviewer continues to have concerns about abuse. The reason for reservations about yes-no use is concern that they may elicit "social desirability" responses, especially in young children. That is, the child may answer in the affirmative because she/he thinks a positive response is desired. Alternatively, the child may not understand the question and nevertheless answer yes.

Unlike focused questions, yes-no questions usually identify both the alleged offender and the sexual behavior in question. (Focused questions, except those about the circumstances of the abuse, contain one or the other.) Examples of yes-no questions are as follows:

Leading Questions

A leading question is one in which the desired answer is specified in the question. Leading questions are commonly encountered by witnesses when they are cross-examined in court. However, they are not appropriate to investigative interviewing of children. Leading questions are usually not necessary and may be perceived as coercive because they convey the interviewer's own view of events. Interrogations using leading questions also may influence children's interpretations of events77 and are likely to lead to an attack on the validity of the interview findings. Examples of leading questions are as follows:

Strategic Use of Questions

The interviewer should use as many open-ended questions as possible. That is, the interviewer endeavors to use general or focused questions and only resorts to multiple-choice or yes-no questions if the former are not eliciting any information. As more close-ended questions are employed, it is prudent to have less confidence in the replies. When information is elicited in response to, for example, a multiple-choice question, the interviewer then reverts to a more open-ended approach, perhaps asking a focused question.

The following series of questions is illustrative: The interviewer asks the child where mom was when the abuse occurred (a focused question), and the child does not reply. The interviewer then asks whether mom was there or not (a multiple-choice question). The child replies that mom was there. The interviewer then asks, "What was she doing?" (a focused question). The child responds, "She was helping my dad." The interviewer then asks how the mom helped (another focused question). The child says, "It's hard to say." The interviewer responds, "Well, did she do any of the touching?" (a yes-no question). The child nods. The interviewer then asks where the mother touched (a focused question).

Use of Anatomically Explicit Dolls

Anatomical dolls are the most widely employed of the media. Although most appropriate for use with children aged 2 to 6, anatomical dolls may be used with children of any age. In this section, the challenges to the dolls, their advantages, and techniques for their use will be discussed.

Challenges to Anatomically Explicit Dolls

The dolls have been challenged, generally by defense attorneys and their expert witnesses, as being "leading," that is, triggering allegations of sexual abuse because they are "suggestive." However, research indicates that they do not elicit sexual responses from children who do not have prior sexual knowledge, and in the few studies that compare the responses of children believed to be sexually abused to those of children not so found, the former are significantly more likely to engage in sexualized behavior with the dolls than the latter. However, many children believed to have been sexually abused do not engage in sexualized behavior with the dolls.

Nevertheless, a definitive determination of sexual abuse is made not merely on the basis of what the child does with the dolls. Children may learn about sexual activity in ways other than being abused, for example, from consensual involvement with peers, from viewing erotica or pornography, or from sex education classes. Therefore, if the child spontaneously demonstrates sexual activity with the dolls, the interviewer needs to ask questions to clarify the source of the child's knowledge.

That is, if a child puts the penis of the adult male doll into the vagina of the female child doll, such behavior is certainly suggestive but not conclusive. In response to such a demonstration, the interviewer might ask, "Who does that?" in order to find out whether or not the child has been sexually abused.

In addition, anatomically explicit dolls have been criticized because they have not been subjected to the validation process employed with psychological tests. As noted above, there have been studies employing the dolls with general populations of children and a small number of studies that compare the responses of children assumed to have been sexually abused to those assumed to have not been abused. However, the dolls are not meant to be a psychological test, any more than Barbie dolls are. Rather, they are a medium through which interviewers may communicate with children, just as language is.

Advantages of Anatomically Explicit Dolls

The dolls are not a magical instrument that makes disclosure of sexual abuse automatic. In addition, the small number of studies comparing anatomical dolls to other media, for example, regular dolls, suggest thus far no particular superiority of the dolls over other media. However, the advantages noted by clinicians include:

How to Use Anatomically Explicit Dolls

There is no scientifically demonstrated right or wrong way to use the dolls. Everson and Boat  have reviewed the various guidelines for using anatomical dolls and have determined that there are five different functions they may serve – comforter, ice-breaker, anatomical model, demonstration aid, or memory stimulus. The most commonly endorsed functions are as an anatomical model, as a demonstration aid, or as a memory stimulus.

When the dolls serve different functions, they may be used in different ways. Three methods of using the dolls and the functions they serve are described.

Scenario in which the child spontaneously engages with the dolls. Some interviewers have the dolls available in the room with their clothing on. Children will sometimes pick up the dolls and begin playing with them. Depending on the stage of the interview, the interviewer may encourage the child to examine the dolls more closely. This process may involve the use of several dolls, usually four, and may include identifying them by gender and whether adult or child, undressing them, and identifying body parts, including the private body parts. In this process, the dolls may serve as a memory stimulus.

The interviewer may interpret unusual reactions to the dolls, for example, marked fear or sexualized behavior, as indicative of possible sexual abuse, and will want to pursue these reactions further. The child might be asked why seeing the doll caused her/him to be so upset. If sexualized behavior was noted, the child might be asked who does that and additional questions about the acts the child has demonstrated.

Similarly the sight of the genitalia on the dolls may serve as a memory stimulus and result in a statement about sexual abuse or something indicating advanced sexual knowledge. Again the interviewer will pursue these leads by asking for specifics and further information.

When the mere sight of the dolls with genitalia does not lead to any information, the interviewer may use them as an anatomical model. Using the names the child has given for the genitalia, the interviewer asks questions about the dolls and their genitalia. Below are sample questions about the penis and possible responses. It is important that the interviewer have in his/her repertoire a range of ways to approach the child, but the interviewer should allow the child ample time to respond and avoid a barrage of questions.

Similar questions can and in many cases should be asked about other genitalia and the anus. However, caution should be used in asking questions about erections, semen, and how the semen tastes when there is no independent information that the child is likely to possess such knowledge. This will avoid a circumstance in which the interviewer introduces the child to advanced sexual knowledge.

In cases in which the child spontaneously picks up the dolls, they can be used somewhat differently as an anatomical model as follows: rather than asking children about their own experiences, once the dolls have been undressed, children can be asked what might have happened to the doll, or the doll can be named (using a name other than the child's) and then questions asked about its experiences. This may make the discussion less threatening. Thus, instead of asking a female victim about her own vagina, the interviewer might ask about "this girl's 'peepee'." If positive information is elicited, it is important to ask if something like that happened to the child and, if so, with whom.

Comparable questions can be asked about the naked dolls, rather than their parts. Examples might be:

Again, the interviewer must ascertain that the child is speaking about her/his own experience if the child reveals any knowledge of sexual activity.

Scenario in which the dolls are introduced during the discussion of sexual abuse. Another way the dolls can be used is during the course of verbal disclosure. In this instance, the dolls are used as a demonstration aid. There are several circumstances in which they can be used in this manner. If a child is saying, "I don't want to talk about it," the interviewer may ask the child if she/he prefers or would find it easier to show. Second, the dolls may be used to clarify or obtain more detail about a verbal disclosure, for example, what exactly "humping" is. Third, the dolls may be used as a medium to corroborate the child's verbal statements. It is especially important, with children who are 2 to 6 years old, to get them to clarify or corroborate any verbal disclosures with the dolls. With children aged 6 and older, the evaluator may ask if they prefer to show what happened with dolls, draw a picture, or tell about it.

To introduce the dolls, the interviewer may say to the child that she/he has some dolls that are a little bit different. The interviewer may then select relevant dressed dolls and might ask the child if she/he has ever seen dolls like these before, as they are undressed. Alternatively, the evaluator may introduce one doll, undressing it to show the child how the dolls are different, and then have the child choose the dolls to use to "show what happened." Children may demonstrate by using two (or more) dolls, or they may use the doll and their own bodies.

For example, one 3-year-old girl, when asked to show how Daddy hurt her, using the dolls, picked up the naked adult male doll and thrust his penis into her crotch, saying "unh, unh, unh."

In such a situation, questions can be asked to obtain specific detail, such as:

Some children will not respond when asked to use the dolls to demonstrate the alleged abuse. The interviewer then may proceed to less spontaneous approaches. For example, the child may be asked to point to the place on the child doll where something happened to her/him, and if the child does point, then the child may be asked what exactly happened. Similarly, the interviewer may ask the child to point to the part of the adult doll's body that was used in the encounter, assuming some sort of an encounter has been affirmed. If the child designates a body part, the child is then asked to demonstrate exactly what happened.

Finally, if no information is forthcoming from the approaches already described, the interviewer can ask the child if she/he will answer "yes" or "no" if the interviewer points on the child doll to the parts of the child's body that might have been involved. Alternatively, the interviewer can use the adult male doll to ask the child to reply "yes" or "no" to the parts of the alleged offender's body that might have been involved. These are yes-no questions and therefore fairly close-ended. It is advisable to point to some body parts very unlikely to be involved in order to test for possible "social desirability" responses. If confirming information is elicited, then, of course, the interviewer reverts to more open-ended questions.

Scenario in which the dolls are introduced without any cues. Finally, the dolls can be introduced independent of any opening by the child. If no opportunities for a discussion on sexual abuse have arisen, some professionals will introduce the dolls toward the middle of the interview. However, others prefer to introduce the dolls rather early to elicit material about possible sexual abuse. When used in this manner, the dolls may serve as a memory stimulus or a diagnostic screen, but their major use is as an anatomical model.

Some professionals use the dolls to assist in identifying private (where it's "ok" to touch yourself in private, but where others should not touch you) versus other body parts, or good and bad touch areas. Sometimes touch is differentiated as good (e.g., a hug), bad (e.g., a slap), and trick – which feels good but is bad because it is in a private area. Then the child is asked about any experiences of touching in the private area or bad or trick touching.

Objections have been raised to the concept of good and bad touch, and it may be advisable to avoid using this concept for three reasons. First, the term "touch" is confusing to young children and may foreclose consideration of some types of activity (e.g., licking and object or penile intrusion). Second, the terms, "good" and "bad" may be too vague in that they do not connote the actual body parts. Third, the use of good and bad to refer to breasts, genitalia, and anus may lead to negative perceptions of the private body parts. However, these views of good and bad touch represent professional preference. There is no evidence that the use of the "good touch/bad touch" approach either contaminates or invalidates an interview.

Use of Anatomical Drawings

Anatomical drawings are pictures of adults and children, males and females, at different developmental stages – elder, adult, adolescent, latency age, and preschooler, without clothing and with primary and secondary sex characteristics. These drawings may have the frontal position presented on one side of the page and the dorsal on the other. They are used like skin maps; therefore, relevant pictures are used for each child interviewed.

In many respects, the use of anatomical drawings parallels the use of anatomically explicit dolls. Anatomical drawings are useful with the same age range of children as the dolls; they are particularly useful with very young children but also appropriate with older children. Appropriate pictures are chosen by either the child or the interviewer. The child can be asked to mark on the drawing or point to the part on the drawing that was involved.

The disadvantage of pictures is that it is more difficult for the child to enact any sexual behavior with pictures. However, children may make clothing for the pictures in order to demonstrate how clothing was removed, put one drawing on another to show "humping" (intercourse), and draw arrows and lines between genitalia in order to indicate intercourse.

On the other hand, anatomical drawings have the considerable advantage of being a permanent, visual record. They become part of the interviewer's case record and, as such, are admissible in court. In addition, the drawings have not been challenged as the anatomical dolls have.

Because of the potential use of drawings as evidence, it is advisable for professionals to put as much information as possible on the drawings. Professionals should have the child write the name of the person whom the particular drawing represents, if the child can do so. If the child cannot write, the interviewer should write the name. The interviewer should encourage a child to write or draw on the pictures to illustrate aspects of the abuse. For example, if the child indicates the offender used a finger to hurt her vagina, the interviewer should have her circle or mark the appropriate finger(s), and then the child or the interviewer should write beside the finger that it is the one that went in her vagina. Professionals should write on the picture the questions asked and the child's responses. For example, in a situation involving sexual abuse in day care, a 4-year-old girl marked the penis, the head, and the feet on the anatomical drawing representing her little brother. These were the places "the teachers did bad things." Beside each of the child's marks was written "a place the teachers did bad things." The questions and the child B's whispered responses were written beside the penis on the picture representing B's brother:

Int.:

"Who did something to his penis?"

B.:

"Miss Rose."

Int.:

"What did she do?"

B.:

"Bit it."

Int.:

"How do you know?"

B.:

"I saw her."

Use of Picture Drawing

Although a few clinicians have made observations about the characteristics of drawings of sexually abused children, there has been no systematic exploration of their content. Nevertheless, many types of pictures can be helpful. Drawing is most useful as a diagnostic technique with latency-aged children. However, children as young as age 4, and in some cases 3, can produce useful drawings as long as the various items in the picture are labeled and explanations are written on the picture. Some adolescents will prefer to draw a picture of what has occurred rather than to describe it verbally.

Drawing can have uses other than gathering information about possible sexual abuse. For instance, drawing can be employed to reduce tension, to understand issues other than sexual abuse, and to assess the child's overall functioning.

The interviewer may employ pictures either indirectly or directly to gather information that may be related to the child's victimization. Asking the child to draw any of the following pictures may indirectly result in findings:

Sometimes sexual content (e.g., genitalia or sexual acts) is noted in the pictures. If this is the case, questions should be asked about this content. The child's responses may provide information about sexual abuse. For example, a 5-year-old child, when asked to draw "anything," drew a picture of "Daddy" with a large "peanuts" (penis). When asked what the "peanut" was and if she had ever seen one, she eventually described her father taking her into his bed and fondling her as he fondled himself.

Alternatively, asking the child to talk about the picture may elicit information about abuse. For example, the interviewer might ask what is happening in the picture or what makes the person in the drawing happy, sad, angry, and scared. A 5-year-old drew a picture of her mother and her mother's boyfriend and then scribbled over the drawing. When asked what they were doing, she indicated the scribbles meant they were having sex.

If the child fails to provide any information about sexual abuse in response to queries about drawings, then caution should be exercised in their interpretation. Although the specifics of the pictures and other information about the case must be taken into account, pictures of genitalia do not necessarily mean the child has been sexually abused, and a sad drawing could have a wide range of significance.

The following drawing requests are aimed at gathering information directly and may be used when the child has already indicated something happened.

These requests may be used when children are having difficulty disclosing, when there is a need to clarify what the child has said or demonstrated, or when the interviewer wants to corroborate disclosures using the medium of drawing.

To facilitate disclosure, the interviewer may ask the child if she/he would rather draw when the child says she/he doesn't want to talk. Further, if the child claims not to remember very much, asking the child to draw the location of the alleged abuse may trigger recollection of detail and free the child to discuss the abuse.

Drawings that may be particularly helpful for clarification are pictures of what the offender used (instrument or body part) and of what happened. A 5-year-old with vaginal injury referred to an instrument used in her abuse as "Daddy's stick" but could not give further detail. The police officer interviewing her asked her to draw it, and she drew what appeared to be a ruler. Her mother was able to say where in the house it would be found, and the officer got a warrant and seized the physical evidence.

Like anatomical pictures, the child's drawings become part of the case record and can be submitted into evidence. Therefore, the interviewer should have the child label various parts of the drawings and write relevant comments. Again, if the child is unable to do this, the interviewer should label the drawings.

The Dollhouse

Very little has been written about the use of the dollhouse in interviewing children alleged to have been sexually abused. Nevertheless many mental health professionals and some CPS workers use it in investigative interviewing. It is especially useful with preschoolers.

Larger dollhouses, with sturdy furniture and people 3 to 6 inches tall, are optimal. The bigger the people, the easier it will be for the child to show activities and for the interviewer to see them. Most dollhouse people do not have removable clothing, which makes it difficult for the child to demonstrate some sexual abuse. However, the dollhouse provides a better opportunity to address the issue of the context of the sexual abuse than most other media.

Like drawings, dollhouse play can have goals other than data gathering about possible sexual abuse. For example, dollhouse play can be used to get to know the child and to understand something about how the child generally perceives families and family activity. And again like drawings, the dollhouse can be used indirectly and directly to gather information about possible sexual abuse.

Indirect use could involve observing the child's dollhouse play and then commenting or asking questions when themes possibly related to sexual abuse are present. For example, the child might repeatedly have the little girl doll going to bed with the adult male. The interviewer might ask what is happening when they go to bed.

The interviewer might use the dollhouse more directly to gather information if he/she has some background about the context of possible abuse. In a case involving a little girl who had just turned age 3, the mother thought the father had inserted something into the child's vagina one evening when the mother was lying ill on the couch and the father gave their daughter a bath. During the second session with the child, the interviewer structured the dollhouse situation so the mother doll was on the couch, the little girl doll in the bathtub, and the father in the bathroom. When the child approached the dollhouse, familiar to her from the previous session, she froze and began to shake. Later she demonstrated sexual abuse by her father.

Other examples of using contextual information might involve setting up a scenario around bedtime or watching television and then asking the child to show what happens at bedtime or TV time and other relevant questions.

Research on the Reliability and Suggestibility of Child Witnesses

Along with other challenges to allegations of sexual abuse have come challenges to the credibility of children as witnesses. Questions regarding the accuracy of their memories and their suggestibility have been raised.

Fortunately for professionals concerned about the sexual abuse of children, these questions have been addressed through a series of experiments that simulate some of the circumstances of sexual abuse. In general, these studies indicate that children can remember and that they are resistant to suggestion.

Children's Memories

Older children have more complete recall than younger children. However, studies indicate children as young as 3 years old can recall experiences comparable to those found in sexual abuse. Young children remember fewer details and recall central rather than peripheral events when compared to older children. Moreover, although children may not volunteer information about concerning events (a genital exam) or traumatic events (an inoculation or having blood drawn), similar in some respects to sexual victimization, such events are recalled as well by children as adults. Children's ability to provide accurate accounts appears to be facilitated by the availability of "props," such as anatomically explicit dolls, regular dolls, and anatomical drawings. As noted in the discussion of appropriate questions, children may require fairly direct questions in order to provide information. Children's memories will fade over time, but their recall can be enhanced by periodic recall of the events in question.

Children's Suggestibility

The research indicates that most children are resistant to giving false positive responses to leading and suggestive questions. When they do provide false positives, they are generally limited to a nod or a simple "yes." Older children are more resistant to suggestion than younger ones. Children are much more likely to deny actual experiences, which are perceived as traumatic or unacceptable, than to make false assertions about events that did not occur.

However, one study found that children are suggestible, not with regard to factual data but as to the interpretation of the facts. In a study involving 75 children, Clarke-Stewart had a cleaning man interact with toys. In one condition, the man described his activities as cleaning and in the other as playing. The children were then interrogated by an interviewer who pressured the child to interpret the man's behavior as either cleaning or playing. The researchers found that children did not change their statements regarding what had actually taken place, but most children were highly influenced by the interviewer's interpretation of the cleaning man's acts (cleaning versus playing). The implications of this study are clear. They reiterate the importance of using open-ended questions as much as possible and caution professionals to be careful about interpreting behavior, especially child care behaviors.

Criteria To Be Used To Substantiate Sexual Abuse

Once data have been gathered from the child interview and other sources, the interviewer must decide whether, in her/his opinion, the child was sexually abused. Indeed, there is a fair amount of consensus among these writings about the characteristics of a true account of abuse.

However, there has been very little research on the extent to which these clinical criteria are actually present in true cases, in large part because it is so difficult to isolate cases that are proven to be true. The criteria developed by Faller will be presented here because there is one research study that examines the extent to which they are found in cases substantiated by offender confession, because they are parsimoniously organized, and because they are fairly consistent with the criteria developed by other writers.

There are three general categories of information that should be assessed in the child's statements and/or behavior:

A Description of the Sexual Abuse

In assessing the child's description of the sexual activity, the interviewer is looking for:

Advanced sexual knowledge and a child's perspective are, of course, more persuasive findings with younger children. An explicit account is relevant for children of all ages.

Information About the Context of the Sexual Abuse

Information about the context of the sexual abuse might include:

The child may have been sexually abused many times and, therefore, may not remember details about all instances. It is best to ask the child to tell about the last time in order to obtain contextual information. In the research on these criteria, the child was considered to have provided sufficient contextual material if she/he gave three pieces of contextual information.

Preschool children will probably have a hard time focusing on and describing the most recent incident. In addition, they will not have the ability to abstract and say, for example, "Sometimes it happened in the bathroom, at other times in the basement, and once at my grandmother's house." As a consequence, their accounts of the context (and the abuse, itself) may be confusing and apparently inconsistent. What may be happening is the child may be recalling different incidents when being questioned at different times or by different people. These problems may occur when preschool children are interviewed by different people and/or at different times, or when they recount two or more different incidents, or parts of them, in the same interview.

An Emotional Reaction Consistent With the Abuse Being Described

Children may have a variety of emotional reactions to sexual abuse, depending on the characteristics of the child and the abuse. The following are common emotional reactions and associated child or abuse characteristics:

Situations In Which the Clinical Criteria May Not Be Found

The small number of studies that examine clinical criteria in proven cases (which are usually substantiated with offender confession) find that a substantial number of children's accounts lack the expected criteria.106 107 108 For example, in Faller's study, only 68 percent of accounts contained all three criteria. Young age of the victim and being a boy were associated with not satisfying the expected criteria. Younger children were less likely to provide contextual detail and to evidence an emotional response consistent with the account. Similarly, boy victims were less likely to describe the abuse and to exhibit affect.

There can be other good reasons why children fail to manifest the expected clinical criteria. Affect may be absent because the child dissociates, the child has told about the abuse many times, or the trauma has already been addressed in treatment. In addition, emotionally disturbed children, who have suffered many other traumas, may not become upset about sexual abuse because, compared to their other life experiences, it is not as bad. Detail may be absent because the abuse has been repressed or because it happened long ago and has been forgotten.

It is legitimate to substantiate a case with only a description of the sexual abuse.

Moreover, it is important for interviewers to appreciate that a child's inability to describe sexual abuse does not mean it did not happen. It means that sexual abuse cannot be confirmed, but that is different from it not having happened. Research on adult survivors indicates that many victims never tell.

Criteria for Confirming an Allegation From Other Sources

There are other sources of information that can support a finding of child sexual abuse.

Suspect's Confession

The most definitive finding is the suspect's confession. Unfortunately it is uncommon, particularly at the point of investigation, when the alleged offender may be very frightened and concerned primarily with his own well-being.

An operational definition of a full confession is that the alleged offender admits to all or more sexual activity described by the child. As a partial confession, the suspect may make "incriminating" statements by admitting to some but not all of the child's allegations. Alleged offenders may minimize their behavior by admitting to "just touching," may deny acts involving severe penalties, or may not admit to certain behavior they find particularly shameful. These incriminating statements deserve attention because they may be found in cases in which the suspects are frightened to admit. There appear to be several types:

The alleged offender may claim diminished capacity.

The suspect admits to the behavior but says it was not intended to be sexually abusive. There are actually two types of cases that fall within this category, those in which the suspect says the mistake was on his part and those in which he insists his behavior has been misinterpreted. Examples follow:

The evaluator must use common sense in assessing the probability that the alleged offenders' explanations are likely and feasible. There will be cases, especially those involving child care activities, where this is quite difficult.

In addition, the suspect may admonish professionals to attend to the accounts of others.

Finally, the alleged offender may say that he didn't abuse the child, but he is confessing to it to get on with treatment or to keep his daughter from having to testify against him in court.

Medical Evidence

As noted in the previous chapter, there has been considerable progress in the documentation of physical findings from sexual abuse.

Other Physical Evidence

In some cases, the police and sometimes others will have obtained physical evidence such as pornography or instruments used in the abuse.

Eyewitnesses

Occasionally, there will be eyewitnesses to sexual abuse. These may be other children who were also abused or who observed abuse. They may also be adult eyewitnesses, sometimes the spouse of the offender.

Forming a Conclusion About Sexual Abuse

In order to arrive at a conclusion about the likelihood of sexual abuse, the professional weighs the clinical findings from the child's interview as well as confirming evidence from other sources. Rarely is the professional 100-percent sure that the abuse occurred as described, with absolutely no room whatsoever for doubt. On the other hand, it is extremely difficult to determine without any doubt that the sexual abuse did not occur. In this regard, Jones has developed a useful concept, a continuum of certainty. Cases fall somewhere along a continuum from very likely to very unlikely.

Treatment Of Child Sexual Abuse

Treatment of child sexual abuse is a complex process. Orchestration of treatment in the child's best interest is a genuine challenge. Moreover, it is often difficult to know how to proceed because there are so few outcome studies of treatment effectiveness.

In this chapter, case management issues are discussed; a model for understanding why adults sexually abuse children is proposed; treatment modalities are described; and treatment issues are examined. The focus of the discussion is primarily on intrafamilial abuse.

Case Management Considerations

One of the reasons sexual abuse treatment is such a challenge is that it occurs in a larger context of intervention. Therefore, coordination is of utmost importance and ideally is provided by a multidisciplinary team. Treatment issues are then handled by the team as part of overall intervention.

The team usually consists of the various professionals directly involved in the case and their consultants and, as noted earlier, begins its activity at the time of case investigation. The composition and functioning of teams vary by locality, and the level of participation of team members often varies depending on the stage of the intervention. In an intrafamilial case, the members active at the treatment stage will ordinarily include the Child Protective Services (CPS) and/or foster care workers, the therapists treating various family members, professionals providing other services (e.g., homemaker, parenting guidance), a representative from the prosecutor's office, and relevant consultants. The frequency of meetings will depend on the needs of the case and how the team is structured.

The following issues are the most important of those the team should consider at this stage of intervention: separation of the child and/or the offender from the family, the role of the juvenile court, the role of the criminal court, the treatment plan for the family, visitation, and family reunification.

Case management decisions are often provisional; that is, they are based on what information about the family members and their functioning is available when decisions are made. Treatment is often a diagnostic process. The positive or negative responses of family members to treatment determine future case decisions. Outcomes of court proceedings can impinge upon and alter case management decisions and treatment.

The team meets periodically to assess progress and make future plans. Because of the complexity of case management decisions and the fact that a decision in one realm can have an impact on other aspects of the case, especially on treatment progress and outcome, multidisciplinary decision making is crucial. In the absence of a multidisciplinary team, such decisions should be made in consultation with other relevant professionals.

Before the implementation of the treatment plan, the following case management decisions should be addressed:

    * Should the child remain a part of the family?

    * Do the courts have a role in the case?

    * Is there a question of visitation?

Guidelines for making these decisions will be discussed.

Should the Child Live With the Family?

The preferred outcome in cases of sexual abuse, as in other types of child maltreatment, is that after intervention the family will be intact.

Generally at the time of disclosure of the sexual abuse, the offender is not separated from the family. The victim may be removed if the mother is unable or unwilling to protect and support the victim or if the victim wishes to be removed. Many professionals advocate the removal of the offender even in circumstances in which the victim is removed.

After these initial decisions, a longer term plan must be made about whether the child should be a part of the family and, if so, whether or not that family should include both parents. This plan will be based on an assessment of each parent.

Aspects of the functioning of both parents outlined previously in the discussion of risk assessment should be examined in deciding about the child's future living situation. These include the following factors for the offender:

    * the extent of the offender's sexually abusive behavior;

    * the degree to which the offender takes responsibility for the sexual abuse;

    *

      the number and severity of the offender's other problems, for example;

      - substance abuse,

      - violent behavior,

      - mental illness, and

      - mental retardation.

Regarding the nonoffending parent, the following factors should be assessed:

    * reaction to knowledge about the sexual abuse,

    * quality of relationship with the victim,

    * level of dependency on the offender, and

    * the number and severity of other problems.

Other possible problems are similar for the nonoffending parent and the offender.

Although these factors are universally useful to consider, in specific cases other factors may be important or even overriding.

Offenders who have engaged in a small number of sexual acts, have taken responsibility for their behavior, and have few other problems are judged to have positive findings in these key areas and are usually treatable. Negative findings in these three areas mean that the prognosis for positive treatment outcome is quite guarded. When mothers are protective of victims when they discover the sexual abuse, have good relationships with victims, are not unduly dependent on the offender, and do not have other significant problems, their treatment prognosis is positive. Again negative findings mean that the treatment prognosis is poor.

These proposed variations in parental functioning suggest four possible combinations: both parents may have positive findings, indicating a good treatment prognosis (case type 1); the nonoffending parent may have positive findings, and the offender negative ones (case type 2); the offender may have positive findings and the nonoffending parent negative ones (case type 3); and finally, both parents may have negative findings (case type 4).110

Different combinations argue for different intervention plans and long-term goals. General strategies are suggested in the decision matrix in Chart 3.

This matrix suggests how professionals hope to be able to make decisions. However, the parents are usually more complex than the matrix suggests. Probably in the majority of cases, the parents present a mixed picture, rather than appearing to have either a very good or bad prognosis. Moreover, as already suggested, there may be gaps in information about the family when treatment planning is undertaken and parental functioning is not static. Progress or lack of progress in treatment may result in reconsideration of the initial placement and treatment plan. Because of these complexities, most sexually abusive families should and do receive a trial of treatment. This generally entails individual treatment for all parties and the appropriate use of groups. Initial case decisions are periodically evaluated based on treatment outcome and reassessed accordingly. In addition to being useful in placement and treatment planning decisions, the matrix may offer guidance in terms of court intervention. Most professionals would agree that the Juvenile Court should be involved in all four types of cases, perhaps with the exception of a small number of those falling into case type 1. These might be cases in which the offender confesses to his wife or family, the family seeks treatment, and the abuse is then reported to CPS by their therapist.

There is also increasing consensus that criminal charges should be filed, even though the offender appears treatable. Some professionals feel that even treatable offenders should do some jail time, while others see the criminal process as a means of ensuring that the treatable offender will take responsibility for his behavior and/or enter into treatment. However, criminal prosecution is especially important in cases categorized as case types 2 and 4 to offer some protection to both the family and society from the offender.

In addition, factors related to the child should also be considered. These include the child's wishes. To be more precise, if the child does not wish for a reunified family, that desire should be given a great deal of weight. A child's wish for the offender not to leave the home, however, should generally not be granted. In addition, some sexually abused children are so damaged, because of the abuse and other conditions, that they require specialized care outside the home.

The same assumption is made here as in earlier chapters, that there is a single offender, usually a father figure, and a nonoffending parent, usually a mother figure. If that is not the case, and there is more than one offender, especially within the family, prognosis is much poorer. Even more problematic are cases in which both parents are offenders; in such instances, family reunification is extremely unlikely to be in the child's best interest.

The Role of the Courts

Two or three courts are potentially involved in a sexual abuse case—the Juvenile Court, responsible for child protection; the Criminal Court, responsible for offender prosecution; and the Divorce Court, if either parent decides to pursue divorce.

Court involvement can be either a help or a hindrance to therapeutic goals. The challenge is to integrate court involvement into the overall intervention. Early decisions about the role of the court can facilitate its role in the therapeutic process.

The court can be helpful in compelling family members, especially offenders, into treatment; in protecting victims and families from offenders; and in effecting alternative living situations for offenders (or victims, if necessary).

Court involvement can be problematic because legal safeguards for the defendant may prevent certain evidence from being admitted; because the adversarial process may interfere with the therapeutic process, including disruption of offender treatment by incarceration; and because it allows procedural delays that may prevent timely intervention.

Finally, testifying in court may have a positive or negative effect on the child. The effect, in part, depends on its outcome. That is, if the case is won, the impact of court testimony is more likely to be positive.

Victims may gain a sense of mastery over the sexual abuse from testifying. If they are believed, they may derive a degree of vindication when they see that the offender has to pay for what he did. Completing the court process may also engender a sense of closure for the victim.

On the other hand, victims may experience court testimony as additional trauma. Some are required to confront their abusers, endure lengthy cross-examination, and reveal shameful experiences to an audience. If possible, the courtroom should be cleared during the child's appearance. Testifying in court, which rarely entails a single appearance, may enhance the child's perception of him/herself as a victim, rather than a normal child. Moreover, because the court process tends to be protracted, it may delay resolution of the victim's treatment issues. For more detailed information on the role of the court in child abuse and neglect cases, the reader is referred to another manual in this series entitled Working With the Courts in Child Protection.

Visitation

As noted previously, in most cases it is appropriate for the offender to leave the home and for the victim to remain. In other cases, the victim should be removed to protect her/him from further sexual abuse and/or emotional abuse. (In a very small number of cases, it will be appropriate to leave the family intact after disclosure.) Obviously what constitutes visitation will vary depending on the living arrangements.

However, there are some guidelines to be used by the court and the professionals in making decisions about visitation. Many professionals recommend no contact between the victim and the offender, if the child is to appear in court, until after her/his testimony. If the mother and/or other family members are unsupportive of her/his testifying, they may be prohibited from seeing her/him until after her/his testimony.

If the child genuinely does not wish visitation, there should be none. There should be no unsupervised visitation until the child feels she/he will be safe and the offender has been assessed and found not at risk to reoffend. In some cases, the child may want visitation or unsupervised visitation when it is not deemed in her/his interest by the professionals. In such a circumstance, professional opinion should prevail.

Assuming all parties want visitation, as the offender (and other family members) make progress in treatment, visitation is initiated and becomes progressively more liberal (i.e., more frequent, for longer time periods, and with less supervision). As successive steps are taken to make visitation more liberal, it is important to make sure the victim (and her/his caretaker) want this change. The multidisciplinary team or the child's therapist needs to make these decisions.

Causal Models of Sexual Abuse

Before developing a treatment plan, it is important to have an understanding of why the sexual abuse occurs, both generally and in the particular case under consideration.

It is useful to briefly examine the history of causal theories of sexual abuse before a discussion of the current level of professional understanding. Historically there have been two rather separate efforts to understand the phenomenon of sexual abuse, its causes, and its resolution. These can be conceptualized as the family-focused perspective and the offender-focused perspective.

The Family-Focused Perspective

Those taking a family perspective focused their attention on incest and developed hypotheses that family dynamics are at the root of sexual abuse. Specifically, clinicians taking this perspective described the collusive mother, who has estranged herself from the father, as the "cornerstone" of the incestuous triad and the victim as a parental child who has replaced her mother as sexual partner to the father.

The implications of this model in terms of treatment are that the mother and the daughter must change, but the offender is not necessarily required to take responsibility for his behavior and develop strategies to control it. Most professionals working in the sexual abuse field recognize the limitations of a perspective that focuses purely on family dynamics.

This perspective does not help very much in explaining extrafamilial sexual victimization and, taken to its extreme, represents the offender as the hapless victim of family dynamics. Moreover, recent research, which finds that a substantial proportion of incest offenders begin their sexual victimization as adolescents and experience arousal to children before they become fathers, calls into question assumptions about the pivotal role of family dynamics in incest.112

The Offender-Focused Perspective

Those who work primarily with perpetrators have historically been located in institutions for adjudicated offenders. Most of these clinicians/researchers appreciate that their clientele do not represent the full spectrum of sex offenders. Their focus has been on understanding the etiology of sexual abuse by examining the physiological and psychological functioning of offenders. They typically do not have access to families to understand any role they might have played in the victimization, nor its impact on the families. Moreover, as these clinicians develop and implement treatment strategies, they may have to do so in a vacuum and in an artificial environment. There are frequently both problems translating what is learned in treatment in the institution to the offender's normal environment and failure to continue needed treatment when the offender returns to the community.

An Integrated Model

Efforts to integrate the family and offender perspectives to the causes of sexual abuse began in the mid-1980's. Finkelhor examined the spectrum of clinical literature and research into the causes of sexual abuse and developed a model of causation that incorporates both the family-, and offender-focused perspectives. He posits four preconditions that must obtain for sexual abuse to occur: factors related to the offender's motivation to sexually abuse; factors predisposing the offender to overcoming internal inhibitors; factors predisposing to overcoming external inhibitors (e.g., absence of environmental obstacles); and factors predisposing to overcoming child's resistance (e.g., a vulnerable child or the use of coercion). Finkelhor applied this model on both the individual (case) level and the sociocultural level.113 114

The model presented here is somewhat different and more practice-focused. It proposes that there are some causal factors that are prerequisites for sexual abuse and there are others that play a contributing role. Prerequisite factors – sexual arousal to children and a propensity to act on arousal – are to be found within the offender, whereas contributing factors may come from the culture, from the family system (including the marital relationship), from his current life situation, from his personality, or from his past life experience.

An Integrated Model of the Casual Factors of Sexual Abuse

The presence of the two prerequisite factors (sexual arousal to children and propensity to act on arousal) is both necessary and sufficient to result in sexual abuse. This is not the case for the contributing factors. For example, a man does not sexually abuse his daughter because his marriage is unhappy. More than half of American marriages end in divorce, suggesting that a substantial number of marriages are unhappy. But only a very small number of men in unhappy marriages sexually abuse their children.115 116

Contributing factors may enhance the prerequisite factors or they may, independent of an effect on the prerequisites, increase risk. An example of the former dynamics is found in the role of alcohol abuse. It usually leads to diminished capacity to control behavior, which may increase the propensity to act on sexual arousal to children. (Chemicals are also used by some offenders to cope with guilt related to their abuse behavior.) An example of the latter dynamic is that found in situations of unsupervised access to children. It may enhance risk because it provides opportunity for an offender who is aroused to children and prone to act on that arousal. This model will be referred to again in the discussion of treatment issues.

Treatment Modalities

In this section, the role of various treatment modalities is described. An approach to treatment that addresses prerequisite and contributing causes of sexual abuse and meets the treatment needs of victim, family, and offender must be multimodal. Ideally, individual, dyadic, family, and group treatment modalities should be available, especially if reintegration of the offender and/or the victim into the family is planned. However, therapists and programs without this full spectrum of services can be successful in treatment.

Although group, individual, dyadic, and family modalities should be available, it does not appear to be necessary to have a rigid progression from individual to dyadic to family therapy. However, it is crucial that progress be made in individual and sometimes dyadic therapy before family therapy is indicated and before individuals can benefit from it. The types of treatment and their uses will be discussed as follows:

    *

      Group therapy is generally regarded as the treatment of choice for sexual abuse. However, usually groups are offered concurrent with other treatment modalities, and some clients may need individual treatment before they are ready for group therapy. Furthermore, there will be a few clients who are either too disturbed or too disruptive to be in group treatment.

      - Groups are appropriate for victims, siblings of victims, mothers of victims, offenders, and adult survivors of sexual abuse. In addition, "generic" groups that include offenders, parents of victims, and survivors of sexual abuse have been found to be very powerful and effective for all parties involved.

      - Groups may be time-limited, long-term, or open-ended. They may deal with specific issues (e.g., relapse prevention, sex education, or protection from future sexual abuse), or they may deal with a range of issues. Some programs have "orientation" groups for new clients, usually with separate groups for children and adults.

      - Victim's and offender's groups have been brought together for occasional sessions. Models that have concurrent groups for victims or children and their nonoffending parents, where from time to time the two groups join for activities, are very productive.

    * Individual treatment is appropriate for victim, offender, and mother of victim (as well as for siblings of victims and survivors). As a rule, an initial function and a major one for individual treatment is alliance building. All parties have to learn to trust the therapist and come to believe that change is possible and desirable. The members of this triad may have different levels of commitment to therapy, with the victim usually the most invested and the offender the least.

    * Dyadic treatment is used to enhance and/or repair damage to the mother-daughter relationship, the husband-wife relationship, and the father-daughter relationship, as well as to deal with issues initially addressed in individual treatment.

    * Family therapy is the culmination of the treatment process and is usually not undertaken until there has been a determination that reunification is in the victim's best interest.

    *

      Multiple therapists can be very helpful. Such a complex series of interventions can rarely be provided by one individual. If possible, two therapists should be involved, even if it is only one person doing the group work and another the individual, dyadic, and family work. However, because each family member will typically participate in a group as well as other treatment modalities, there are usually several clinicians involved with a single family. Moreover, there are reasons other than logistics for involving several clinicians.

      - Sexually abusive families are very difficult to work with, and therapists need one another's support. Such families are crisis-ridden and multiproblem, making it very difficult for one person to have total responsibility for the family.

      - Assigning a different therapist to the victim and to the offender "recreates," although artificially, a family boundary that was crossed when the sexual abuse occurred. It also enhances a sense of privacy and safety for the victim—two elements violated by the offender.

      - In addition, cotherapy, using both a male and female therapist, has considerable therapeutic advantage. It exposes family members to appropriate role models of both sexes. Cotherapy also enhances the ability of clinicians to effect change because of the leverage it allows, particularly in group therapy.

      - Finally, decisions that must be made in the course of treatment are very difficult ones, and mistakes are potentially devastating. Two or more heads may be better than one. And as noted earlier, ideally clinicians should be guided in their decisions by the input of a multidisciplinary team.

Treatment Issues

There are two main objectives in sexual abuse treatment:

    * dealing with the effects of sexual abuse, and

    * decreasing risk for future sexual abuse.

Victim treatment tends to focus more on the former; mother's treatment issues are fairly evenly split; and the offender's issues are predominantly in the realm of preventing future victimizing behavior, although the initial stage of treatment may focus on the effects of the abuse disclosure on him/her.

Treatment Issues for the Victim

The saliency of treatment issues discussed in this section will vary for each victim, some possibly being irrelevant. Also, there may be additional treatment issues for victims that are not discussed here. The following issues appear to be the most important:

    * trust, including patterns in relationships;

    * emotional reactions to sexual abuse;

    * behavioral reactions to sexual abuse;

    * cognitive reactions to sexual abuse; and

    * protection from future victimization.

These issues are interrelated. As the following discussion illustrates, the categorization is somewhat artificial.

Trust

Being a victim of sexual abuse can have a devastating effect on children's object relations, particularly the ability to trust other people. In intrafamilial sexual abuse, the impact may be pervasive because a caretaker, who should be a protector and a limit-setter, exploits the child and violates the boundaries of acceptable behavior. Furthermore, this damage may be exacerbated by an unsupportive nonoffending parent. Moreover, sexual abuse may not be the only way in which the child's trust is undermined. The victim may experience other maltreatment or traumatic experiences in the family.

However, children sexually molested outside the home may also experience problems with trust. This may come about because the person who victimizes the child is someone to whom the child has been entrusted by the parents, as happens, for example, when the abuser is a child care provider. These victims frequently perceive their parents as having given permission for the exploitation. Alternatively, the offender may be a person in a position of authority over the child and she/he feels compelled to comply. Then children may have considerable difficulty trusting persons in positions of authority in the future.

The challenge to the therapist is to create circumstances in which the child has positive experiences with trustworthy adults in order to ameliorate the damage to the child's ability to trust. This may involve rehabilitating the parents and/or creating opportunities for appropriate relationships with adults, for example, with foster parents, mentors, or other relatives. An admonition to therapists is that they must be honest and dependable in order to create an atmosphere of trust.

Emotional Reactions to Sexual Abuse

Three common emotional consequences of sexual victimization are a sense of somehow being responsible and therefore feeling guilty, an altered sense of self and self-esteem because of involvement in sexual abuse, and fears and anxiety.

    * Feeling responsible. An offender may make the victim feel responsible for the sexual abuse, for the offender's well-being, and/or for the consequences of disclosure. Victims may also feel guilty for not having stopped the sexual abuse as well as for any positive aspects of the abuse, such as physical pleasure, the special attention given by the offender, or an opportunity to have control over other family members because of "the secret."

The role of the clinician is to help the child understand intellectually and accept emotionally that the child was not responsible. The adult sexually abused the child; the child did not sexually abuse the adult. It was the adult's job – not the child's – to stop or prevent the abuse.

    * Altered sense of self. Guilt feelings as well as the invasive and intrusive nature of the sexual activity impact negatively on the child's sense of self and self-esteem. As Sgroi puts it, victims suffer from "damaged goods" syndrome.117 The effect is both physical, in that children have an altered sense of their bodies, and psychological, in that children may see themselves as markedly different from their peers.

The task of the therapist is to make victims feel whole and good about themselves again. Work, mentioned above, that addresses the issue of self-blame is helpful. However, so are interventions that help children view themselves as more than merely victims of sexual abuse. Normalizing and ego-enhancing activities, such as doing well in school, participating in sports, getting involved in scouts, or helping a younger victim, can be very important in victim recovery.

    * Anxiety and fear to be discussed here are related to the traumatic impact of the abuse per se on the child rather than environmental responses to it. The victim develops phobic reactions to the event, the offender, and to other aspects of the abuse. Experiences that evoke recollections of the abuse come to elicit anxiety. In some children this anxiety and phobias become pervasive and crippling because of the level of avoidance they engage in to reduce their stress.

Before treating the child's fears and anxiety, the therapist must be sure the child is not being sexually abused or at risk for sexual abuse. Then the therapist engages the victim in a series of interventions that allow her/him to gradually deal with the abuse and related phobias and anxiety in ways that usually avoid excessive stress and allow mastery.118 These may include discussions, play therapy, or interventions in the child's environment. For example, the victim may be encouraged to ventilate by talking about the abuse and accompanying feelings, thereby reducing the level of distress related to it. Similarly, a child who is phobic about being left with a babysitter may be left with a relative first for short and then longer time periods, then with a babysitter for brief and then longer periods and thereby be desensitized to babysitting situations.

    * Additional emotional reactions may be found. Depending on the circumstances of the victimization and the child's personality, she/he may react with regression, anger, depression, revulsion, or posttraumatic stress disorder to sexual abuse. These emotional reactions are likely to manifest themselves in problematic behaviors. These behaviors will be discussed in the next section.

Behavioral Reactions to Sexual Abuse

As suggested in the second chapter, behavioral effects of sexual abuse can include sexualized behavior and other behavior problems.

    * Sexualized behavior. A serious reaction is sexualized behavior. Children who have been sexually victimized may masturbate excessively and openly or sexually interact with other people. Every act of sexualized behavior has the potential for increasing the probability of future acts. Not only is the activity likely to be physically pleasurable, but it may also enhance the child's view of her/himself as a sexually acting out person. Such acts may also stigmatize the child, which has a negative impact on the child's sense of self.

Clinicians should work to diminish and/or eliminate sexualized behavior through teaching behavioral controls. Sexual acting out may be controlled, for example, by teaching the child to masturbate privately. Behavior management techniques, which can involve rewarding "sex-free" days and using "time-out" for sexual acting out, can be taught to the child's caretaker. In addition, the child's energies that might have gone into sexual behavior can be channeled into more age-appropriate activities by having a caretaker monitor the child, interrupt any sexual acting out, and provide opportunities for positive alternative behaviors. These interventions are conducted with the child's caretaker and/or in dyadic work with child and caretaker.

One of the reasons treatment of sexualized behavior is so essential is because of a recently recognized phenomenon called the victim to offender cycle. Both male and female victims are at risk for this problem. Many offenders begin as victims, whose response to sexual abuse is to identify with the aggressor and to sexually act out in order to cope with their own sense of vulnerability and trauma. Professionals must recognize the potential danger of allowing sexualized behavior to go untreated, which is that the child then is at risk for becoming first an adolescent offender and eventually an adult offender. The child not only damages him/herself, but also may cause grave harm to many other children over the course of time.

    * Other behavior problems. Other behavioral reactions to sexual abuse include such problems as aggression toward people and animals, running away, self-harm (cutting or burning), criminal activity, substance abuse, suicidal behavior, hyperactivity, sleep problems, eating problems, and toileting problems.

Some of these problems, for example, difficulties with sleep, eating, toileting, and being alone, may be acute after disclosure but diminish over time and eventually disappear. Short-term intervention, labeling the behavioral problems as common reactions, and helping the victim resolve the underlying emotional or cognitive issues is generally helpful. Parents are encouraged to be understanding.

Treatment strategies for all behavioral problems include helping the victim understand the relationship between the behaviors and the sexual abuse and emotional or cognitive reactions to it; helping the child develop insight into the self-destructive nature of some of these behaviors; assisting the victim in more appropriate expression of the emotions, for example, anger; and behavioral interventions to diminish and eliminate problematic behavior. With older children, group therapy is usually very useful in addressing these problems.

Cognitive Reactions to Sexual Abuse

An important part of treatment of victims of sexual abuse is to help them understand the meaning of the abuse. This includes learning what appropriate and inappropriate touching entails; what is wrong about sexual activity between adults and children, if they do not know this; why adults or a particular adult was sexual with them; and in some cases, why they were chosen as targets and what that means to them. How these issues are addressed will vary with the child's developmental stage. They may be more adequately dealt with in group treatment than individual therapy, and sometimes having the offender take full responsibility for the abuse in dyadic therapy with the victim is useful.

Moreover, an adequate explanation for a child at a young age may not be sufficient as she/he grows older. Thus, this particular issue will need to be addressed at a more sophisticated level as the child matures. This may be done by a parent but in some cases will need to be done by a therapist.

Protection From Future Victimization

Treatment of victimized children needs to include strategies for future protection. Teaching children to say no and tell someone may be useful, especially if the material is presented in a group setting and there are opportunities to role play resisting sexual advances. Specific protective strategies involving family members and helping professionals need to be developed in intrafamilial sexual abuse situations. Additionally, the therapist must appreciate that placing even partial responsibility for self-protection on the victim is potentially an overwhelming burden.

Treatment Issues for the Mother (Nonoffending Parent)

Although the discussion that follows refers specifically to mothers as nonoffending parents, much of the material is also applicable to nonoffending fathers. Treatment issues for mothers of victims can be categorized under the following four general headings.

    * issues related to the sexual abuse,

    * issues related to the mother-victim relationship,

    * issues related to the offender (spouse), and

    * other personal issues.

These issues are particularly relevant to cases involving mothers in intrafamilial sexual abuse but also can be important when other persons are the abusers. Like victim treatment issues, they are interrelated, and there may be other issues that are salient in a given case. The relationship of the mother's treatment issues to factors to be assessed in making decisions about victim reunification with the family will become apparent.

Issues Related to the Sexual Abuse

It is difficult for most people, including mothers of victims, to understand why an adult might want to be sexual with a child. This is often the first issue that the clinician must address with the mother. This may be especially difficult for the mother to understand if the offender is her spouse or another close relative.

The therapist may offer professional understanding into the general causes of sexual abuse or those specific to the case. The parent might also be given material to read. However, group involvement, in either a generic sexual abuse or mothers' group, may be the most effective method for addressing this issue.

A related issue is that of believing the victim's disclosure of sexual abuse. Many parents will try to explain it away. As noted in the discussion of assessment of the nonoffending parent, coming to believe a victim is usually a process, rather than instantaneous.

The therapist may describe what in the child's disclosure makes her/him believe the child or speak generally about the conclusion that children rarely make false allegations and the reasons for that belief. However, group treatment, in which the mother is confronted by others who have also struggled with disbelief, is often the most effective mode for dealing with this issue.

Finally, the therapist will want to help the mother understand her role in the abuse, if she has had one. The nonoffending parent is not to blame for the victimization but in some instances may have contributed to risk of abuse or prolonged abuse, for example, by leaving the child for long periods of time with the offender or by discounting the child's early disclosures.

Interestingly, a good prognosis is suggested when a mother feels very guilty and the therapist must work to alleviate her sense of responsibility. Conversely, a poorer prognosis is indicated when the mother sees herself as absolutely blameless and the therapist has to point out things that the mother might have done differently that could have prevented or minimized the abuse. As with other issues related to the abuse, this issue may be best dealt with in group therapy.

Issues Related to the Mother-Victim Relationship

Treatment of intrafamilial sexual abuse that results in successful reunification of the family rests upon the mother's relationship with the victim. This may be a very problematic relationship at the time of disclosure. The offender may have engaged in manipulations that have alienated mother and victim from one another. The victim may have developed problematic behaviors because of the abuse, which have damaged her relationship with the mother. The consequences of disclosure may be blamed on the victim, or the mother may never have related well to the victim (or other people).

This problem appears to be less severe with boy victims. Mothers are more likely to be supportive of them. In part this is because when boys are sexually abused, the offender is more often, than with girls, someone outside the family. Moreover, when victimized within the family, boys tend to be abused along with their sisters,119 meaning the mother is less likely to regard a single child as to blame or as the source of her frustrations. However, this phenomenon may also relate to differences in role relationships between mothers and daughters and mothers and sons.

The therapist tries to enhance the mother-victim relationship by assisting the mother in developing empathy for the victim; by facilitating their communication; by helping them resolve ongoing problems in their relationship, such as disputes regarding bedtime or chores; and by helping them develop opportunities for mutually enjoyable experiences. Initial work is usually done in individual treatment with the mother, and later within the mother-child dyad.

Improving the mother-child relationship is generally a prerequisite to assisting the mother in being protective of her child in the future. Although interventions are employed to help the offender control his behavior in the future, the major source of protection for the child is the mother.

Intervention to make the mother more protective is implemented in a variety of ways. If the mother has a more positive relationship with the child, she will be more predisposed to protect the child. Treatment to improve the mother-child communication should enhance the likelihood the child will tell mother. Moreover, the therapist usually works with both the child and the mother to encourage communication specifically about the child's safety.

Especially if the family has not been separated or, if separated, as the family is reunited, specific guidance should be given to the mother regarding safety. For example, she may be instructed not to leave the child alone with the offender, not to let the offender bathe the child, not to allow the offender any control over the child's activities, and/or not to give the offender the responsibility for disciplining the child. How long these protections remain in place will depend on the case.

Finally, the therapist usually helps the mother develop a specific plan in case the offender does reoffend. Her plan is communicated to the victim, the offender, and the rest of the family. It can often involve dissolving the marriage.

Issues Related to the Offender (Spouse)

In cases of intrafamilial sexual abuse, the mother must decide whether she wants to sever her relationship with the offender or try to salvage the relationship. Some mothers decide at the time of disclosure to terminate the relationship or, alternatively, to work to preserve it. For others, this decision takes time and observation of the offender's progress or lack thereof in treatment. Still others are indecisive and change their minds more than once.

The clinician may have an opinion about what the mother should do. However, it is wise to allow the mother to make her own decision. This does not preclude sharing opinions about the offender's treatability and the likelihood of the victim remaining or returning home should the mother choose to stay with an untreated or untreatable offender.

In cases in which the offender is the mother's partner, regardless of the decision to leave or to stay, the mother will need to address her relationships with men. The goal is to help her gain some insight into these relationships, including that with the offender, and to understand their problematic aspects. If she intends to stay with the offender, she must be assisted in changing that relationship. If she leaves him, the goal of insight is to help her in future relationships. Group treatment with other mothers is particularly useful in this work. Of course, if her intention is to preserve the relationship with the offender, dyadic work with the offender is necessary.

Often mothers are very dependent on the men who have abused their children. In most instances, it is important to help her become less dependent so that she will be better able to seek what is in her children's and her interest, should there be a conflict between the offender's interest and that of the rest of the family.

Independence may be fostered by involving the mother in activities outside the home, including therapy; enhancing her financial independence; encouraging her to do things without his assistance; and facilitating her assertiveness when they are in conflict. Opportunities for these types of interventions may present themselves quite naturally if the offender must leave the home at the time of disclosure of the sexual abuse. Because of the mother's need to function autonomously in his absence, he may return home to a situation quite different from the one he left.

Other Personal Issues

Most mothers must deal with other issues related to current functioning and past experiences in therapy. The most common issue regarding current functioning is low self-esteem. However, other issues, such as substance abuse, experiences of violence, dependency, and emotional problems, often need to be addressed as well.

The most common issue in terms of past trauma is having been sexually victimized themselves. Such an experience can have a variety of implications in terms of the mother's ability to deal with her children's sexual abuse. For example, at the time of disclosure, a mother may be so overwhelmed because of her own abuse that she cannot deal with her child's victimization. In such instances, her abuse may have to be addressed first. Her own victimization may have an impact on her willingness to believe the victim, her ability to discern risky situations (she may not note them), and her choices of partners, playing a role in her choosing someone who is sexual with children. In addition, it may cause her to mistakenly believe her children are being victimized.

Treatment Issues for the Father as the Offender

Although the following discussion will refer to the father as the offender, it is equally applicable to cases involving stepfathers and unmarried partners of mothers who are offenders. It is also relevant to some situations involving other intrafamilial offenders. Treatment issues for the offending fathers can be broadly defined as falling into three categories:

    * issues related to the father's past sexual victimization of children,

    * issues related to the father's possible future victimization of children, and

    * other dysfunctional behaviors and problems.

These broad categories tend to be overlapping.

Issues Related to the Father's Past Sexual Abuse of Children

In many cases, the first challenge for the clinician is obtaining a confession of the sexual offenses. Many fathers are too ashamed to admit what they have done. Others are reluctant to disclose their abuse during litigation because they are afraid of its impact on the outcome. They may be more willing once the court case is resolved. Others are ordered into treatment by the court while continuing to protest their innocence.

Operationally, confession means an admission to all of the acts the child has described. However, it is common for the child not to disclose all of the abuse; therefore, it is important for the offender's therapist to stay in touch with the victim's therapist in case there are additional disclosures. (In treating intrafamilial sexual abuse, it is important for each family member to consent to share information with each therapist treating each family member.) To obtain a confession, the therapist actively confronts the father with the information on his offenses provided by the victim and others. In addition, group treatment, in which the father observes others confessing their victimizing behavior, can facilitate full disclosure.

With confession must come an acceptance of responsibility for the abusive acts. That is, the father must disavow any past excuses, such as his wife was not giving him sex or that he was drunk at the time. He must not minimize the behavior by saying, for example, "it only happened once," "there was no penetration involved," or "I stopped when she asked me to." As is probably apparent, it is extremely difficult to know when the offender has actually accepted responsibility rather than saying what he thinks the therapist wants to hear. Again, the use of group treatment can be especially helpful because other offenders may be more capable of discerning and confronting deception than a therapist.

A related task of treatment is for the father to appreciate the harm the abuse has caused the victim, his partner, and finally himself. There may be others affected as well, for example, siblings of the victim and the extended family. Some sort of communication from the victim and the offender's partner about the effects of the abuse on them can be useful. This may be in the form of a letter, a video or audiotape, or a face-to-face confrontation involving the therapist. Generic groups in which offenders are confronted by adult survivors and mothers of victims, other than the offender's own, can facilitate these insights. Written accounts, by victims, journalists, and professionals, of the impact on victims may be used, and offenders' groups can be the context for this work. As with the issue of responsibility, being sure the father is doing more than saying the right thing is a significant challenge.

At some point in treatment after the offender has confessed, taken responsibility, and come to appreciate the harm he has done, a series of apologies should be made. The offender must apologize to the victim, to his partner, and to the family in intrafamilial cases. There may be others who have been affected and deserve an apology as well. This is a process, not a single act, usually conducted in the context of dyadic or family treatment. The fact that the offender apologizes does not imply that the victim and others need to forgive him. These interventions need to be carefully orchestrated and controlled by the therapist. Only after the offender has completed the process, demonstrating an appreciation of the harm done, should his return home be considered.

A final treatment issue related to past abuse has to do with prevention. In order to prevent future sexual abuse, it is important for the offender and the therapist to understand why the offender sexually abuses children. In this regard, the model presented earlier in this chapter is relevant.

Thus, the treatment process involves coming to understand the offender's arousal pattern and why he acts on the arousal. Then contributing factors are explored.

Sexual arousal to children. Arousal patterns vary. They may be conceptualized as follows:

    * Child is the offender's primary sexual object. Some offenders' sexual preference, sometimes exclusively, is for children. The term pedophile is generally used to refer to this type of offender. Often pedophiles not only prefer children, but children of a particular age and sex. Pedophiles tend to have multiple victims and actively seek opportunities whereby they can have sexual access to children, by choosing vocations and avocations that afford them contact with children. A contributing factor to this type of arousal pattern is often traumatic childhood sexual experience.120

    * Child is one of multiple sexual objects. Other offenders have multiple paraphilias or aberrant sexual preferences and sometimes normal sexual preferences as well. The behavior of these offenders is characterized by sexual contact with children but may also include rape of adults, promiscuity with adults, exposure, voyeurism, sadomasochism, group sex, bestiality, and other sexual acts. The term sexual addict is often applied to this type of offender. The contributing factors or etiology of this pattern of sexuality appear to be a combination of childhood and adolescent experiences.

    * Child is a situational sexual object. Finally, there are offenders whose normal sexual orientation is toward peers but who become aroused by children under certain circumstances. Factors that contribute to such arousal may include the absence of other sexual outlets, stresses affecting normal marital and/or peer relations and communications, child pornography, and physical exposure or contact to children that is sexually stimulating. Although initial sexual contact involving this type of offender may be situationally induced, the experience may be very gratifying. Clinical experience indicates this is likely to result in an increased desire for and preference for sex with children.

As may be apparent from the last point, although these three arousal patterns are presented as though they are discrete, they probably are not. For example, it may be inappropriate to classify some offenders as having either a primary orientation to children or to adults.

Understanding the offender's arousal patterns may be done by having the offender describe what he experiences about his victims as arousing, having him discuss in detail his sexually abusive behavior, having him reveal his sexual fantasies, or measuring his erectile responses to various visual and auditory sexual stimuli using the penile plethysmograph.* Treatment prognosis with pedophiles and sexual addicts is much poorer than for those who have situational sexual arousal to children.

The propensity to act on arousal. There is research that suggests that a substantial minority of the male population experiences sexual arousal to children.121 (Comparable research has not been conducted on women.) However, it appears that a great many more men experience these feelings than act on them. The willingness to act on these feelings appears to be related to one or in most cases more than one of the following deficits:

    * pervasive superego deficits,

    * circumscribed superego deficits,

    * cognitive distortions,

    * impulse control difficulties, and

    * diminished capacity.

Persons whose superego deficits are pervasive have little or no conscience. The term psychopath is often applied to them. This condition is thought to be a result of early traumatic life experiences. Those who have some superego deficits may experience an absence of conscience related specifically to sexual activity or sexual activity with children, or they may generally have a weak or impaired superego. Some combination of early experience, lifestyle, and cultural norms may create this sort of superego. Differing in degree is the offender who has cognitive distortions related to his sexual deviance. He will have persuaded himself that sexual abuse is not bad or not so bad by such rationalizations as "The child won't know what I'm doing so it's not harmful" or "Everyone needs sex; this is my way." After the initial act, distortions may be "The child didn't resist, so she must have liked it," "There was no penetration so it wasn't really sexual abuse," or "It's my wife's fault because she withheld sex from me." Some offenders appreciate that what they do is wrong, but they do it anyway because they have poor impulse control.

Finally, some offenders experience diminished capacity, which enhances propensity to act on arousal. Typically, this is a temporary condition, and its most common cause is substance abuse. Thus, the offender acts on his arousal because alcohol or drugs have decreased his ability to control his behavior. Initial instances of victimization when drunk may occur without a prior plan. However, subsequently, the offender may drink so that he will have an excuse to abuse. Furthermore, after the initial acts, the attraction of the behavior itself may increase and chemicals are less necessary to diminish control. There can be other causes of diminished capacity. Offenders may lack adequate ability in handling stress, depression, anxiety, and/or anger in healthy ways. In addition, some persons suffer from chronic diminished capacity as a result of mental retardation or organic brain syndrome. If they experience arousal to children, it will make them at ongoing risk for sexual abuse.

Contributing factors. Some factors that may enhance arousal or increase the propensity to abuse have been described above. There may be other factors that act on these prerequisites and ones that independently contribute to risk for sexual abuse, for example, child behaviors, mother behaviors, and opportunity to sexually abuse.

It is an important part of the treatment process to understand why the offender has sexually abused children so that he can be empowered to gain control over his arousal and propensity to act on arousal. Some of the intervention that addresses contributing factors may be initiated with the offender alone, but much is done in the treatment of other individuals in the family and in dyadic and family work.

Issues Related to Possible Future Sexual Abuse

As noted in the previous section, preventing future sexual abuse relies on understanding what made the offender abuse in the first place. In this section, interventions that address arousal to children and propensity to act on arousal are discussed.

Sexual arousal to children. It has already been pointed out that sexual and other trauma during childhood may play a role in later sexual arousal to children. However, understanding the relationship of the offender's previous history to his arousal patterns is probably the least useful in prevention of future sexual abuse. In fact, often offenders manipulate the treatment process so that past history becomes an excuse for their offending. In spite of this risk, for some offenders, understanding the origins of previously incomprehensible behavior can render it manageable. Moreover, realizing that what the offender learned about sex roles as a child was wrong can lead to the development of more appropriate definitions of sex role behavior.

When deviant arousal patterns have been defined, the therapist will attempt to change these patterns. That is, the therapist will endeavor to decrease sexual arousal to children and increase arousal to appropriate sex objects. This is done through a variety of behavioral interventions that rely on both respondent and operant conditioning. These techniques include aversive conditioning, covert sensitization, thought stopping, masturbatory satiation, behavioral rehearsal, systematic desensitization, and masturbatory reconditioning. These techniques are often used in conjunction with social skills training, empathy training, and behavioral assignments.122

Behavioral interventions are exacting, and some require a laboratory setting. They also require the full cooperation of the client if they are to be successful. Moreover, the changes they create are not assumed to be permanent (nor are those from other types of intervention), and clients may need booster sessions. Many mental health professionals are untrained in and uncomfortable with behavioral interventions. However, to date they are the only therapeutic techniques that have been found, based on empirical evidence, to decrease sexual arousal.123 It behooves every clinician treating offenders to be familiar with these techniques and use those that can be suitably employed in his/her agency.

The propensity to act on arousal. Two approaches may be used to address propensity to act: techniques that enhance superego functioning by taking responsibility for sexual abuse and relapse prevention. Offenders whose propensity to act is based on pervasive superego deficits will probably not respond to treatment to reduce this propensity. However, those who have circumscribed superego deficits or are engaged in cognitive distortions probably will respond to interventions to address superego deficits. Treatment that is focused on getting the offender to take responsibility for his abusive behavior, to appreciate its harm, to acknowledge the feelings of traumatized parties, and to make amends or reparation is meant to enhance the offender's superego functioning and eliminate cognitive distortions, thus decreasing the probability of his acting on arousal in the future. Making amends or reparation usually involves a physical (e.g., community service) or monetary consequence that may serve to teach empathy and inhibit further abuse. In addition, when an offender lacks a strong internalized superego, the fact that there will be consequences for reoffense, such as prison or his wife leaving him, serves as an external superego. The strength of such interventions is in their deterrent effect.

In recent years, sex offender therapists have experienced success by using relapse prevention strategies, a technique borrowed from addiction treatment, in their intervention.124 Relapse prevention addresses propensity to act based on impulse control problems, reduced inhibition, and diminished capacity. Relapse prevention assumes that there are emotional states and behaviors on the offender's part that precede and ultimately precipitate the sexually abusive behavior. Often the offender is unaware of these factors and believes that his behavior is out of his control.

The clinician assists the offender in understanding these precursors and helps him develop a plan to manage such situations so that he does not reoffend. The clinician uses disclosures from the offender and others, including the victim, to obtain an accurate understanding of the circumstances that led to offending. Obviously such an intervention requires a candid and cooperative offender.

With some offenders, particularly those with cognitive limitations and difficulty being introspective, the clinician merely teaches the offender to anticipate, identify, and avoid risky situations. Thus, the offender may be instructed that he cannot assist at summer camp anymore or he cannot be left alone with his daughter.

With other offenders, the clinician helps him understand the chain of events, often seemingly unrelated to the sexual abuse, that precedes the victimization. This might include a series of procedures, such as the grooming process an offender may employ in the seduction of his victim, or acts such as getting upset with his wife and getting drunk after she goes to bed as a prelude to going into the daughter's room to molest her. The therapist then teaches the offender to interrupt the chain of events rather early while he still has control of his behavior. Thus, the pedophile is instructed to avoid driving by playgrounds, and the offender whose abuse is precipitated by drunkenness is instructed to abstain completely. If he has a serious substance abuse problem, he is sent to a substance abuse treatment program, either before treatment of his sexually abusive behavior is begun or in conjunction with sexual abuse treatment.

The relapse prevention plan is usually written out, and the offender carries it with him so he can refer to it when he thinks he is in a high-risk situation.

Interventions with the family mentioned earlier, such as not allowing the offender to be alone with the child or to discipline her, are meant to prevent him from being in high-risk situations. Moreover, there are numerous other ways the family and others can be involved in helping the offender prevent a relapse. Because most offenders experience more than one deficit leading to propensity to act, interventions that focus both on his taking responsibility and on relapse prevention are advised.

Other dysfunctional behaviors and problems. The offender may experience many other problems, and often these are contributing factors to the sexual abuse. Examples might be violent behavior, problems with the law, poor parenting skills, marital discord, poor social skills, low self-esteem, lack of education, and unemployment.

These are appropriate foci of treatment, and indeed it may be necessary to treat them because they increase the risk for future sexual abuse. Nevertheless, it is crucial that the clinician not allow him/herself to become sidetracked into only dealing with these other problems. Distraction can occur more easily than one might think if the offender refuses to admit to the sexual abuse or is reluctant to focus on it in treatment, yet is more than willing to work on his other problems. This pitfall is usually avoided if group therapy, which forces the offender to deal with his abuse, is a major component of the intervention and/or if there are several therapists involved in the case.

 

SIGN AND SYMTOMS

Decrease concentration

Overactive- can not relax

Restlessness

Daydreaming

Lack of trust

Aggressiveness

Guilt, shame, fear

No relationship

Sexual acting out

Antisocial

Decrease self esteem

Victim syndrome

Over responsible

Submissiveness

Parentification

OCD

Nail biting

Thumb sucking

Self destruction

Suicidal

Phase 1

Stabilization

-to focus

-to calm down

- to stay in body

 1) Building trust

Behavior counseling

Show interest, Listen

Eye contact

Non judgmental

Acknowledge feeling

Put words for their feeling

Give them chance to express

Be comfortable with silence

Excepting client

Excepting client space

Avoid critical questions

a  Focus on breathing

b. Grounding

c. Coping cards ( cognitive behavior therpy

d.  Hope kit

E. Resource

Proplem- face it ------- solve it

                          -------- accept

run away -----ignore

SUPPORT GROUP FOR ADOLESCENT SEXUAL ABUSE:

Objectives:

Choosing a group:

Pre-Module Sessions

SESSION 1: introduction and establishing a safe place:

Activity 1:

The session begins with an energizer to make the group members comfortable and to help them reduce their anxieties.

Activity 2:

 Pair group members and ask them to share information about each other for 10-15 minutes such as:

Then each partner introduces the other partner to the group, along with what one has learned from the partner. The facilitator should go first and share the same information about himself/herself with the members. Then the session focuses on the following aspects:

This may be the first time that group members have been able to talk so openly about their experience, so each may feel that their story and their experience demand center stage. It is important for group members to own their experience and to understand that others may experience things differently. The counselor on a poster may put the following rules:

Session 2: definitions and view about abuse

Activity 1: 

Each member is encouraged to express how she is feeling right now?

 How she is feeling about the week?

Activity 2:

Brainstorming: the counselor puts up the following words on a chart and encourages the group members to respond to these words, may be in the form of other words, thought or feelings

A discussion is then generated about the various perceptions shared by the group. This should lead to the understanding that one is not alone facing these circumstances, but one is sharing it with the other group members.  

Activity 3: journal time

During this session the journal time is introduced. The journals are handed out and their purpose is explained. Each member is encouraged to use her journal during all the sessions to keep a record of her inner life. She may draw to reflect on how she is feeling, write stories, poems; use it for her dreams, flashbacks, homework etc. the journal is private but during the journal time they are given opportunity to share if they wish.

The group members are then given some magazines and other craft material to make something at the first of their journal, which reflects some aspect about their personality.

Activity 4: home work

Write positive and negative thoughts and feelings about yourself.

Session 3: responsibility and power as they relate to group members experience

Activity 1: each member is encouraged to express how she is feeling right now?

 How she is feeling about the week?

Activity 2: How the inductor freed him/herself from the responsibility for the incest:

The facilitator can begin this as in the following:

Most of us here feel guilty for what happened. The adult however, who was the inductor, used his/her power and position to free himself from taking any responsibility. Go back in your memory and focus on your offender/offenders.

Activity 3: How the inductor made you feel responsible for it:

The facilitator can begin this as in the following:

Another factor that is most frequently true is that the adult offender goes to a great deal of trouble and planning to entice and entrap the child victim to make sure that he/she is not caught or found out, that in fact, the incest is kept a secret.

Go back in your memory and focus on your offender.

Activity 4: The difference in power between adult and child:

Divide the flipchart between child and adult. Encourage the group members to think of words that help to understand the difference between an adult and a child.  The aim of this discussion would be to indicate the helplessness, vulnerability and innocence of the child that is taken advantage of by the powerful, cognitively aware and matured adult. This would clearly indicate that “the child is not to blame for the trauma” as she/he did not know how to protect himself/herself, did not know whether it was right or wrong, but it was the adult who is responsible for it.

This session is intended to reduce feelings of guilt, shame and embarrassment that the group members feel about the traumatic experience.

Activity 5: journal time

Discussing the previous session’s homework. Sharing thoughts from their journal with the group members.

Session 4: ways that the group members used to erase the memories of abuse

Activity 1: review of the previous session

This session helps the group members to discuss the ways they had adopted to erase the memories of abuse. This helps group members to see the connection between behaviors and feelings generated by their abuse experience.

  1. What do I want to get out of coming to the group?
  2. What will I do in the group to achieve this?
  3. What do I want from the group to help me achieve my goals?
  4. How will I know that my goals are achieved?

The facilitator can then lead the group members towards the preparation of telling their stories from the next session onwards.

Session 5:  breaking the silence

Activity 1: review of the previous 4 sessions

Activity 2: breaking the silence by telling stories.

This involves encouraging members about sharing their experiences. The counselor can use certain probes such as “tell me more about it”? , What did you did when you came to know about it? How did u feel about it?

After one group member finishes the narrative, the members are invited to ask questions or to comment as long as the focus remains on the storyteller. The intensity of the first session leaves the group members emotionally drained. Hence, a relaxation exercise is introduced at the end of the session.

Activity 3: group hug

After the discussion following the narration, the group hug is introduced. The group hug symbolizes inclusion and acceptance by the group and fosters group cohesion. It also allows a safe physical contact between group members. This initiates an acceptance of their bodies and their need for closeness. Anyone who wishes is invited to gather in a circle for a group hug. However, the wishes of those who do not participate is respected.

Activity 4: relaxation

Quick Relaxation

 

Long-Term Relaxation

 

The following 2-3 sessions should be devoted to story telling and would be similar to session 5. In a session not more than 2 stories should be shared.

Session 9: saying goodbye; working through feelings associated with abuse

The facilitator can begin as following:

Working through feelings associated with the abuse. Now that accounts have been told, it is important to begin to say goodbye to whatever stops each group members from moving forward in her/his healing. In order to do this, she/he must begin to say “NO” to the thing or things that are preventing her/him from moving ahead and taking charge of his/her life.

Inside you there is a tiny little girl/boy who is terrified and alone. We have acknowledged that little child by telling our ‘stories’ that was the pain, and it was necessary to honor the pain within the child. But the pain won’t last forever, we can say ‘goodbye’ to the pain, we can learn to say “NO”.

Think about what may be the controlling issues or feelings that you need to say “NO” to now in order to move forward. This may be something or someone outside you/inside you.

Here feelings and thoughts about one self of others can be explored and if necessary would require finishing the unfinished business.

In order to really say good-bye to the dominance and control of the abusive experience, it is crucial to first feel again with the hear and mind, the helplessness that you experienced. Each of you has been doing that in telling your stories and in feeling of the powerlessness of that child within.

Now close your eyes, and talk to the child inside you.

Activity 2: affirmation exercise

Pass a basket of square papers and ask each member to write one positive thing about each member. This exercise would make the group members feel positive about themselves when they hear affirming messages about themselves from others. This would serve to enhance their self-esteem.

Activity 3:

Journal time. Sharing among the group members about what they have included in their journals in the past week.

Session 10: effective methods of coping

Activity 1: recap of the previous session.

Activity 2:

The facilitator uses guided imagery as in the following:

Imagine yourself leaning back on a tree in a village. This is beautiful, has survived so many years, has gone through so many traumas like wind, lightening, floods etc. this is your special tree and no one can harm you here, and no one can find you here. You have gone through so much, but you are healing, you are making peace with yourself.

You are an inspiration for the whole village.

Activity 3:

The previous activity leads to the third activity.

It leads to the discussion of method of coping now effectively. The facilitator can take note of the suggestions on a flipchart and encourage the members to take charge of their lives. The methods of coping should focus on why coping is essential and what are the effective ways of doing so. this may include taking up a hobby which would sere as an outlet for releasing emotions, maintaining journal, self-talk, going for a walk, talking to any a group member etc.

Activity 2:

The facilitator prepares the group for termination in the next session.

Session 11: wrap up and termination:

Activity 1:

This session begins with how everyone feels about leaving the group. Ask members to name a positive thing they can do for themselves after group has ended. It is the facilitator’s responsibility to ask the members how they plan to continue keeping themselves after the group has ended.

Decide on a follow-up date when all group members would meet and share their experiences.

Activity 2:

Materials: blank paper, crayons, colorful markers, pencils, scissors, ribbon, glue and glitter.

Introduce the name exercise. Ask the group members to draw what they think their name means. After each member has finished the drawing, the group member should be asked to share the drawing and meaning behind the art. Ask each member to say something positive about what the other member has just shared.

Activity 3:

Encourage members to share what they have feel have gained from this group process. Thank the group members and commend them on their courage and strength.

Phase2

Processing and dealing with trauma

Somatic experience

EMDR

Eye movement

Desensitization

Reprocessing

Clinical hypnosis

I )

From that talk: "I propose that the core issue is betrayal -- a betrayal of trust that produces conflict between external reality and a necessary system of social dependence. Of course, a particular event may be simultaneously a betrayal trauma and life threatening. Rape is such an event. Perhaps most childhood traumas are such events." Betrayal trauma theory was introduced: "The psychic pain involved in detecting betrayal, as in detecting a cheater, is an evolved, adaptive, motivator for changing social alliances. In general it is not to our survival or reproductive advantage to go back for further interaction to those who have betrayed us. However, if the person who has betrayed us is someone we need to continue interacting with despite the betrayal, then it is not to our advantage to respond to the betrayal in the normal way. Instead we essentially need to ignore the betrayal....If the betrayed person is a child and the betrayer is a parent, it is especially essential the child does not stop behaving in such a way that will inspire attachment. For the child to withdraw from a caregiver he is dependent on would further threaten his life, both physically and mentally. Thus the trauma of child abuse by the very nature of it requires that information about the abuse be blocked from mental mechanisms that control attachment and attachment behavior. One does not need to posit any particular avoidance of psychic pain per se here -- instead what is of functional significance is the control of social behavior. "

Betrayal trauma theory posits that there is a social utility in remaining unaware of abuse when the perpetrator is a caregiver (Freyd, 1994, 1996). The theory draws on studies of social contracts (e.g., Cosmides, 1989) to explain why and how humans are excellent at detecting betrayals; however, Freyd argues that under some circumstances detecting betrayals may be counter-productive to survival. Specifically, in cases where a victim is dependent on a caregiver, survival may require that she/he remain unaware of the betrayal. In the case of childhood sexual abuse, a child who is aware that her/his parent is being abusive may withdraw from the relationship (e.g., emotionally or in terms of proximity). For a child who depends on a caregiver for basic survival, withdrawing may actually be at odds with ultimate survival goals, particularly when the caregiver responds to withdrawal by further reducing caregiving or increasing violence. In such cases, the child's survival would be better ensured by being blind to the betrayal and isolating the knowledge of the event, thus remaining engaged with the caregiver.

The traditional assumption in trauma research has been that fear is at the core of responses to trauma. Freyd (2001) notes that traumatic events differ orthogonally in degree of fear and betrayal, depending on the context and characteristics of the event.

DePrince (2005) found that the presence of betrayal trauma before the age of 18 was associated with pathological dissociation and with revictimization after age 18. She also found that individuals who report being revictimized in young adulthood following an interpersonal assault in childhood perform worse on reasoning problems that involve interpersonal relationships and safety information compared to individuals who have not been revictimized.

Basic cognitive processes involved in attention and memory most likely play an important role in dissociating explicitawareness

Interestingly, Edwards et al (2001) reported that general autobiographical memory loss measured in a large epidemiologic study was strongly associated with a history of childhood abuse, and that one of the specific factors associated with this increased memory loss was sexual abuse by a relatiThe role of betrayal in betrayal trauma theory was initially considered an implicit but central aspect of some situations. If a child is being mistreated by a caregiver he or she is dependent upon, this is by definition betrayal, whether the child recognizes the betrayal explicitly or not. Indeed, the memory impairment and gaps in awareness that betrayal trauma theory predicted were assumed to serve in part to ward off conscious awareness of mistreatment in order to promote the dependent child's survival goals......While conscious appraisals of betrayal may be inhibited at the time of trauma and for as long as the trauma victim is dependent upon the perpetrator, eventually the trauma survivor may become conscious of strong feelings of betrayal." ve. It appears that men experience more non-betrayal traumas than do women, while women experience more betrayal traumas than do men

Betrayal blindness is the unawareness, not-knowing, and forgetting exhibited by people towards betrayal

II )

Brief Description of EMDR Therapy

8 PHASES OF TREATMENT 

The amount of time the complete treatment will take depends upon the history of the client. Complete treatment of the targets involves a three pronged protocol (1-past memories, 2-present disturbance, 3-future actions), and are needed to alleviate the symptoms and address the complete clinical picture. The goal of EMDR therapy is to process completely the experiences that are causing problems, and to include new ones that are needed for full health. "Processing" does not mean talking about it. "Processing" means setting up a learning state that will allow experiences that are causing problems to be "digested" and stored appropriately in your brain. That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future. The inappropriate emotions, beliefs, and body sensations will be discarded. Negative emotions, feelings and behaviors are generally caused by unresolved earlier experiences that are pushing you in the wrong directions. The goal of EMDR therapy is to leave you with the emotions, understanding, and perspectives that will lead to healthy and useful behaviors and interactions.

Phase 1: History and Treatment Planning 

Generally takes 1-2 sessions at the beginning of therapy, and can continue throughout the therapy, especially if new problems are revealed. In the first phase of EMDR treatment, the therapist takes a thorough history of the client and develops a treatment plan. This phase will include a discussion of the specific problem that has brought him into therapy, his behaviors stemming from that problem, and his symptoms. With this information, the therapist will develop a treatment plan that defines the specific targets on which to use EMDR. These targets include the event(s) from the past that created the problem, the present situations that cause distress, and the key skills or behaviors the client needs to learn for his future well-being. One of the unusual features of EMDR is that the person seeking treatment does not have to discuss any of his disturbing memories in detail. So while some individuals are comfortable, and even prefer, giving specifics, other people may present more of a general picture or outline. When the therapist asks, for example, "What event do you remember that made you feel worthless and useless?" the person may say, "It was something my brother did to me." That is all the information the therapist needs to identify and target the event with EMDR.

Phase 2: Preparation 

For most clients this will take only 1-4 sessions. For others, with a very traumatized background, or with certain diagnoses, a longer time may be necessary. Basically, your clinician will teach you some specific techniques so you can rapidly deal with any emotional disturbance that may arise. If you can do that, you are generally able to proceed to the next phase. One of the primary goals of the preparation phase is to establish a relationship of trust between the client and the therapist. While the person does not have to go into great detail about his disturbing memories, if the EMDR client does not trust his clinician, he may not accurately report what he feels and what changes he is (or isn't) experiencing during the eye movements. If he just wants to please the clinician and says he feels better when he doesn't, no therapy in the world will resolve his trauma. In any form of therapy it is best to look at the clinician as a facilitator, or guide, who needs to hear of any hurt, need, or disappointments in order to help achieve the common goal. EMDR is a great deal more than just eye movements, and the clinician needs to know when to employ any of the needed procedures to keep the processing going. During the Preparation Phase, the clinician will explain the theory of EMDR, how it is done, and what the person can expect during and after treatment. Finally, the clinician will teach the client a variety of relaxation techniques for calming himself in the face of any emotional disturbance that may arise during or after a session. Learning these tools is an important aid for anyone. The happiest people on the planet have ways of relaxing themselves and decompressing from life's inevitable, and often unsuspected, stress. One goal of EMDR therapy is to make sure that the client can take care of himself.

Phase 3: Assessment 

Used to access each target in a controlled and standardized way so it can be effectively processed. Processing does not mean talking about it. See the Reprocessing sections below. The clinician identifies the aspects of the target to be processed. The first step is for the person to select a specific picture or scene from the target event (which was identified during Phase One) that best represents the memory. Then he chooses a statement that expresses a negative self-belief associated with the event. Even if he intellectually knows that the statement is false, it is important that he focus on it. These negative beliefs are actually verbalizations of the disturbing emotions that still exist. Common negative cognitions include statements such as "I am helpless," " I am worthless," " I am unlovable," " I am dirty," " I am bad," etc. The client then picks a positive self-statement that he would rather believe. This statement should incorporate an internal sense of control such as "I am worthwhile/ lovable/ a good person/ in control" or "I can succeed." Sometimes, when the primary emotion is fear, such as in the aftermath of a natural disaster, the negative cognition can be, "I am in danger" and the positive cognition can be, "I am safe now." "I am in danger" can be considered a negative cognition, because the fear is inappropriate -- it is locked in the nervous system, but the danger is actually past. The positive cognition should reflect what is actually appropriate in the present. At this point, the therapist will ask the person to estimate how true he feels his positive belief is using the 1-to-7 Validity of Cognition (VOC) scale. "1" equals "completely false," and " 7" equals "completely true." It is important to give a score that reflects how the person "feels," not " thinks." We may logically " know" that something is wrong, but we are most driven by how it " feels." Also, during the Assessment Phase, the person identifies the negative emotions (fear, anger) and physical sensations (tightness in the stomach, cold hands) he associates with the target. The client also rates the disturbance using the 0 (no disturbance)-to-10 (the worst feeling you? ve ever had) Subjective Units of Disturbance (SUD) scale.

Reprocessing 

For a single trauma reprocessing is generally accomplished within 3 sessions. If it takes longer, you should see some improvement within that amount of time.

Phases One through Three lay the groundwork for the comprehensive treatment and reprocessing of the specific targeted events. Although the eye movements (or taps, or tones) are used during the following three phases, they are only one component of a complex therapy. The use of the step-by-step eight-phase approach allows the experienced, trained EMDR clinician to maximize the treatment effects for the client in a logical and standardized fashion. It also allows both the client and the clinician to monitor the progress during every treatment session.

Phase 4: Desensitization 

This phase focuses on the client's disturbing emotions and sensations as they are measured by the SUDs rating. This phase deals with all of the person's responses (including other memories, insights and associations that may arise) as the targeted event changes and its disturbing elements are resolved. This phase gives the opportunity to identify and resolve similar events that may have occurred and are associated with the target. That way, a client can actually surpass her initial goals and heal beyond her expectations. During desensitization, the therapist leads the person in sets of eye movement (or other forms of stimulation) with appropriate shifts and changes of focus until his SUD-scale levels are reduced to zero (or 1 or 2 if this is more appropriate). Starting with the main target, the different associations to the memory are followed. For instance, a person may start with a horrific event and soon have other associations to it. The clinician will guide the client to a complete resolution of the target. Examples of sessions and a three-session transcript of a complete treatment can be found in F. Shapiro & M.S. Forrest (2004) EMDR. New York: BasicBooks.

Phase 5: Installation 

The goal is to concentrate on and increase the strength of the positive belief that the person has identified to replace his original negative belief. For example, the client might begin with a mental image of being beaten up by his father and a negative belief of "I am powerless." During the Desensitization Phase he will have reprocessed the terror of that childhood event and fully realized that as an adult he now has strength and choices he didn't have when he was young. During this fifth phase of treatment, his positive cognition, "I am now in control," will be strengthened and installed. How deeply the person believes his positive cognition is then measured using the Validity of Cognition (VOC) scale. The goal is for the person to accept the full truth of his positive self-statement at a level of 7 (completely true). Fortunately, just as EMDR cannot make anyone shed appropriate negative feelings, it cannot make the person believe anything positive that is not appropriate either. So if the person is aware that he actually needs to learn some new skill, such as self-defense training, in order to be truly in control of the situation, the validity of his positive belief will rise only to the corresponding level, such as a 5 or 6 on the VOC scale.

Phase 6: Body scan 

After the positive cognition has been strengthened and installed, the therapist will ask the person to bring the original target event to mind and see if he notices any residual tension in his body. If so, these physical sensations are then targeted for reprocessing. Evaluations of thousands of EMDR sessions indicate that there is a physical response to unresolved thoughts. This finding has been supported by independent studies of memory indicating that when a person is negatively affected by trauma, information about the traumatic event is stored in motoric (or body systems) memory, rather than narrative memory, and retains the negative emotions and physical sensations of the original event. When that information is processed, however, it can then move to narrative (or verbalizable) memory and the body sensations and negative feelings associated with it disappear. Therefore, an EMDR session is not considered successful until the client can bring up the original target without feeling any body tension. Positive self-beliefs are important, but they have to be believed on more than just an intellectual level.

Phase 7: Closure 

Ends every treatment session The Closure ensures that the person leaves at the end of each session feeling better than at the beginning. If the processing of the traumatic target event is not complete in a single session, the therapist will assist the person in using a variety of self-calming techniques in order to regain a sense of equilibrium. Throughout the EMDR session, the client has been in control (for instance, he is instructed that it is okay to raise his hand in the "stop" gesture at anytime) and it is important that the client continue to feel in control outside the therapist's office. He is also briefed on what to expect between sessions (some processing may continue, some new material may arise), how to use a journal to record these experiences, and which techniques he might use on his own to help him feel more calm.

Phase 8: Reevaluation

Opens every new session At the beginning of subsequent sessions, the therapist checks to make sure that the positive results (low SUDs, high VOC, no body tension) have been maintained, identifies any new areas that need treatment, and continues reprocessing the additional targets. The Reevaluation Phase guides the clinician through the treatment plans that are needed in order to deal with the client? s problems. As with any form of good therapy, the Reevaluation Phase is vital in order to determine the success of the treatment over time. Although clients may feel relief almost immediately with EMDR, it is as important to complete the eight phases of treatment, as it is to complete an entire course of treatment with antibiotics.

PAST, PRESENT, AND FUTURE 

Although EMDR may produce results more rapidly than previous forms of therapy, speed is not the issue and it is important to remember that every client has different needs. For instance, one client may take weeks to establish sufficient feelings of trust (Phase Two), while another may proceed quickly through the first six phases of treatment only to reveal, then, something even more important that needs treatment. Also, treatment is not complete until EMDR therapy has focused on the past memories that are contributing to the problem, the present situations that are disturbing, and what skills the client may need for the future. Excerpts from: F. Shapiro & M.S. Forrest (2004) EMDR: The Breakthrough Therapy for Anxiety, Stress and Trauma. New York: BasicBooks. http://www.perseusbooksgroup.com/perseus-cgi-bin/display/0-465-04301-1

For another description: 

III )

Pierre Marie Félix Janet (May 30, 1859 - February 24, 1947) was a pioneering French psychologist in the field of dissociation and traumatic memory.

He was one of the first persons to draw a connection between events in the subject's past life and their present day trauma, and coined the words ‘dissociation’ and ‘subconscious’

Janet was the first to describe somnambulism as a phenomenon whereby two or more states of consciousness are dissociated by a cleft of amnesia and seem to operate independently of one another. Janet's early understanding of rapport also had roots in dissociation in that the patient seemed unable, due to dissociative restriction of the conscious field, to perceive anyone other than his own therapist. The implications of this dissociated conscious field for treatment led Janet to provide structure in therapy by assigning tasks and to mirror the patient's experience rather than to confront it. These techniques are important even today in the treatment of dissociated states.

Seminar 1: Development
Historically, there has been a separation between the study of development in biology (reproduction, birth, and the growth of the child), psychology (attachment theory, and separation-individuation) and psychoanalysis (oral, anal and genital stages).
They have all implied linear progression and focussed on relatively isolated aspects of the total process of development.

The handouts introduce a variety of contemporary perspectives which offer more holistic integrative models. Some are not easy pieces to read if you are unfamiliar with the terminology but the important theme to grasp is the interrelatedness of physiological and psychological development. There are a variety of ways to explore the impact of mother and baby on each other, as well as the effect of other people and aspects of the physical environment on the baby.

1. The chaos model which highlights the importance of ‘critical’ and ‘sensitive’ periods of development, and stresses the interaction between the organism (the baby) and the environment (mother & other key figures). Development is seen as a process of increasing levels of organisation and complexity. (Scharff, Schore)

2. The embodied model details the somatic patterns and physiological systems which are an intrinsic part of psychological maturation. (Grohman, Hartley)

There will be some experiential exploration of developmental movement patterns and their implications for psychological states. Your experience of babies and children will be a useful reference. We will look at photos to contemplate the qualities each child is embodying – you are welcome to bring 3-4 photos of your own for discussion.

Seminar 2: Bones

Bones are the deepest layer of the body. Mistakenly they are often associated with the inert. In fact bones are vital processors and protectors. The skeleton provides a structure for orientation, co-ordination and articulation in spatial, perceptual, relational and conceptual fields.

The skeletal system has not yet been considered as a subject of study by neuroscience or (as far as I’m aware) psychoanalysis. However Johnson’s work on the body foundation of image schemata which underpin our thinking provides a rigorous contemporary framework to integrates with the understanding of bone in the traditions of body psychotherapy and osteopathy.

1.The nature of bone as a container - structure, stablizer; deep internal support.

2.Bones in their role of absorbing physiological and psychological shock

3. Image schemata derived from the skeletal structure – articulation, relationship, order.

4. Reflexes – orientation in space, grounding, centring, lines of intention

5. Ego/self – neurotic and psychotic defences in organisation of skeleton


Seminar 3: The Muscular system

1. Muscle and development
Muscle is the fundamental structuring, mediating, enabling tissue in the body.
The child’s muscle is developed through contact with the world, and in relation to space and objects, including people. Like the ego (conceived in psychoanalysis as a mental structure) it reflects the individual’s history, and their way of adjusting to the external world. Muscles are the structure through which repression and expression, defence and resource, are embodied.

2. Movement as Cognition
We will look at proprioception, metabolism, sensory-motor integration in their psychological and physiological aspects.


3. The Motoric Ego
Parallel responses of ego and muscle.
Intention, will and agency at the crossroads with the unconscious. Conflict & tension.
Body image, identity and identification


Seminar Four: The Fluid System

Neurochemistry – the ‘chemical’ or wet brain. The neurosendocrine system is older, slower acting (than the central nervous system), and highly distributed in its function. Endocrine glands are situated throughout the brain and the body, with a high concentration of production in the belly (hence the name ‘the enteric brain) Hormones, neurotransmitters and peptides are transported throughout the body via the fluids influencing mood and behaviour. (see Pert)

The fluid system embodies the dynamic shifts in feeling, the ebbs and flows of desire, rage, fear, sadness, mediated..If muscle and bone inform the structure of our perception, the fluids in their singular and complex combinations, provide the colour, the affective tone.

All the fluids in the body are essentially one fluid – largely made up of water – that changes properties and characteristics as it passes through different membranes, flows through different channels and interacts with different substances. The characteristics of each fluid system relate to a different quality of movement, touch, voice, and state of mind:
Blood – weight, earth, heart-felt, full.
Lymph – clarity, boundary, defence.
Interstitial fluid – vitality, strength, sensuousness
Cellular fluid – presence, being, rest.
Synovial fluid – loose, rebounding, carefree
Cranio-sacral fluid – lightness, spatiousness (see Cohe, Hartley)

Connective tissue is the main fluid structure. Tension within the cell membrane influences the local qualities of the tissue. Build up, containment, dispersal, or drying of fluids reflects the individual’s patterns and capacities with relation to their own feelings. (see Juhan, Boyesen)

Seminar Five: The Skin and the senses
The skin as the surface of the brain, and touch as the mother of the senses. Tactile feedback is vital in organising the brain, acting as nourishment. (see Juhan) Touch receptors are dominant for information gathering in the first months. The infant’s integrated sense of its own skin has been correlated with the initiation of a sense of boundary and a rudimentary ego.

The senses are interrelated and work in concert – the synthesis of the sensory modalities gives depth and vividness to our experience of the world. ‘Synaesthesia’ is the term for the cross-modal working together of the senses. (see Abram) Working in concert they give us holographic consciousness. But like the other systems, the sensory organs can become armoured, inhibited in their function and thus distort perception..

The order of emergence, development and dominance of senses is complex. This reflects different survival priorities in our orientation to the world. For example, the very first nerves to myelinate are the vestibular nerves which help us distinguish our own movement in relationship to our environment.In early development, vision and movement are strongly linked. At birth, smell is the first sense to be strongly activated, helping the baby bond with mother’s milk.

Polyvagal theory (see Trevarthen handout) describes the social engagement system, a revised version of the role of the autonomic nervous system. Here the senses are utilised and engaged dynamically in relationship. Facial expression (looking and listening) is linked directly with regulation of the viscera, hear t and lungs.

IV)

Somatic Experiencing

 

Somatic Experiencing (SE) is a form of body psychotherapy developed by Dr. Peter Levine. Based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized due to an innate mechanism that regulates/discharges the high levels of energy arousal associated with defensive survival behaviors thus enabling them to return to normal in the aftermath of highly ''charged'' life-threatening experiences.

Although humans are born with virtually the same regulatory mechanisms as animals, this function is often overridden or inhibited by, among other things, the ''rational'' portion of our brains. This restraint prevents the complete discharge of survival energies, and does not allow the nervous system to regain its equilibrium. The undischarged energy remains in the body, and the nervous system becomes stuck in ''survival mode.'' The various symptoms of trauma result from the body's attempt to ''manage'' and contain this unused energy.

 

Somatic Experiencing employs the awareness of body sensation to help people ''renegotiate'' and heal their traumas rather than relive them.  With appropriate guidance into the body's instinctive ''felt sense,'' individuals are able to access their own built-in immunity to trauma, allowing the highly aroused survival energies to be safely and gradually discharged. When these energies are discharged, people frequently experience a dramatic reduction in or disappearance of their traumatic symptoms. 

What is Somatic Experiencing® (SE)?
Somatic Experiencing® (SE) is a short-term naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized. Animals in the wild utilize innate mechanisms to regulate and discharge the high levels of energy arousal associated with defensive survival behaviors. These mechanisms provide animals with a built-in ‘’immunity’’ to trauma that enables them to return to normal in the aftermath of highly ‘’charged’’ life-threatening experiences.

Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation ("disorders of extreme stress not otherwise specified"; DESNOS). Structured clinical interviews with 345 sophomore college women, most of whom (84%) had experienced at least one traumatic event, indicated that the DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were reported by a majority of respondents. Controlling for PTSD and other anxiety or affective disorders, DESNOS symptom severity was associated with a history of single-incident interpersonal trauma and with more severe interpersonal trauma in a dose-response manner. Noninterpersonal trauma was associated with elevated prevalence of PTSD and dissociation but not with DESNOS severity. Study findings indicate that persistent posttraumatic problems with self-regulation warrant attention, even in relatively healthy young adult populations.

V ) 

Complex Post-Traumatic Stress Disorder (C-PTSD) is a clinically recognized condition that results from prolonged exposure to prolonged social and/or interpersonal trauma, including instances of physical abuse, emotional abuse, sexual abuse, domestic violence, torture, chronic early maltreatment in a caregiving relationship, and war. Van der Kolk and Courtois (2005) suggest that C-PTSD better describes the pervasive negative impact of chronic trauma than does Post traumatic stress disorder, as PTSD fails to capture some of the core characteristics of C-PTSD. These include psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized, and, most importantly, the loss of a coherent sense of self. This loss of the coherent sense of self, and the ensuing symptom profile, is what most pointedly differentiates C-PTSD from PTSD. C-PTSD is under consideration for inclusion in the next revision of the Diagnostic and Statistical Manual (DSM-V) as a formal diagnosis.

C-PTSD is characterized by chronic difficulties in many areas of emotional and interpersonal functioning. Symptoms include:

Assessment of Complex Trauma in Children

Children exposed to complex trauma (chronic maltreatment, abuse, neglect, witnessing domestic violence, etc.) often evidence impairment in several domains. Cook et al. (2000, 2003) describe symptoms and behavioral characteristics in seven domains:

  1. Attachment - Uncertainty about the reliability and predictability of the world, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty attuning to other people's emotional states and points of view
  2. Biology - hypersensitivity to physical contact, analgesia, somatization, increased medical problems
  3. Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty deescalating, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, overinhibition or excessive expression of anger
  4. Dissociation - distinct alterations in states of consciousness, amnesia, depersonalization and derealization 
  5. Behavioral control - poor modulation of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance
  6. Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development
  7. Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma

After exposure to complex trauma, children and their families should receive a comprehensive trauma assessment that examines functioning in all domains of impairment. This comprehensive assessment should include behavioral and play observations, clinical interviews with children and primary caretakers, collateral information from day care or school personnel, child protection workers, and pediatricians (if applicable), and the results of structured assessment instruments. Information about the traumatic events the child and family experienced, trauma-related symptoms, pre-exposure and post-exposure development, and emotional and social functioning should also be gathered.

Trauma History and Caretakers

The impact of trauma on children varies depending on many factors, including the type and circumstances of the trauma, participants, sequence of events, the age at which the child was exposed, the child’s history of previous trauma exposure and loss, the availability of attachment figures, and aftermath of the traumatic event. For this reason, it is imperative that clinicians gather very detailed information about the child’s recent and past trauma exposure (Bosquet, 2004).

There is also very strong evidence that caregiver trauma history and functioning significantly impact young children’s reactions and recovery from trauma (Appleyard & Osofsky, 2003). For this reason, clinicians should obtain a thorough assessment of caregiver’s trauma history and trauma-related symptomatology.

Trauma-Related Symptoms

Children and caregivers exposed to trauma often suffer from some of the characteristic symptoms of post-traumatic stress disorder. Children may reexperience the trauma through nightmares and post-traumatic play, they may show avoidance and numbing in the form of constricted play, social isolation, and developmental regression, and they may suffer from hyperarousal manifested as hypervigilence and difficulty sitting still. A comprehensive assessment should gather information about these symptoms through play and behavioral observations, clinical interviews, and structured assessment instruments. Some examples of structured assessment instruments are:

UCLA PTSD Reaction Index for DSM-IV (Pynoos et al., 1998) is a self-report measure that screens for exposure to a wide range of traumatic events and symptoms of PTSD. Versions for children (ages 7-12), adolescents (ages 13-18) and parents are available, and the measure has been translated into Spanish. Research is under way to examine the psychometric properties of the measure.

Traumatic Events Screening Instrument – Parent Report - Revised (TESI-PR-R - Ghosh Ippen et al., 2002) is a 24-item measure used with parents of children aged 0 to 6 years. It screens for a wide range of exposures including accidents, abuse, witnessing community and domestic violence, and terrorism. It also screens for the presence of traumatic responses in young children. The TESI-PR-R is a revised form of the Traumatic Events Screening Instrument (TESI), a reliable and valid measure designed to assess trauma history in older children (Ribbe, 1996). The TESI-PR-R was revised to be developmentally sensitive to the types of trauma that young children may experience. Research is under way to examine the psychometric properties of the revised measure. The TESI-PR-R is available in Spanish.

The Life Stressor Checklist-Revised (LSC-R; Wolfe & Levin, 1991) is a 31-item self-report measure for adults that assesses lifetime exposure to trauma and the incidence and impact of stressful life events on current functioning. Data support the validity of the LSC-R (Kimerling et al., 1999). The LSC-R is available in Spanish.

The Davidson Trauma Scale (DTS; Davidson, 1996) is a self-report measure designed to assess posttraumatic stress disorder. The scale consists of 17 symptoms rated for frequency and severity. Research indicates that the measure is internally consistent, reliable, and valid and that it distinguishes between groups with and without PTSD diagnoses (Davidson, Tharwani, & Connor, 2002). The DTS is available in Spanish.

Development & Social/Emotional Functioning

Children exposed to trauma often suffer from developmental disruption, behavior problems, and attachment problems and show impaired school, peer, and family functioning. A comprehensive assessment will gather information about functioning in these areas through play and behavioral observations, clinical interviews, and structured assessment instruments.

 Treatment

Treatment for C-PTSD requires a multi-modal approach, as noted by The National Child Traumatic Stress Network (2003). van der Kolk et al. (2005) suggest that treatment for C-PTSD should differ from treatment for PTSD in several important ways. While treatment for PTSD focuses on the impact of specific past events and the processing of specific trauma memories, treatment for C-PTSD should also include a focus on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six core components of complex trauma treatment have been identified by Cook, Spinazzola, Ford and Lanktree (2005):

  1. Safety
  2. Self-regulation
  3. Self-reflective information processing
  4. Traumatic experiences integration
  5. Relational engagement
  6. Positive affect enhancement

Treatment for those experiencing C-PTSD should address each dimension. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Cognitive Behavioral Therapy interventions, education, EMDR and other approaches.

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), developed by Cohen, Deblinger, and Mannarino (2004), is a highly effective, evidence-based treatment for children with complex trauma. TF-CBT targets posttraumatic, depressive, and anxiety symptoms and addresses cognitive distortions associated with the trauma. TF-CBT works with both children and their caretakers, and includes the following core components:

Assessment of Complex Trauma in Children

Children exposed to complex trauma (chronic maltreatment, abuse, neglect, witnessing domestic violence, etc.) often evidence impairment in several domains. Cook et al. (2000, 2003) describe symptoms and behavioral characteristics in seven domains:

  1. Attachment - Uncertainty about the reliability and predictability of the world, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty attuning to other people's emotional states and points of view
  2. Biology - hypersensitivity to physical contact, analgesia, somatization, increased medical problems
  3. Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty deescalating, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, overinhibition or excessive expression of anger
  4. Dissociation - distinct alterations in states of consciousness, amnesia, depersonalization and derealization 
  5. Behavioral control - poor modulation of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance
  6. Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development
  7. Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma

After exposure to complex trauma, children and their families should receive a comprehensive trauma assessment that examines functioning in all domains of impairment. This comprehensive assessment should include behavioral and play observations, clinical interviews with children and primary caretakers, collateral information from day care or school personnel, child protection workers, and pediatricians (if applicable), and the results of structured assessment instruments. Information about the traumatic events the child and family experienced, trauma-related symptoms, pre-exposure and post-exposure development, and emotional and social functioning should also be gathered.

Trauma History and Caretakers

The impact of trauma on children varies depending on many factors, including the type and circumstances of the trauma, participants, sequence of events, the age at which the child was exposed, the child’s history of previous trauma exposure and loss, the availability of attachment figures, and aftermath of the traumatic event. For this reason, it is imperative that clinicians gather very detailed information about the child’s recent and past trauma exposure (Bosquet, 2004).

There is also very strong evidence that caregiver trauma history and functioning significantly impact young children’s reactions and recovery from trauma (Appleyard & Osofsky, 2003). For this reason, clinicians should obtain a thorough assessment of caregiver’s trauma history and trauma-related symptomatology.

Trauma-Related Symptoms

Children and caregivers exposed to trauma often suffer from some of the characteristic symptoms of post-traumatic stress disorder. Children may reexperience the trauma through nightmares and post-traumatic play, they may show avoidance and numbing in the form of constricted play, social isolation, and developmental regression, and they may suffer from hyperarousal manifested as hypervigilence and difficulty sitting still. A comprehensive assessment should gather information about these symptoms through play and behavioral observations, clinical interviews, and structured assessment instruments. Some examples of structured assessment instruments are:

UCLA PTSD Reaction Index for DSM-IV (Pynoos et al., 1998) is a self-report measure that screens for exposure to a wide range of traumatic events and symptoms of PTSD. Versions for children (ages 7-12), adolescents (ages 13-18) and parents are available, and the measure has been translated into Spanish. Research is under way to examine the psychometric properties of the measure.

Traumatic Events Screening Instrument – Parent Report - Revised (TESI-PR-R - Ghosh Ippen et al., 2002) is a 24-item measure used with parents of children aged 0 to 6 years. It screens for a wide range of exposures including accidents, abuse, witnessing community and domestic violence, and terrorism. It also screens for the presence of traumatic responses in young children. The TESI-PR-R is a revised form of the Traumatic Events Screening Instrument (TESI), a reliable and valid measure designed to assess trauma history in older children (Ribbe, 1996). The TESI-PR-R was revised to be developmentally sensitive to the types of trauma that young children may experience. Research is under way to examine the psychometric properties of the revised measure. The TESI-PR-R is available in Spanish.

The Life Stressor Checklist-Revised (LSC-R; Wolfe & Levin, 1991) is a 31-item self-report measure for adults that assesses lifetime exposure to trauma and the incidence and impact of stressful life events on current functioning. Data support the validity of the LSC-R (Kimerling et al., 1999). The LSC-R is available in Spanish.

The Davidson Trauma Scale (DTS; Davidson, 1996) is a self-report measure designed to assess posttraumatic stress disorder. The scale consists of 17 symptoms rated for frequency and severity. Research indicates that the measure is internally consistent, reliable, and valid and that it distinguishes between groups with and without PTSD diagnoses (Davidson, Tharwani, & Connor, 2002). The DTS is available in Spanish.

Development & Social/Emotional Functioning

Children exposed to trauma often suffer from developmental disruption, behavior problems, and attachment problems and show impaired school, peer, and family functioning. A comprehensive assessment will gather information about functioning in these areas through play and behavioral observations, clinical interviews, and structured assessment instruments.

[edit] Treatment

Treatment for C-PTSD requires a multi-modal approach, as noted by The National Child Traumatic Stress Network (2003). van der Kolk et al. (2005) suggest that treatment for C-PTSD should differ from treatment for PTSD in several important ways. While treatment for PTSD focuses on the impact of specific past events and the processing of specific trauma memories, treatment for C-PTSD should also include a focus on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six core components of complex trauma treatment have been identified by Cook, Spinazzola, Ford and Lanktree (2005):

  1. Safety
  2. Self-regulation
  3. Self-reflective information processing
  4. Traumatic experiences integration
  5. Relational engagement
  6. Positive affect enhancement

Treatment for those experiencing C-PTSD should address each dimension. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Cognitive Behavioral Therapy interventions, education, EMDR and other approaches.

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), developed by Cohen, Deblinger, and Mannarino (2004), is a highly effective, evidence-based treatment for children with complex trauma. TF-CBT targets posttraumatic, depressive, and anxiety symptoms and addresses cognitive distortions associated with the trauma. TF-CBT works with both children and their caretakers, and includes the following core components:

Assessment of Complex Trauma in Children

Children exposed to complex trauma (chronic maltreatment, abuse, neglect, witnessing domestic violence, etc.) often evidence impairment in several domains. Cook et al. (2000, 2003) describe symptoms and behavioral characteristics in seven domains:

  1. Attachment - Uncertainty about the reliability and predictability of the world, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty attuning to other people's emotional states and points of view
  2. Biology - hypersensitivity to physical contact, analgesia, somatization, increased medical problems
  3. Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty deescalating, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, overinhibition or excessive expression of anger
  4. Dissociation - distinct alterations in states of consciousness, amnesia, depersonalization and derealization 
  5. Behavioral control - poor modulation of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance
  6. Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development
  7. Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma

After exposure to complex trauma, children and their families should receive a comprehensive trauma assessment that examines functioning in all domains of impairment. This comprehensive assessment should include behavioral and play observations, clinical interviews with children and primary caretakers, collateral information from day care or school personnel, child protection workers, and pediatricians (if applicable), and the results of structured assessment instruments. Information about the traumatic events the child and family experienced, trauma-related symptoms, pre-exposure and post-exposure development, and emotional and social functioning should also be gathered.

Trauma History and Caretakers

The impact of trauma on children varies depending on many factors, including the type and circumstances of the trauma, participants, sequence of events, the age at which the child was exposed, the child’s history of previous trauma exposure and loss, the availability of attachment figures, and aftermath of the traumatic event. For this reason, it is imperative that clinicians gather very detailed information about the child’s recent and past trauma exposure (Bosquet, 2004).

There is also very strong evidence that caregiver trauma history and functioning significantly impact young children’s reactions and recovery from trauma (Appleyard & Osofsky, 2003). For this reason, clinicians should obtain a thorough assessment of caregiver’s trauma history and trauma-related symptomatology.

Trauma-Related Symptoms

Children and caregivers exposed to trauma often suffer from some of the characteristic symptoms of post-traumatic stress disorder. Children may reexperience the trauma through nightmares and post-traumatic play, they may show avoidance and numbing in the form of constricted play, social isolation, and developmental regression, and they may suffer from hyperarousal manifested as hypervigilence and difficulty sitting still. A comprehensive assessment should gather information about these symptoms through play and behavioral observations, clinical interviews, and structured assessment instruments. Some examples of structured assessment instruments are:

UCLA PTSD Reaction Index for DSM-IV (Pynoos et al., 1998) is a self-report measure that screens for exposure to a wide range of traumatic events and symptoms of PTSD. Versions for children (ages 7-12), adolescents (ages 13-18) and parents are available, and the measure has been translated into Spanish. Research is under way to examine the psychometric properties of the measure.

Traumatic Events Screening Instrument – Parent Report - Revised (TESI-PR-R - Ghosh Ippen et al., 2002) is a 24-item measure used with parents of children aged 0 to 6 years. It screens for a wide range of exposures including accidents, abuse, witnessing community and domestic violence, and terrorism. It also screens for the presence of traumatic responses in young children. The TESI-PR-R is a revised form of the Traumatic Events Screening Instrument (TESI), a reliable and valid measure designed to assess trauma history in older children (Ribbe, 1996). The TESI-PR-R was revised to be developmentally sensitive to the types of trauma that young children may experience. Research is under way to examine the psychometric properties of the revised measure. The TESI-PR-R is available in Spanish.

The Life Stressor Checklist-Revised (LSC-R; Wolfe & Levin, 1991) is a 31-item self-report measure for adults that assesses lifetime exposure to trauma and the incidence and impact of stressful life events on current functioning. Data support the validity of the LSC-R (Kimerling et al., 1999). The LSC-R is available in Spanish.

The Davidson Trauma Scale (DTS; Davidson, 1996) is a self-report measure designed to assess posttraumatic stress disorder. The scale consists of 17 symptoms rated for frequency and severity. Research indicates that the measure is internally consistent, reliable, and valid and that it distinguishes between groups with and without PTSD diagnoses (Davidson, Tharwani, & Connor, 2002). The DTS is available in Spanish.

Development & Social/Emotional Functioning

Children exposed to trauma often suffer from developmental disruption, behavior problems, and attachment problems and show impaired school, peer, and family functioning. A comprehensive assessment will gather information about functioning in these areas through play and behavioral observations, clinical interviews, and structured assessment instruments.

 Treatment

Treatment for C-PTSD requires a multi-modal approach, as noted by The National Child Traumatic Stress Network (2003). van der Kolk et al. (2005) suggest that treatment for C-PTSD should differ from treatment for PTSD in several important ways. While treatment for PTSD focuses on the impact of specific past events and the processing of specific trauma memories, treatment for C-PTSD should also include a focus on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six core components of complex trauma treatment have been identified by Cook, Spinazzola, Ford and Lanktree (2005):

  1. Safety
  2. Self-regulation
  3. Self-reflective information processing
  4. Traumatic experiences integration
  5. Relational engagement
  6. Positive affect enhancement

Treatment for those experiencing C-PTSD should address each dimension. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Cognitive Behavioral Therapy interventions, education, EMDR and other approaches.

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), developed by Cohen, Deblinger, and Mannarino (2004), is a highly effective, evidence-based treatment for children with complex trauma. TF-CBT targets posttraumatic, depressive, and anxiety symptoms and addresses cognitive distortions associated with the trauma. TF-CBT works with both children and their caretakers, and includes the following core components:

Phase 3

Reconnecting or reintegrating

Cope in present, sorting oneself

Develop relation with study/ job/ college/ vocation/ family