This Issue:
Sexual Abuse Treatment **Unapproved DRAFT January 31, 2000**

See also these newsletter issues for coverage of related topics:
Sexual Abuse (general topics)
Sexually Abusive Children and Youth.

THE DCFS PERSPECTIVE
DCFS Article (Pending)

LITERATURE SUMMARIES
Therapy Effectiveness
1. Therapy for Sexual Abuse Shows Promise

Models for Therapy
2. A Model for Cognitive Behavioral Therapy
3. The Internalization Model for Therapy
4. Strengths and Resiliency in Therapy

Sexually Abused Teens
5. Problems of Abused Teens
6.Treating Abused Teens

Program Evaluation
7. The Recovery From Abuse Project

Nonoffending Parents
8. Nonoffending Parents are Poorly Studied
9. Nonoffending Parents Experience Significant Losses
10. How to Support Nonoffending Parents

Foster Parents
11. Foster parents Fear False Allegations

WEB RESOURCES

DCFS Article     top
by - DCFS Division
Article pending...


1. Therapy for Sexual Abuse Shows Promise     top

Berliner, Lucy (1997). "Trauma-Specific Therapy for Sexually Abused Children." Pages 157-176 in Child Abuse: New Directions in Prevention and Treatment Across The Lifespan. Thousand Oaks, CA: Sage Publications.

Finkelhor, David and Lucy Berliner (1995). "Research on the Treatment of Sexually Abused Children: A Review and Recommendations." Journal of the American Academy of Child and Adolescent Psychiatry v34 n11 p1408-23.

Sexual Abuse is Not a Disorder
Sexual abuse is an experience, not a disorder or syndrome that can be diagnosed from specific symptoms. Abused children may show a wide range of symptoms, from none to serious problems. Treatment therefore deals with very diverse children and it is unlikely that any one therapy will be effective with all victims. This diversity makes it difficult to study treatment effectiveness.

"Sleeper" Effects of Abuse
The effects of sexual abuse may not surface immediately. It is unclear whether early treatment can prevent these effects or if they are triggered during later developmental stages. Also, some short-term deterioration following abuse may actually be related to recovery. This lack of clarity about sleeper effects makes short-term studies less reliable.

Treatment Shows Promise But More Research is Needed
Two studies give preliminary evidence that abuse-specific treatment for sexual abuse is effective. Also, research about other areas of child psychotherapy are more advanced, and confirm that treatment is useful with a wide range of other problems and disorders. However, randomized, large-scale studies are needed to establish the effectiveness of treatment for sexual abuse. Long-term follow-up studies are needed to learn more about sleeper effects and later developmental consequences.

Abuse-Specific Therapy
Researchers have mostly agreed that abuse-specific therapy (also called "abuse-focused" or "trauma-specific") is the preferred approach for most sexual abuse treatment. As opposed to supportive therapy in which children are not encouraged to discuss their abuse experience, abuse specific therapy:

  • encourages expression of abuse-related feelings
  • clarifies mistaken beliefs about the abuse that might lead to negative attributions about self or others
  • teaches abuse-prevention skills
  • diminishes victims' stigma and isolation
  • tries to both relieve and prevent problems and symptoms
  • helps children see the connections between their distress and the abuse and understand that distress is a legitimate response to this experience
  • does not usually target the symptoms that are most resistant, such as sexualized and acting-out behaviors.

Treatment Should Have These Characteristics
Studies suggest that effective treatment for sexually abused children should:

  • be relatively brief
  • be structured
  • use the cognitive-behavioral approach
  • include both child victims and their caretakers in a joint alliance
  • provide caretakers with education, support, individual therapy as needed, and specific skills to help manage children's behavior problems.

Treatment Begins With Assessment
Treatment must begin with a thorough assessment of the child and family to evaluate everyone's emotional-behavioral functioning and treatment goals. Clients should also be assessed during treatment to track their progress. Sharing progress with clients may be encouraging and empowering.

Abuse-Specific Measures
To improve both research and practice, the abuse-specific measures listed below should be used more consistently to assess abused children and their caretakers:

  • Trauma Symptom Checklist for Children
  • Children's Impact of Traumatic Effects Scale
  • Children's Attributions and Perceptions Scale
  • Negative Appraisals of Sexual Abuse Scale
  • Child Sexual Behavior Inventory
  • Parental Response to Abuse Disclosure Scale
  • Parent Support Questionnaire
  • Parent Emotional Reaction Questionnaire.

Family Factors Influence Recovery
Studies clearly show that these family factors predict a positive response to treatment:

  • greater parental support for the child
  • less maternal distress about the abuse
  • greater family help-seeking in response to the crisis
  • greater family cohesion
  • more effective family conflict management.

Treatment Outcomes
As a result of trauma-specific treatment, children should:

  • understand they have experienced abuse that was wrong and that may have caused them temporary problems
  • no longer suffer from abuse-related emotional and behavioral problems
  • have the knowledge and skills to recognize and deal with future difficulties
  • have supportive relationships with adults about the abuse
  • be on track with normal developmental processes and experiences.


2. A Model for Cognitive Behavioral Therapy     top

Deblinger, Deborah and Anne Hope Heflin (1996). "Overview of the Treatment Model." Pages 11-25 in Treating Sexually Abused Children and Their Nonoffending Parents: A Cognitive Behavioral Approach. Thousand Oaks, CA: Sage Publications.

About Cognitive Behavioral Therapy
Cognitive behavioral therapy is well-suited for treating sexually abused children.

  • It includes a variety of interventions that can be applied to a variety of symptoms.
  • It encourages empowerment because the process is explained to clients and because clients and therapists work together to decide what they will do.
  • It teaches coping skills that can be used throughout life.
  • The therapeutic style is preferred by minority groups.
  • It is supported by empirical research.

Dealing With Avoidant Coping
Children may work hard to avoid thinking, talking, or being reminded of sexual abuse. They often use the same method of coping that they used to deal with the abuse (such as denial, numbing, avoidance, dissociation) to deal with the cues that remind them of abuse. The cognitive-behavioral approach helps children break their associations with abuse-related cues using gradual exposure and modeling of more effective coping methods.

The child's nonoffending parent or caretaker is included in the therapy, first in individual sessions and later in joint sessions. The therapist should first do a thorough assessment to try to determine if abuse has occurred. Psychotic symptoms and suicidal behavior should be treated before using this therapy. Treatment can last 12 to 40 weeks; the longer duration may be needed when the family might be reunified.

Coping Skills Training
The first step for both child and parent is to teach these skills.

  • Emotional expression skills help clients label and communicate feelings about the abuse.
  • Cognitive coping skills help clients identify and dispute unhelpful beliefs about the abuse and replace them with more accurate and effective beliefs.
  • Relaxation skills help reduce clients' physical tension and anxiety about addressing the abusive experiences.

Gradual Exposure With Cognitive and Affective Processing
Gradual exposure is the foundation of this treatment. It combines prolonged exposure and systematic desensitization in ways that are suitable for children. Children get used to lower levels of anxiety before discussing topics that are more anxiety provoking. The goal is to help children deal with abuse reminders and memories without experiencing significant distress. Younger children may be given less exposure, because they cannot understand the need to feel badly in therapy in order to feel better later.

During gradual exposure, clients identify and correct unhelpful beliefs they may hold about themselves, relationships, sexuality, and personal safety. Since children learn their parents' coping styles, it is important that parents be involved.

Child-Behavior Management Skills Training
Parents are taught child-behavior management skills which helps them model and reinforce good coping in their children and respond effectively to their child's difficult behaviors,

Educational Components
Education is provided in these three areas:

  • Information about sexual abuse, including what sexual abuse is, why it happens, who it affects, who the perpetrators are, how children feel when they have been abused and why they do not tell.
  • Information about healthy sexuality, along with help in exploring clients' feelings and beliefs about sexuality.
  • Personal safety training, often done in parent-child sessions, including acceptable and unacceptable touching and skills for responding to sexual approaches.

Therapist's Roles
Sexual abuse therapists must model a view of the world that is accurate and hopeful. They must also:

  • demonstrate clear and open communication about the abuse
  • respond to a child's disclosures with calm, empathic comments
  • process their own emotional reactions with supervisor and colleagues
  • model appropriate ways of dealing with emotion
  • model open, unembarrassed communication about sexuality
  • not allow client embarrassment to alter their communication style.


3. The Internalization Model for Therapy     top

Wieland, Sandra (1997). "The Need for a Framework: The Internalization Model." Pages 1-51 in Hearing the Internal Trauma: Working With Children and Adolescents Who Have Been Sexually Abused. Volume 17 in Interpersonal Violence: The Practice Series. Thousand Oaks, CA: Sage Publications, Inc.

From the Book Jacket:
The author provides a clear description of how children and adolescents present themselves in therapy, identifying how distress from abuse can be exhibited in their play, conversation, and behavior. Then, using a carefully balanced combination of psychoanalytic, behavioral, and cognitive therapies, Wieland imparts a psychodynamic trauma-focused therapy designed especially for abused children and adolescents and their parents.

Summary of Chapter 1: The Internalization Model
Several models have been developed over the last decade to help therapists understand the dynamics of sexual abuse. All of these except the author's Internalization Model fail to address how abuse affects the child's internal sense of herself and the world, and how these internalizations in turn affect the way the child behaves. The internalizations that a child makes about her abuse need to be addressed in therapy to help her recover.

Behaviors Suggest Internalizations Needing Therapy
A child's behaviors following abuse are the therapist's key to uncovering her internalizations. A specific behavior is not determined by one specific internalization; however, in order to be useful in therapy, this model simplifies the relationship of internalizations to behavior. Below are internalizations that sexually abused children commonly make, with a discussion of the situations that encourage them, and the behaviors that may result from them.

"I am damaged"
All sexual abuse is intrusive on the child's physical self and normal development. It disregards the normal stages of sexual development and the separateness of the child. Intrusion creates feelings of being altered or damaged, and usually at the unconscious level which cannot be repaired by simply affirming that the child is attractive or worthwhile.

Children who experience themselves as damaged treat themselves that way, including:

  • alcohol and drug misuse
  • self-mutilation or suicide attempts
  • social withdrawal or involvement in abusive relationships
  • engaging in promiscuity
  • engaging in behavior they know will be punished
  • overexerting or neglecting their bodies
  • over or under achievement academically or in other areas.

Children may also experience normal sexual curiosity and arousal as proof there is something wrong with them.

"I am powerless"
Intrusion can make children feel powerless to control what happens to them. Powerlessness leads to a sense of fear that may be pervasive or only felt in certain situations. It may be conscious or subconscious and emerge as anxiety attacks.

Feeling powerless can also lead to learned helplessness and acting-out behavior. Often, girls respond with helplessness and boys with increased aggression. Either response can appear in all facets of a child's life or only in sexual situations.

"I am guilty/bad/an object to be used"
Children commonly believe that abuse happens to them because of their personal characteristics, and internalize guilt and feeling inherently bad. Both before and after disclosure, abuse is likely to be kept secret, so children are not aware of how common it is. The abuser may also tell the child that the abuse is her fault for a variety of reasons.

Children can be taught that the abuse is the responsibility of the perpetrator, but a sense of guilt and of being bad remain. The child may fail to protect herself and put herself in situations where abuse is likely to recur. The child may also not protect her right to her own thoughts, feelings, and decisions. Children who see themselves as objects may not care for themselves physically or unduly focus on their outward appearance with little attention to their internal life.

"I am responsible for what happens to others"
All sexual abuse situations involve threats, such as "If you tell, I will go to jail," or unspoken messages that the family will fall apart. This gives the child an inordinate sense of responsibility for what happens to others, and if she exposes her abuse, she feels responsible for the family distress that results. She is in a double bind of needing to do something about a situation but not being able to, leading to fearfulness and avoidance of decision making.

"I feel chaotic"
Children abused by loved or trusted persons experience great emotional confusion and internalize "I feel chaotic." This may lead to cut-off emotions or extremes of emotion. Children may act out their feelings about the abuse toward their caretakers or themselves.

"I am betrayed by people close to me"
Children who are abused by a loved person may internalize, 'I am betrayed by people close to me.' This may become a self-fulfilling prophecy in her other relationships.

"I have no boundaries"
Children who are abused by a loved person may be unable to develop healthy boundaries. If she internalizes "I have no boundaries", she may withdraw or become intrusive with others, take on the role of caring for others and ignoring her own needs, or seek attachment indiscriminately, becoming promiscuous or tolerating abusive relationships.

"When I am sexual, good things happen"
During sexual abuse, children are conditioned to engage in sexual behaviors as the result of the attention, physical pleasure and sense of power associated with them. The child internalizes 'When I am sexual, good things happen,' and repeats the sexual behaviors consciously or unconsciously.

Sexualized behavior in adolescents often takes the form of promiscuity. In younger children, it includes:

  • masturbating in public
  • reenacting sexual behavior with dolls or other children
  • rubbing the genitals of adults
  • making sexual sounds or motions
  • dressing and/ or moving provocatively
  • using sexual language
  • exposing their genitals.

"My sexuality means no feeling/ no control/negative feelings"
For children who experience sexual responses of their own and/or behaviors of the abuser that are out of the range of the child's normal perception of that person, sexuality becomes linked with a sense of fear and being out of control. Children who cut off their physical sensations link sexuality with lack of feeling, or freezing and rigidity. These internalizations may affect all their later sexual experiences or only those of a particular kind or with a particular type of person.

"What I am told is not what is meant"
Some level of distortion of communication occurs in all sexual abuse. With extreme abuse, distortion becomes more pervasive and results in the child's internalizing 'What I am told is not what is meant.' For some children, all statements will become suspect, while for others only statements by people similar to the abuser will be affected.

"I have no emotions/no experience/no integrated self"
In severe abuse, the child is placed in nightmarish situations from which there is no physical escape, leaving only emotional and cognitive routes of escape. The distortions of reality that result include:

  • denying the experience occurred
  • distorting the meaning of the experience
  • repressing the memory of the experience
  • dissociating, including developing dissociative identity disorder (previously called multiple personality disorder).


4. Strengths and Resiliency in Therapy     top

Anderson, Kim M. (1997). "Uncovering Survival Abilities in Children Who Have Been Sexually Abused." Families in Society v78 n6 p592-599.

The strengths perspective in social work and the resiliency literature that comes from research in developmental psychopathology can be combined into an approach that helps sexually abused children.

The Strengths Perspective
The strengths perspective recognizes that an individual has resources and potential for growth which should be identified and built upon to help meet her or his treatment goals. The Strengths Assessment is a tool used to identify an individual's personal and environmental strengths in the areas of family, school, health, leisure, daily living and social supports. For a sexually abused child, a strengths assessment should also explore what survival skills the child developed to deal with the abuse.

Definitions of Resiliency
Resiliency studies look at how certain qualities in children living in adverse conditions helped them resist stress and avoid adult pathology. Resilient children are defined as those who successfully 'engage' with risk and come through as competent individuals with few problems.

To use the resiliency concept with sexually abused children, we should broaden the definition of resilience so that it is not restricted to competence. Sexually abused children may not be fully competent, but they are still resilient. All their work on self-repair takes tremendous energy and may prevent them from finishing important developmental tasks.


Seven Resiliency Attributes
A broader definition of resiliency is that the child develops some of the following attributes as the result of surviving adversity. The practitioner can use this list to help uncover strengths in sexually abused children.

Insight - Young children may sense that something is wrong with their families but are not able to express it. During adolescence, the problem can be identified and named.

Independence - Independence refers to the child's ability to create emotional, intellectual or physical distance from a troubled family. Children may find a protective place by fantasizing or dissociating, or by keeping a low profile in the family. Children may establish activities outside the family to spend less time with their family.

Initiative - During childhood, initiative consists of experimenting to find what aspects of the family environment the child can control. For example, children may figure out ways to avoid abuse by sleeping with a sibling or feigning illness. Adolescents may maintain hope that the abuse will end and that they can persevere until it does. Planning for the future helps separate them from the current trauma. Spiritual beliefs can encourage faith in their ability to survive.

Relationships- Children may develop relationships with dolls, pets, or people outside the immediate family to fulfill their need for nurturance. Adolescents may develop an alternate family by choosing friends whose parents they like or pursue relationships with role models such as a coach or a teacher.

Morality - Children may channel their disappointment with their families into trying to make a difference for others. Adolescents may sacrifice themselves in an attempt to protect younger siblings, or rebel against the abuser's rules and demands. They demonstrate compassion toward others even though they have received little themselves.

Creativity and Humor - Children may use play to help repair themselves emotionally and endure the trauma. Adolescents may pursue music or art, or cultivate a sense of humor that also helps them connect with others.

Practitioners Should Honor Survival Skills
Honoring children's survival skills in treatment is important because these skills helped children exercise some control over their abuse experiences. By learning to respect their survival abilities, children can learn to see themselves positively.

Survival abilities, such as daydreaming, are often assumed to be problems instead of valuable tools to relieve trauma. Practitioners may try to change or eliminate 'problem' behaviors that are actually essential strengths. Rather than trying to eliminate daydreaming, the practitioner can help the child become aware of how it helped her cope and how it can be used constructively in other negative situations. If children's survival skills are ignored and practitioners focus only on their problems, children may continue to see themselves as damaged rather than learning to use their skills for recovery.


5. Problems of Abused Teens     top

Chandy, Joseph M., Robert W. Blum, and Michael D. Resnick (1996). "Gender-Specific Outcomes for Sexually Abused Adolescents." Child Abuse and Neglect v20 n12 p1219-1231.

Garnefski, Nadia and Ellen Arends (1998). "Sexual Abuse and Adolescent Maladjustment: Differences Between Male and Female Victims." Journal of Adolescence v21 n1 p99-107.

Sexual Abuse Can Distress All Age Groups
Previous studies on the effects of sexual abuse have found that:

  • preschool children may show inappropriate sexual behavior and increased internalization such as withdrawal, anxiety and depression
  • school-age children may show academic problems, behavioral and emotional problems, and inappropriate sexual behaviors such as excessive masturbation and sexual aggression
  • adolescents may show poor self-esteem, suicidal thoughts and behavior, substance abuse, involvement in prostitution, sexual confusion and sexualized behaviors, emotional disturbances and behavioral problems, eating disorders, delinquency, and school problems
  • adults may show sexual dysfunction, anxiety and depressive symptoms, sleep disturbances, dissociation, anger, suicidal thoughts and behavior and victimization of others.

Boys May Externalize While Girls May Internalize
There are few studies on the differences in problems between male and female victims, and they have limitations in method. However, they suggest that girls are more inclined to internalize their problems and boys to externalize.

  • boys may show confusion over sexual identity, inappropriate attempts to reassert masculinity, and identification with the perpetrator
  • men may show higher rates of psychiatric diagnoses, especially substance abuse disorders and antisocial personality disorder.

Two Current Studies
The authors conducted two separate surveys of public school students to learn about the different responses of female and male adolescents.

Boys Reported Significant Behavioral Problems
Abused boys' responses showed:

  • a similar rate of emotional problems as for abused girls
  • a higher rate of loneliness than abused girls
  • a higher rate of suicidal thoughts and behavior than abused girls
  • more reports of poor school performance and higher dropout risk
  • higher rates of sexual risk taking, including earlier and more frequent experience of intercourse, more frequent report of ever having intercourse and less frequent use of contraceptives
  • use of alcohol at three times the rate of nonabused boys
  • more use of marijuana than abused girls
  • higher rates of involvement in vandalism, hitting others, group fighting, stealing, forcing sex, involvement in prostitution, and cheating on tests than girls.

Girls Reported More Self-Image Problems
As opposed to boys, abused girls' responses showed:

  • a higher rate of anxiety than for boys
  • use of alcohol only slightly higher than for nonabused girls
  • more frequent suicidal thoughts and behavior
  • significantly more perception of overweight, dissatisfaction with present weight, lack of pride in body, bingeing, nonstop eating, dieting, and self-induced vomiting than boys.

Resiliency Factors
One of the surveys also identified protective factors and found that 26% of the boys and 43% of the girls showed resiliency characteristics. For girls, the protective factors included:

  • having a strong emotional attachment to family as the most powerful factor
  • considering oneself a religious or spiritual person as the second most powerful factor
  • experiencing less concern about being sexually forced
  • being younger than nonresilient counterparts
  • being more likely to live with both biological parents
  • having better heath
  • experiencing less frequent use of alcohol by mother
  • experiencing less physical abuse
  • not perceiving high rates of drug use by other students in their schools.

For boys, the protective factors included:

  • having a mother with education above high school
  • experiencing high degree of concern from both parents.

Anticipate Problems in Both Girls and Boys
The possibility of severe multiple problems in both boys and girls with a history of sexual abuse should be taken very seriously. These studies suggest that the consequences of sexual abuse may be even more severe for boys than for girls, particularly in behavioral problems and suicidal tendencies.


6. Treating Abused Teens     top

Chaffin, Mark, Barbara L. Bonner, Karen Boyd Worley, and Louanne Lawson (1996). "Treating Abused Adolescents." Pages 119-139 in The APSAC Handbook on Child Maltreatment. Thousand Oaks, CA: Sage Publications.

Effects of Sexual Abuse in Teens
Compared to younger children:

  • Teens are more apt to display low self-esteem, depression and suicidal thoughts or behavior.
  • Teens are more likely to expose their abuse deliberately and in anger, rather than accidentally.
  • Teens who attempt suicide have a high prevalence of sexual abuse.
  • In teen girls, school problems, conflicts with authority, early sexual behavior and eating disorders are associated with sexual abuse.

Which Teens Need Treatment?
Not all abused teens need treatment, and it can be difficult to determine who does. Teens may be reluctant about treatment because they want to forget about the abuse, or fear stigmatization by their peers or being blamed for the abuse. However, avoidant coping styles, such as wishful thinking, detachment, distancing and denial, are associated with poorer psychological adjustment and higher symptom levels, so teens should not be excluded from treatment on the basis of their reluctance.

The Initial Interview
Sensitive assessment of abused teens must:

  • respect their personal boundaries
  • acknowledge their reluctance to be involved in therapy
  • give them some control over discussion of the abuse (let them decide what amount of detail to discuss while encouraging them to believe that talking about the abuse will become easier in the future)
  • show respect for their current coping mechanisms and emphasize how well they have coped with the experience.

Assess for a Variety of Difficulties
Teens should be assessed for these possible difficulties:

  • additional abuse or violent assault experiences
  • posttraumatic stress disorder symptoms, including dissociation, avoidance, numbing, intrusive thoughts, or flashbacks
  • triggers for anxiety and fearfulness
  • relationship issues, including those with adults and peers of the same gender as the abuser
  • sleep disturbances, including nightmares
  • depression
  • suicidal or self-injurious behavior
  • sexual behavior
  • substance use/abuse or eating problems
  • possible dissociative disorder
  • ongoing stressors such as court appearances, family pressure, or unwanted advice
  • any lack in their social support systems.

It is crucial that teens have support that includes the belief of their nonoffending parent(s), which is the factor that predicts recovery most strongly. Teens also fear being stigmatized by their peers as a 'slut' or being gay, and need the ability to confide in at least one trusted peer.

Assessing Attributions
If teens attribute control of the abuse to themselves, they can experience lower self-esteem and more depression. However, teens who blame outside forces for the abuse in a global way can experience themselves as helpless in a world with random, unavoidable victimization. Explore teens' attributions nonjudgementally first before suggesting alternative points of view.

Psychological Testing Can be Useful
Testing can help determine a teen's resources and difficulties and also provides a baseline for tracking progress in treatment. The testing experience should emphasize strengths and coping resources.

Is Inpatient Treatment Needed?
Sexually abused adolescents are admitted to inpatient units for the same reasons as nonabused teens:

  • self-mutilation or suicide attempts
  • severe behavioral problems
  • drug or alcohol addiction
  • eating disorders
  • dissociative disorders
  • posttraumatic stress disorder symptoms
  • psychosis.

Because it is disruptive, inpatient treatment should be used as sparingly and briefly as possible. Disclosure of abuse is often followed by intense emotion and dramatic behaviors, and these should not be mistaken for psychotic symptoms or lead to hospitalization because the therapist is uncomfortable or unprepared to deal with them.

Treat the Most Painful Problems First
Therapy should first address acutely painful problems, such as panic attacks, sleep problems, severe anxiety or fearfulness, that need immediate relief. Relieving these problems first helps the progress of therapy. These treatments can help:

  • relaxation training
  • distraction and self-control techniques
  • systematic desensitization
  • stress inoculation training
  • short-term psychoactive medications.

Teens Need Therapeutic Education
Discussions, readings and handouts can help teens feel validated and supported. They will need education about:

  • why someone would commit sexual abuse
  • what to expect in therapy and the therapy client's 'job'
  • their role in any legal proceedings.

Teens may appear 'worldly' about sexuality, but their information may be inappropriate. Abused teens may think of sex as either as "all bad" or "anything goes." They may need to correct and develop their understanding of healthy sexuality and respectful relationships, and how they differ from abusive sexuality. They will also need to learn how to protect themselves from future abusive experiences.

Group Psychotherapy is Helpful
Studies do not demonstrate that either group or individual therapy is better, or that therapies of different duration or format are more effective, or that it is better to offer therapy right after abuse or wait until issues arise. However, group therapy is widely recommended for this age group. Its advantages include:

  • peer interactions and relationships can offer support and validation that overcome isolation and lack of family support
  • teens can learn vicariously from others and observe different interpersonal styles and social skills
  • teens can withdraw or participate in the sessions as they need to.

Group therapy should not be used with teens who:

  • have severe depression, psychosis, or developmental delays
  • are unable to control their impulses and tolerate limits
  • are very fragile, shy, antagonistic or acutely in crisis.

Therapy With Abused Teens is Challenging
Working with sexually abused teens is challenging to therapists. Therapists may need consultation with their supervisors or therapy for themselves in order to remain compassionate and objective and to avoid withdrawing, retaliating, reenacting abuse, or exploiting their clients.


7. The Recovering From Abuse Project     top

Hazzard, Ann (1996). "Structured Treatment and Prevention Activities for Sexually Abused Children." Pages 23-39 in The Hatherleigh Guide to Child and Adolescent Psychotherapy. New York: Hatherleigh Press.

The Recovering From Abuse Project
The Recovering From Abuse Project (RAP) was developed for sexually abused girls and their nonoffending caretakers in a low-income, primarily African-American population where single-mother families were the norm; however, it can be adapted for use with anyone. It is unusual in using structured activities for individual therapy. Eight hour-long sessions, are used with half of each session spent with the child and half spent with the mother.

Evaluation Shows Parental Improvement
The Project was evaluated by comparing 15 girls and their mothers with those of 17 control families who participated in "treatment as usual." Both treatment programs reduced children's symptoms and improved their functioning. However, the RAP was more effective in increasing caretakers' support of the children, decreasing caretakers' self-blame and decreasing caretakers' expectations of unduly negative impact of abuse on the children.

Specific RAP Activities
The activities described below were developed for the RAP. A complete RAP treatment manual is available from the author at Box 26065 Grady Hospital, 80 Butler Street, Atlanta, GA 30335.

The Posttraumatic Stress Disorder (PTSD) Model of Sexual Abuse
According to this model, sexual abuse is an anxiety-provoking experience for most children. Children respond with heightened physiologic reactions, anxious feelings and distorted thinking. Children may experience intrusive recollections of the abuse and engage in play representations of it. They may also have abuse-related dreams and distress at cues or symbols of the abuse. Children defend against these experiences by avoidance, withdrawal or emotional numbing. One limitation of this model is that it does not include emotional reactions to abuse other than anxiety.

RAP Activities for Coping with PTSD Symptoms
PTSD symptoms must often be addressed first in therapy. Mastering rather than suppressing abuse-related anxiety is crucial to a child's long-term recovery. These activities can help:

  • Explain why it is important to discuss the abuse ("Talking about the abuse here, where you feel safe, can help you get over the scared feelings you have right now whenever you think about what happened.").
  • Control the level of exposure to anxiety-provoking memories by limiting the amount of time spent dealing with the abuse and by alternating abuse-related activities with nonthreatening activities.
  • Ask the child to draw the abuse, which promotes discussion and may give information about what aspects of the abuse were most significant to the child.
  • Develop an "Abuse Reminder List" by asking the child to list anxiety triggers in all of the following areas: people, places, things, sounds, smells, activities, times of day, television, or books.
  • Develop a "Ways to Cope List" by planning how the child will respond to these triggers.
  • Provide consistent praise and support to reinforce the child's mastery of anxiety-provoking situations.

Finkelhor's Traumagenic Factor Model
According to the model proposed by David Finkelhor, most sexually abused children must cope with these four major issues to varying degrees:

  • self-blame
  • betrayal
  • traumatic sexualization
  • powerlessness.

RAP Activities For Coping with Self-Blame
Many children feel some degree of guilt about sexual abuse. Rather than simply stating that "The abuse is not your fault," learn first about the child's attributions using these activities:

  • Reading together the"Why Me?" story, a fill-in-the-blank story about a girl who was abused and wonders why this happened.
  • Asking the child to divide the "Why Pie," a drawing of a pie with each piece representing how much she or he blames a particular person.
  • Asking the child to choose her or his thoughts from a "Why List" of various attributions, such as "I didn't fight back," or "I accepted gifts."

Treat Parental Blame
When parents blame themselves or the child in any way, their attributions should be addressed. When their self-blame is appropriate, the therapist must help parents take responsibility for their contributions while discouraging global self-blame and undue guilt.

"Who I Told" Worksheet Helps With Betrayal
Children usually feel betrayed by a known perpetrator and may feel betrayed by their nonoffending parent(s). They may avoid disclosing the abuse to people who could be supportive out of fear of a negative reception. Use the "Who I Told" worksheet and discussion to help the child develop positive yet realistic and individualized expectations about trusting others. Ask children to list whom they told about the abuse and to paste sticker faces to indicate how each person reacted. In another column they are asked to list people not told and to use stickers to indicate each person's expected response.

RAP Activities For Coping with Traumatic Sexualization
Asking the children to draw pictures of ages they would like to be can reveal if children have developmentally regressed or become prematurely sexualized. If children draw themselves as younger or older, discuss the positive aspects of being the age they are now and how they can be safe now.

Education about healthy sexuality is essential and can be provided by reading appropriate printed materials together (therapist, parent and child). Parents may appreciate this structured approach to sex education. Playing a "Name That Touch Game" - in which brief situations are read from cards and the child classifies each situation as OK or not OK - can be helpful.

Parents of children who have developing sexualized behavior problems may need help in setting appropriate limits to these behaviors.

Prevention Activities Help With Powerlessness
Prevention activities may help children recover from feelings of helplessness. A number of good materials are commercially available. Asking "what if" questions and role playing can teach children how to avoid future abuse by saying no, leaving and telling someone. Girls should be prepared for date rape situations, review "pick-up" lines, and talk about what makes it hard to refuse someone they like.


8. Nonoffending Parents are Poorly Studied     top

Tamraz, Djenane Nakhle (1996). "Nonoffending Mothers of Sexually Abused Children: Comparison of Opinions and Research." Journal of Child Sexual Abuse v5 n4 p75-104.

Joyce, Patricia A. (1997). "Mothers of Sexually Abused Children and the Concept of Collusion: A Literature Review." Journal of Child Sexual Abuse v6 n2 p75-92.

Corcoran, Jaqueline (1998). "In Defense of Mothers of Sexual Abuse Victims." Families in Society: The Journal of Contemporary Human Services v79 n4 p358-369.

Most Writing About Mothers is Opinion
Most of the literature about nonoffending mothers is opinion-based literature.

  • It is based on studies not focusing on mothers but on other child abuse issues.
  • It is based on indirect evidence, such as perceptions, interpretations or unverified assumptions.
  • It usually fails to provide a context or explanation for the behaviors of mothers that are being described or criticized.
  • It is biased, often presenting mothers as solely responsible for family problems and expressing no concerns for their needs.

Opinion-Based Descriptions of Mothers
In opinion-based literature, mothers are described as physically ill, disabled, depressed, psychotic, suicidal, alcoholic, sexual abuse victims themselves, battered, dependent, passive, submissive, masochistic, dissatisfied with their marriages, absent from home, sexually dysfunctional, detached or overinvolved, lacking parenting skills, engaged in role reversal with their daughters, frightened or terrorized by their partners, and not always supportive of their children when they learn of abuse.

Collusion is Often Assumed
Authors often believe mothers consciously or unconsciously collude with the abuse or are more concerned with maintaining the appearance of an ideal family. If a mother initially denies abuse when it is first exposed, this is seen as evidence of collusion. Mothers' distress and the difficulties and complexities of reporting the abuse are rarely considered.

There Are Few Research Studies of Mothers
Only a few studies have investigated nonoffending mothers from a research perspective. Unfortunately, these studies often have limitations, such as lacking comparison groups and reliable instruments.

Psychology - One study of mothers' psychological functioning found that nonoffending mothers may tend to be conformists with a need to belong. The other studies have found conflicting results about whether these mothers have greater difficulties with depression and psychiatric problems than other mothers.

Role - One study has found conflict or confusion between the mothers' marital and maternal roles. Mothers may reverse their roles with their daughters, usually the eldest, or experience role confusion between their daughters and partners.

History of Abuse - Two studies have found that nonoffending mothers have experienced sexual abuse themselves at a higher rate than other mothers. This suggests that sexual abuse may be passed from one generation to another, although how this happens has not been studied.

Battering - Three studies have found that mothers of incest victims are more subject to battering than other mothers. It is not known if the mothers have an inclination to engage in abusive relationships or to tolerate victimization.

Awareness of Child Abuse - Two small studies have found that the majority of nonoffending mothers were not aware of the sexual abuse of their children in cases involving both intra- and extrafamilial offenders.

Distress at Child Abuse - Four studies have found that nonoffending mothers are distressed when they learn about their children's abuse. They experience:

  • cognitive belief with emotional denial
  • feelings of loss and bereavement
  • loss of trust in a partner
  • loss of confidence in mothering ability and femininity
  • feeling of loss of control over life events and loss of belief that the world is just.

One study found that mothers' symptoms decline over 12 months after disclosure, and are helped by family therapy. This suggests that mothers are distressed as a result of learning about sexual abuse, rather than that they were distressed prior to the abuse and thus contributed to it.

Four studies have found that nonoffending mothers who have experienced sexual abuse themselves are significantly more distressed than other mothers when their children are abused

Belief of Child - Studies of how mothers try to protect and support their children have found that a majority of mothers believe their children and take some action, including pressing charges and seeking counseling. Some study results include:

  • In a study of 193 mothers, 78% believed their children.
  • In studies of 99 mothers and 156 mothers, both found that 84% of mothers protected their children all or some of the time.
  • In a study of 92 mothers, 70% believed the child, 50% arranged for legal protection and counseling, while 26% provided only legal protection.
  • In a study of 103 mothers, 69% were supportive.

Influences on Support of Child - Five studies of the factors that influence how nonoffending mothers support their children found these results:

  • A mother's support depended more on her relationship with the perpetrator than with the child.
  • Conversely, a mother's support was affected by her relationships with the child, the offender and the mother's family.
  • Mothers were less supportive of the child when mothers felt burdened by or hostile toward the child.
  • A mother was more supportive of the child when the offender was a distant relative, abuse was limited to fondling, and she was not at home when the abuse occurred.
  • A mother's individual personality and coping strategies influenced her support of the child.

Practitioners Should Rely on Research
More valid sources of information are needed in order to fully understand the behaviors, experiences, and capacities of mothers of incest and other sexual abuse victims.

The existing research suggests that a nonoffending mother is generally unaware of the abuse, has high levels of distress after disclosure and reacts differently depending on her relationship with the offender, the victim and her own family, as well as her personality traits and coping style. Research does not support collusion as a way to explain the behavior of nonoffending mothers. A more useful concept would be a continuum of 'diminished capacity to protect' their children experienced by some mothers.


9. Nonoffending Parents Experience Significant Losses     top

Massat, Carol Rippey and Marta Lundy (1998). "Reporting Costs to Nonoffending Parents in Cases of Intrafamilial Sexual Abuse." Child Abuse and Neglect v77 n4 p371-88

Past Literature Blamed Mothers
In the past, literature about child sexual abuse took a severely blaming stance toward nonoffending parents (usually mothers). Now, researchers are more interested in trying to understand the factors that affect a nonoffender's parenting ability.

Mothers May Experience Substantial Losses
The authors surveyed a sample of 104 nonoffending parents (100 female and 4 male) and found that 99% experienced significant losses when their children disclosed sexual abuse.

Relational Losses
A mothers may lose her intimate partner if that person is the offender as well as loss of support from family and friends due to the blame and shame associated with incest. In this survey:

  • 54% reported that some family members were dissatisfied with them and 35% reported that family members were angry with them.
  • 41% reported that friends became less friendly but 72% indicated some friends supported them completely.
  • 29.7% lost custody of their children for a time.
  • The number of parents married to and living with the perpetrator dropped from 35 to 2.
  • The level of intimacy with perpetrators described as 'not close in any way' increased from 35.7% before disclosure to 87% after disclosure.

Financial and Vocational Losses
A mothers may lose the offender's income, which may have been the primary means of family support. Nonoffending parents may also lose income for time away from work, or lose their jobs due to court appearances and therapy appointments. In this survey:

  • 56% reported income loss, 20% reported income increase, and 27% reported no change in income.
  • The mean predisclosure income was $50,293, while the mean postdisclosure income dropped to $29,600.
  • 26% reported problems with their jobs after disclosure and 25.7% had to get a new job.

Residential Losses
After divorce, separation or loss of income, the nonoffending parent may have to move, with the possibility of reduced living conditions. 50% of this sample had to move after disclosure, although none reported reduced living conditions.

Nonoffending Parents Need Support
The needs of nonoffending parents may be as great as those of abused children. They must deal with emotional trauma and material adversity at a time when they are called upon to give extraordinary support to their children. The fears that nonoffending parents have about reporting sexual abuse have a realistic foundation. Initial denial and disbelief on a nonoffending parent's part is a normal response to loss and not necessarily an indication of the parent's ultimate support of the child. Blaming nonoffending parents for the abuse may strengthen their denial and reduce their ability to provide their children with much-needed help.


10. How to Support Nonoffending Parents     top

Steinmetz, Melissa (1996). "Intervening with Non-Offending Parents During an Abuse Investigation." APSAC Advisor v5 n3 p4-5.

Nonoffending Parents Have Painful Feelings
Often, nonoffending parents are so focused on dealing with their own reactions to learning that a child has been sexually abused that it is difficult for them to help the child at first. They often experience:

  • denial of the abuse, its negative consequences, or the need for help
  • jealousy when the abuser and the child have developed a symbiotic relationship
  • anger, sometimes at themselves for failing to protect the child, at the abuser, or at the child for not revealing the abuse
  • helplessness and fear that the child will be removed from their custody, and at being involved in a legal system from which they have no idea what to expect
  • invisibility, because all attention is focused on the child and the alleged perpetrator to try to determine if the abuse has occurred
  • shock, numbness, and repulsion, especially in parents who have been abuse victims
  • guilt and self-blame
  • hurt and betrayal due to losses or damage to relationships with the abuser, and other friends and family
  • sexual inadequacy or rejection, if the abuser is a partner or spouse
  • financial insecurity due to loss of an offending spouse's income.

Assess the Mother's Feelings and Needs
Child protective workers should anticipate a nonoffending parent's feelings and needs. Ask these questions at the initial interview to help assess her feelings, strengths, relationship with the abuser, relationship to her child, and needs.

  • How has the process of disclosure and investigation been for you?
  • Did you have any idea this could have been occurring? In hindsight, do some behaviors or situations stand out in your mind?
  • How was your past relationship with the abuser, and how has it changed?
  • How are things between you and your child?
  • Who do you have for support? What do you need now?
  • What are your greatest concerns about your partner leaving your home?
  • What do you do to handle stress?
  • Are there other areas in which your family could use assistance?
  • What do you know about child abuse? Have you known anyone else who was abused?
  • How would you like to see the future for you, your child, and the rest of your family?

Offer Weekly Support
Regular contact with parents to talk, provide support and help with connections to other services is very beneficial. Also offer these supports:

  • contact with other parents who have been involved with the child protective system and have completed treatment
  • connection as soon as possible with other sources of support
  • printed information about the usual course of an abuse investigation and court proceedings, and the juvenile and criminal courts
  • information about emotional recovery and the benefits of counseling for children
  • guide to agencies that can help with other problems, such as child care, transportation and education.


11. Foster Parents Fear False Allegations     top

Swan, Tracy A. (1997) "Problems in Caring for Sexually Abused Girls: Care Providers Speak Out." Community Alternatives v9 n1 p71-87.

Concern is growing about the possibility of false allegations of sexual abuse when sexually abused children are in foster care. Literature suggests that sexually abused children in foster care may be unable to tell the difference between appropriate, affectionate family touching and behavior that was connected with their past abuse. Also, children might use allegations to accomplish a goal such as moving to a different foster home. Out of fear of experiencing false allegations, foster parents may refuse to take sexually abused children.

The author studied eight well-experienced foster care providers in Toronto who had fostered abused girls.

Families Feel Vulnerable and Anxious
The possibility of men and boys in the fostering homes being falsely accused of sexual abuse was the major concern of the families. They felt continually vigilant, anxious, and vulnerable. They tended to view the child as untrustworthy, seductive and threatening, a view that is shared with much of society and child welfare agencies.

Families Protect Males With Rules for Behavior
The families protected the males in the households by establishing rules, such as:

  • The father/brothers will never be alone with the abused child
  • The father/brothers will not initiate contact with the child, especially physical contact
  • The father/brothers will not discuss the past sexual abuse with the child
  • The father/brothers will not enter girls' bedrooms.

Distinct Roles for Fathers and Mothers
These rules resulted in distancing the fathers/brothers from the child and limited the fathers' role to taking care of the physical home environment. This made the foster mother responsible for the girl's care. Foster mothers also felt obliged to provide constant supervision to enforce the rules and to help mediate the relationship between the household males and the child - an exhausting burden for the mothers. These parental roles prevented the family from providing a normal environment and reduced its therapeutic value for the child.

Parents Felt Isolated
Foster parents also felt isolated and unsupported by the child welfare agency as well as by friends and family who did not understand their way of life. The mothers particularly felt they had inadequate training and support from the agency about how to care for the children. They felt that the agency ignored their concerns about false allegations and failed to support them when allegations were made.

Child Welfare Agencies Should Make Changes
It would be a better environment for abused girls if foster families could model more egalitarian sharing of parenting roles, but it is unrealistic and unfair to expect the parents to make these changes. Agencies should consider these points:

  • Sexually abused girls could be placed in homes with only female care providers.
  • Foster parents need more training to help them feel comfortable with the child's sexualized behavior and more skilled in responding to it.
  • Agencies could work with the foster parents and child together, helping the child to understand normal family interactions and the parents to understand the child's perspective.
  • Agencies should treat foster parents as therapists rather than clients and encourage a trusting and open relationship with the agency.
  • Agencies should seek the input of foster parents about how allegations are investigated.


Web Resources     top

Links to Sexual Abuse Websites
A collection of links to resources on child sexual abuse is found here.
http://www.cs.utk.edu/~bartley/index/childSexualAbuse/

Hotline
The National Child Abuse Hotline website is found here.
http://www.childhelpusa.org/

Parents United
This page gives contact information for all chapters of the Parents United support organization.
http://members.tripod.com/~Parents_United/Chapters/PUI.htm

List of Illinois Sexual Assault Centers
The Rape Abuse and Incest National Network maintains a list of sexual assault crises centers. Enter "Illinois" to get a list of centers in Illinois. http://www.rainn.org/counseling.html

Champaign County Help Groups
These two sites maintain lists of sexual abuse/assault help groups and services in Champaign County.
http://www.prairienet.org/helpbook/key246.htm
http://www.prairienet.org/selfhelp/abuse.htm#sexualabuse

Materials for Parents

Sexual Abuse of Boys
A paper on this topic is offered by an individual researcher at Boston University School of Medicine.
http://www.jimhopper.com/male-ab

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