Introduction
Sexually abused children experience a wide range of psychological and behavioral sequelae ranging from little discernable impact to a variety of psychiatric disorders and serious behavioral problems. Among the most common reactions in children are increased anxiety, depression, posttraumatic stress disorder (PTSD), inappropriate sexual behaviors, nightmares, behavioral regression, learning problems, increased distrust, and fearfulness. Recent research has also found strong associations between adverse childhood experiences (including child sexual abuse) and many of the most serious long-term chronic illnesses, including the top 10 causes of death in the United States. The heterogeneous nature of sexual abuse, differing reactions of caregivers, individual strengths and vulnerabilities—both biological and social—and differing access to mental health care among children are the most likely sources of this variability of reactions to child sexual abuse. As Putnam noted in his 2003 review of child sexual abuse, “Childhood sexual abuse is a complex life experience, not a diagnosis or a disorder.”
Despite and perhaps because of the heterogeneity of psychological and behavioral reactions to child sexual abuse, a number of treatments have demonstrated some effectiveness in diminishing the impacts of this abuse. A recent metaanalysis reviewed 28 studies describing the effectiveness of cognitive-behavioral, play, supportive, group, abuse-specific, individual, and family therapy for children who have experienced sexual abuse. As detailed later in this chapter, the authors found that these different treatments appear more effective for some sequelae than others and that careful assessment of the effects of sexual abuse on individual children is the best way to decide which specific treatments are most likely to help that child. They also found that longer duration of treatment was associated with greater treatment effectiveness.
History of Awareness
The recent history of our knowledge and understanding of childhood sexual abuse (CSA) includes several cycles of discovery and resuppression. Its complexity, disturbing nature, and serious ramifications of confronting CSA underlie these cycles.
Early in his career, Sigmund Freud was influenced by the work of French physicians like Ambroise Auguste Tardieu, whose forensic records beginning in the 1850s demonstrated that contrary to previous beliefs, sexual abuse was common and occurred in all socioeconomic levels. Toward the end of the nineteenth century, Freud presented The Aetiology of Hysteria , a paper in which he described adult onset hysteria, obsessions, chronic paranoia, and other psychoses to women’s experiences of CSA. At the same time, Pierre Janet was observing dissociative symptoms among individuals who had experienced significant trauma. The widespread nature of hysteria in Europe, especially among the upper classes, implied that abuse and incestual relationships were abundantly more common than the intellectual or religious communities believed or could tolerate.
Freud was met with great hostility for his “seduction hypothesis” and within a few years he completely repudiated his hypothesis, stating instead that these sexual abuse disclosures were memories of sexual fantasies rather than actual experiences. Furthermore, psychological trauma was not seen as central to psychiatry at that time, resulting in Janet’s findings being ignored for decades. In 1932, one of Freud’s closest psychoanalytic disciples, Sandor Ferenczi, reasserted the “seduction hypothesis” based on confessions from adults he treated regarding their sexual abuse as children. His paper, “Confusion of tongues between adults and the child,” is one of the most insightful and prophetic descriptions of the occurrence and harms associated with child sexual abuse preceding our present era. Ironically, Freud was one of the primary critics expressing skepticism about Ferenczi’s observations. Sexual abuse and childhood trauma were again disregarded by the medical community.
It was not until the feminist movement in the United States during the 1960s, primarily out of their work with rape survivors and the medical “rediscovering” of child abuse, that the subject of CSA again received attention. Dr. C. Henry Kempe, a leader in the recognition of child physical abuse, gave a speech in 1977 to the American Academy of Pediatrics on child sexual abuse, marking a turning point within the modern medical community on the awareness and responsibility of physicians to care for victims of sexual abuse. In the last several decades, the combination of increased research, high-profile cases, and mandatory reporting has established the widespread nature and psychological effects of CSA about which Freud briefly theorized. This has lead to research addressing psychological effects, prevention, and treatment of CSA. Although the descriptions of psychological effects are more specific, the research is much more developed, and the treatment evidence based, the profound effects of CSA found by current research are very similar to the observations of Freud, Janet, and Ferenczi decades earlier.
Efforts to Characterize Child Sexual Abuse and Associated Impacts
Child Sexual Abuse Accommodation Syndrome
One of the most influential articles on the phenomenology of CSA is Roland Summit’s child sexual abuse accommodation syndrome (CSAAS) published in 1983. Through describing the CSAAS, Summit sought to “… disabuse judges and jurors from commonly held misconceptions about child sexual abuse.” CSAAS includes the secrecy; the helplessness of children; entrapment of the child; accommodation to the sexual abuse; a delayed, inconsistent, and unconvincing disclosure of the abuse; and for those who do disclose abuse, frequent retraction of their prior disclosures.
The first aspect of CSAAS is secrecy . Summit observed that sexual abuse, unlike other forms of maltreatment, is more secretive in nature. There are typically no witnesses, the perpetrator uses threats or guilt to quiet the child, and the child relies on the perpetrator to explain the experience since the child is typically sexually naïve. Psychologically, this places the responsibility on the child to maintain the status quo. By the secretive nature of the experience, the child discerns the action is bad or wrong, but is also quite aware, either through direct or implied threat, that disclosing the abuse would cause serious negative consequences. Furthermore, the perpetrator often reinforces the silence of the child by telling him or her that no one would believe a disclosure, or that others would perceive the abuse as the child’s fault.
Helplessness is the second aspect of the syndrome. Summit observes that most adults assume that a child who suffers abuse would simply tell of the abuse at the first possible chance. This thought process, however, does not respect the naturally dependent nature of the child, especially since the majority of CSA is perpetrated by people known to the child and not by strangers. Typically, children lack the authority within the framework of the family to effectively oppose an adult caregiver or another authority. Therefore, most children do not kick or scream out when sexually assaulted, but instead implore tactics such as pretending to be asleep, hiding, or simply dissociating from the experience.
Entrapment and accommodation is the next part of CSAAS. Since the sexual abuse is rarely a one-time occurrence, and the child is already overcome by feelings of secrecy and helplessness, the child becomes entrapped in a cycle of abuse and must learn to accommodate psychologically. This is partly why CSA often continues until the child matures or a third party discovers the abuse. In some ways, this is an attempt by the child to gain some feeling of control of the situation, usually by placing the blame on himself or herself, which can lead to self-hate and self-debasement. Children can further accommodate psychologically through fragmentation, dissociation, and in some extreme cases, the development of dissociative identity disorder.
Delayed, conflicted, or unconvincing disclosure is the fourth principle in CSAAS. Even though studies show that it is quite normal for children to delay their report of sexual abuse, this delay—in combination with the fact that describing chronic abuse long after it began can appear conflicted or unconvincing—leads to questioning the truthfulness of the child. Furthermore, the child’s coping strategies, either positive or negative, can be used as further evidence of the factitious nature of the disclosure. Children are often not considered to be reliable when they have begun to use drugs, engage in self-mutilation behavior, have explosive outbursts, be delinquent, or dissociate as part of their accommodation. Conversely, a child who has maintained good grades, appropriate social skills, and other successes does not appear to be a victim of abuse, leading to dismissive reactions from adult figures. In either context, this lack of congruency with the expected appearance of a “true victim” and a delayed or conflicting disclosure fosters a skeptical response from many adults. This may be the case especially if acknowledging the true nature of the disclosure significantly diminishes that adult’s prior self concept as protector of the child.
Retraction is the final element of CSAAS. Often children who do disclose will recant their previous statement when they discover that many of their previous fears about disclosing were warranted. Nonoffending family members often do not believe disclosures, the perpetrator abandons and blames the child, and the family can fragment when a report of sexual abuse is made. Again the child is faced with the decision to preserve one’s self or the family, and often the child chooses the family. To many adults, the retraction appears much more convincing than the original disclosure because at the moment of retraction, all of the doubts and questions of the adults are answered and the integrity of the family is restored.
Overall, CSAAS describes the phenomenon of CSA for many sexually abused children, especially prolonged, interfamilial forms of CSA. CSAAS is neither a diagnostic checklist nor appropriate evidence to prove CSA. Its value in the legal, investigative, and clinical arenas is to counter attempts to use delayed disclosure and recantation to disprove other evidence of sexual abuse, such as detailed disclosures and testimony by child victims. The syndrome further elucidates the countertransference and projection experienced by nonoffending family members and professionals alike when confronted by reports of CSA. It explains developmentally understandable beliefs and coping strategies of children when they become victims of CSA. The clinician must remember that a child’s experience and reaction to trauma, especially the trauma associated with CSA, is often different than an adult’s expectation of what a reaction should look like. Understanding this juxtaposition is essential to appropriately working with many victims of CSA.
Traumagenic Dynamics
A frequently cited conceptual model for organizing the various effects observed in studies of sexually abused children was proposed by Finkelhor and Browne. It describes four “traumagenic dynamics”— traumatic sexualization, betrayal, stigmatization and powerlessness—as the core psychological injuries associated with child sexual victimization. Finkelhor and Browne believed that by understanding these core dynamics, one could anticipate and understand the origin of psychological reactions to child sexual abuse, with a child’s manifestation of symptoms categorized by one or more of the dynamics described. The child’s own psychological predispositions, environment, and type of trauma affect how the child reacts to the different dynamics. This theory helped focus research presented later describing the childhood and long-term psychological sequelae of CSA. When reviewing the effects of CSA, it is useful to consider which traumagenic dynamics are most salient to the individual child’s reaction.
Traumatic sexualization refers to the changes that occur in the child’s feelings and attitudes toward sex and sexuality. Often when children are victims of CSA, they are rewarded, taught misconceptions about sexual behavior, or are conditioned to perceive sexual activity with negative emotions or memories. This results in increased knowledge of sexual issues and premature and distorted sexualization. Sexually abused children sometimes demonstrate increased sexual behaviors and interest or avoidance and sexual inhibition.
Betrayal is experienced by many CSA victims in two principle scenarios. First, if the CSA is intrafamilial, the perpetrator, a caregiver on whom the child depended, causes direct harm to the child. Second, in either intrafamilial or extrafamilial CSA, when the child discloses the abuse, nonoffending caregivers either cannot believe the child or change their attitude toward the child. Again, the child feels betrayed by someone that they previously viewed as a protector with whom the child felt safe and secure. A lack of trust in the caregiver can be an impetus for depression, extreme dependency or mistrust, anger, and an inability to judge trustworthiness in others.
CSA victims experience stigmatization when they are blamed for the abuse and told to keep the abuse secret by either the abuser or nonoffending caregivers. Furthermore, victims are given the impression, either directly or indirectly, that they are “damaged goods.” The child learns to feel shame and guilt as a result of the abuse and often views himself or herself as different from others, leading to either isolation or maladaptive behaviors that originate from an increased need for acceptance. A significantly stigmatized child might even engage in self-mutilation or suicidal behavior.
The dynamic of powerlessness , or lack of control, results from the child’s inability to prevent the invasion of his or her body, lack of efficacy in stopping the abuse, and the continual fear that many children experience in CSA. This dynamic can be exacerbated if attempts to disclose are not believed. Powerlessness can result in anxiety, fear, and lower self-esteem or an increased need for control and identification with the aggressor.
Risk Factors
Given the ubiquitous nature of CSA in the United States, where in any given year 1 out of every 12 children is sexually abused, all children are at some risk for becoming a victim. However, some retrospective data are available to help guide the practitioner in identifying qualities that make a patient more at risk for sexual abuse.
The first and most well-documented risk factor is gender, with girls being victimized disproportionately more often than boys in both intrafamilial and extrafamilial CSA. Furthermore, it appears that children are at greatest risk to being a victim of sexual abuse when they are between the ages of 8 and 12.
Parental issues, such as conflicted parent-child relationships, living apart from one’s parents, parental mental illness or substance abuse problems, and marital conflict have all been associated with a higher risk of CSA. Experiencing other forms of abuse, either physical or emotional, also increases one’s risk for sexual abuse. Other studies that have only looked at risk factors for women have found that parental drinking and a perception that one’s parents were rejecting rather than loving were risk factors for CSA. Maternal history of CSA is also a risk factor for daughters to be sexually abused, which has led some to speculate that there is an intergenerational transmission of risk through either psychological or environmental factors. Furthermore, when a mother has both a history of sexual abuse and drug use, the co-occurrence of these two risk factors significantly increases the risk that her child will be a victim of sexual abuse.
Children with developmental disability are more at risk for CSA. Specifically, studies have shown that children with mental retardation, behavior problems, and developmental disability have a higher rate of abuse, which may be an underrepresentation of the true rates of abuse, given the difficulty or inability to disclose among disabled children. Disabled children tend to be abused earlier than nondisabled children. Overall, disabled children have been found up to three times more likely to be sexually abused than their nonabused peers.
Of note, socioeconomic status and ethnicity have not been consistently or strongly associated with risk of CSA, indicating that CSA transcends ethnic and economic lines.
Sexual Behavior
Children’s sexual development begins in early childhood and continues through adolescence. Abnormal sexual behavior in a child can be a symptom of increased stress on the child. This stress can arise from a number of origins, including but not limited to major life changes, family dysfunction, and being a victim of abuse. Child sexual development can be quite distressing to parents, making sexual behaviors a common concern in pediatric visits. Furthermore, many parents are concerned that a child who is asking questions of a sexual nature or engaging in sexual activities such as masturbation might be a victim of CSA. It is up to the clinician to be aware of what constitutes normal vs. abnormal and developmentally inappropriate sexual behavior, and to understand that although approximately one third of victims of CSA demonstrate increased sexual behavior, precocious sexual behavior may have other origins.
William Friedrich contributed much to our understanding of sexual behavior development in children by studying sexual behavior in victims of sexual abuse in comparison to other groups of children. Friedrich developed the Child Sexual Behavior Inventory (CSBI), a scale that compares the sexual behavior of normal, psychiatric, and sexually victimized children between 2 and 12 years of age. Friedrich’s work demonstrates that normal young children exhibit sexual behavior and that their sexual behavior increases until about the age of 5 or 6, at which point observed sexual behavior significantly declines until right before adolescence. Specifically, Friedrich observed that it is developmentally appropriate for 2- to 5-year-olds to be sexually intrusive, standing too close to others, touching the breasts/genitalia of themselves or others, or attempting to look at other’s genitalia. Furthermore, even though the overall rate dropped, Friedrich noted that greater than 20% of both boys and girls continued to touch themselves in private and look at others while undressing from the ages of 6 to 9 even though they are considered to be in their “latency” stage of sexual development. Finally, by the time children reached 10 to 12 years old, sexually intrusive behavior had greatly decreased and the only normative sexual behavior was being very interested in the opposite sex.
Age-inappropriate sexual behavior is strongly associated with CSA. However, physical abuse, neglect, exposure to domestic violence, excessive life stress and exposure to family sexuality can also result in inappropriate sexual behavior. Among preschool-age children, changes in sexual behavior are more common because of a lack of understanding concerning social sexual norms. However, only one third of preschool-age CSA victims demonstrate abnormal sexual behavior.
There is some evidence to suggest that age-inappropriate sexual knowledge and emotional reactions might be more specific markers for CSA among young children. When children learn about sex and sexuality in the context of a strong emotion-evoking experience such as CSA, sexuality becomes part of their knowledge base. This is in contrast to nonabused preschoolers who lack sexual knowledge and accompanying emotional reactions. Therefore, when asked about potentially sexual topics such as genitals or nudity, or when shown pictures of people interacting in potentially sexual ways, nonabused children respond naïvely. The CSA victim, however, is more likely to demonstrate knowledge of sexual behavior and function that is beyond their developmental stage. In the CSBI, inappropriate sexual knowledge is one of the most distinguishing factors between sexually abused and nonabused children.
Short-Term Effects
Victims of CSA show a variety of short-term psychological outcomes. These outcomes are quite varied in nature and are most likely dependent on a number of factors including the age of the child, the type and duration of the sexual abuse, the other types of abuse that the child has endured, and the relationship of the child to the perpetrator. Protective factors, such as having a supportive and stable family, feeling safe, and having access to resources, can also play a role in the manifestations of psychological outcomes of sexual abuse. Finally, a large percentage of children, as high as 40%, will have no discernable changes in their affect or behavior following confirmed sexual abuse. This lack of symptomatology, which has been called the “sleeper effect,” does not mean that the victim will never have any short-term psychological effects of the abuse, with as many as 20% of these children being positive for psychological morbidity at 12 to 18 months’ follow-up. This process of a “sleeper effect” seems to occur more often with children who are victims of less severe forms of CSA.
In New Zealand, a longitudinal study looked at factors that correlated with victims of CSA either having symptoms later in childhood or being symptom free from their traumatic experience. The study demonstrated that with increased severity of sexual abuse (i.e., physical restraint or penetration), there was a linear association with increase in emotional and behavioral symptoms. They further observed that there was a statistically greater chance for adjustment problems if the victim was younger than 10 at the time of the abuse, if there was less paternal care and if the victim’s peers engaged in substance abuse. Interestingly, the study found that there was no significant association between adjustment outcomes and intrafamilial vs. extrafamilial abuse, gender of the victim, maternal or paternal protection, or peer attachment. In their cohort, by the age of 18, nearly 25% of all victims of CSA had no discernable adjustment symptoms.
Maternal relationships tend to impact the manifestations of CSA. In one study, there was a direct correlation between the quality of the mother-daughter relationship and the development of internalizing and externalizing symptoms in a group of sexually abused girls. Furthermore, family adaptability and paternal response to abuse have been related to the severity of behavior problems after the discovery of CSA. As will be covered in greater detail in the treatment section of this chapter, parents not only affect the manifestations of CSA, but are important to the effectiveness of treatment as well.
Dissociation, which Summit and others have observed in victims of CSA, recently has been seen not just a symptom of sexual abuse, but also a mediator of psychopathology related to sexual abuse. It has been well established that victims of CSA on average score higher than norms on child dissociative scales. This means that in general, victims of CSA experience disruptions in the normally integrated functions of consciousness, memory, identity, and perception of the environment, even though they may not meet full criteria for dissociative disorder. It has been shown that unlike physical abuse, dissociation is significantly associated with sexual abuse. Further analysis demonstrates that in areas such as increased internalizing and externalizing problems, increased psychiatric illness scales and increased suicidality, dissociation was a significant covariate; when dissociation was controlled, the significant effect of sexual abuse disappeared, indicating that dissociation can be a common adaptation in symptomatic victims of sexual abuse.
Early Childhood (2-6)
In early childhood, children known to have been sexually abused have been observed to have a variety of changes in their behaviors, and these changes are generally the same whether or not the perpetrator is intrafamilial or extrafamilial. Sexually abused children in this age range show higher rates of inappropriate sexual behaviors, demonstrate lower intellectual abilities, and often show evidence of PTSD compared with nonabused children. Three- to 6-year-old CSA victims tend to express more depression and anxiety and to exhibit more symptoms of social withdrawal compared with nonabused children. These children tend to overrate their social competence compared with their peers. Younger children tend not to exhibit increases in nonsexual-related behaviors compared with norms unless there are other stressors in the home such as father’s use of alcohol or a maternal history of sexual abuse.
Middle Childhood (7-12)
Latency-aged children continue to exhibit increased symptoms of depression, anxiety, and PTSD. This age group has increased rates of suicidal ideation. Increased sexual anxiety and inappropriate sexual behavior are also noted in this age range, including sexual aggression. In this age range, the child’s coping strategies and family/peer support appear to play a significant role in the psychological manifestations of their abuse. Also, unlike younger children, children in this age group tend to underrate their social competence. Although no clear evidence of eating disorders has been reported, some studies suggest that body and weight dissatisfaction as well as purging and dietary restriction can begin in this age range among victims of CSA.
Adolescence/Young Adult (13-18)
The psychological effects of child sexual abuse on adolescents are the most studied of the different developmental periods. Just as in the previous developmental periods, depression, anxiety, and PTSD are well documented within this age group. Adolescents experience higher rates of depressive symptoms and lower global self-worth compared with younger children, and the risk of having an affective disorder appears to be strongly related to the severity of their abuse. Suicidal ideation and completed suicide are increased among victims of CSA, with males having more suicidal tendencies than females. Self-harm was also noted to be four times higher among adolescent females compared with controls.
Negative beliefs and emotions about one’s self have been shown to be highly correlated with the symptoms and severity of PTSD in victims of CSA. Specifically, anger, shame, and humiliation have been directly linked to CSA. This negative system of emotions is believed to be based on the feeling of being attacked and defeated, leading to lack of self-worth and self-efficacy. Victims of CSA then tend to engage in activities that reinforce low self-worth, perpetuating negative internalized emotions. The associated sexual behavior reported in this age group is no longer defined by the CSBI observed ratings scales that deal with inappropriate sexualized behavior, but rather come under the definition of risky sexual behavior. For example, adolescents who have been sexually abused are more likely to have had intercourse, have more frequent intercourse, and report an earlier age of onset of intercourse than their peers who have not been sexually abused. , Furthermore, there is a higher rate of sexually transmitted diseases, including HIV, and teen pregnancy. Although many of the sexually related co-morbidities can be linked to increased sexual activity and risky sexual activity, some speculate that the increase in pregnancy is multifactorial and includes a desire by some female victims of CSA to conceive. CSA victims who become pregnant as adolescents have an increased risk for pregnancy complications including preterm birth. CSA victims also report having more difficulty establishing and maintaining relationships within their peer groups. ,
Sleep disturbances are more common in victims of CSA compared with controls. Although sleep disturbances (insomnia, hypersomnia) are a common symptom for other psychiatric illnesses such as PTSD and depression, it has been shown that in adolescence, problems with sleep are independently associated with victimization.
Sexually abused teens also have a higher rate of antisocial traits and other nonsexual behavior problems. These documented findings include being greater likelihood to run away from home and gang affiliation. There is also clear evidence to suggest an association between disordered eating and CSA among adolescents. These behaviors include frequent dieting, binge eating, and preoccupation with weight.
Substance abuse is higher among adolescents with a history of sexual abuse. Alcohol abuse, including binge drinking, is also higher among CSA victims. Victims tend to start using substances earlier, use more frequently, use a greater variety of substances, and report more reasons for using substances than their peers. The risk of substance abuse among adolescents increases even more if one is a victim of both physical and sexual abuse. Reasons for using include coping with previous traumatic memories and emotional problems. In general substance abusers with a history of abuse are more likely than nonvictims to express a specific reason why they abuse substances.
Although some of the relationships between psychological and behavioral co-morbidities with CSA appear clear, the manner in which they are related is far more complex. This is demonstrated by the difficulty in replicating identified relationships in subsequent studies. Adverse childhood experiences such as physical abuse or family dysfunction can increase the risk of adverse psychological outcomes. Sometimes children demonstrate minimal to no effects of CSA when strong family support or internal resiliency is demonstrated. Therefore, many in the field wonder about the mechanism by which CSA leads to its outcomes. To that point, many have begun to look at commonalities that could be used to better predict psychological outcomes associated with CSA. Some have taken a biological approach, looking at serum markers of different hormones associated with psychological distress such as cortisol levels and ACTH. Others have used imaging techniques to compare the brain volume, blood flow, and function in abused and nonabused children. Finally, others have developed theoretical psychological models that attempt to break down the factors that increase or decrease the rate of psychological distress associated with CSA.
Child Sexual Abuse and Psychiatric Diagnosis
A 1985 effort to describe the characteristics of sexually abused children that might be useful for distinguishing them from nonsexually abused children highlighted the limitations of DSM-III psychiatric diagnoses to adequately describe the diverse psychological and behavioral changes observed among sexually victimized children. Subsequent work focused upon the common reactions among victims of interpersonal violence and exploitation including child sexual abuse, rape, and intimate partner violence. Van der Kolk and others developed the concept of complex PTSD to better describe this population. This more pervasive impact of interpersonal victimization is described in the “Associated Features and Disorders” section on PTSD in DSM-IV as follows:
“The following associated constellation of symptoms may occur and are more commonly seen in association with an interpersonal stressor (e.g. childhood sexual or physical abuse, domestic battering): impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs; hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual’s previous personality characteristics.”
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
