Child sexual abuse: prevalence, effects, and prevention

CSA

Child sexual abuse is a major social and familial issue that has impacted the lives of many people throughout the world. Although the maltreatment of children in any form is deplorable, sexual abuse of children has a particularly cruel stigma. The purpose of this discussion is to examine the impact sexual abuse has on victims and the interventions for victims. The discussion will begin by defining child sexual abuse.

Defining Child Sexual Abuse

According to the Encyclopedia of Childhood and Adolescence, sexual abuse is defined as sexual contact with an adult or older child through coercion or deceptive manipulation at an age and stage of development at which they do not possess sufficient maturity to understand the nature of the acts and therefore to provide informed consent. In most cases physical force is not necessary since the perpetrator is likely to be someone with whom the child has a trusting relationship and who is in a position of authority over the child. Sexual abuse can range from requiring the child to view pornographic material (i.e., movies and magazines) to having the child commit sexual acts (Selby, 2008).

Prevalence of Child Sexual Abuse

The American Psychological Association reports that

"precise statistics on the prevalence of child and adolescent sexual abuse are difficult to collect because of problems of underreporting and the lack of one definition of what constitutes such abuse. However, there is general agreement among mental health and child protection professionals that child sexual abuse is not uncommon and is a serious problem in the United States."

With this understood large population-based surveys have found that between 15% and 25% of the general female population have been sexually abused (Molnar et al. 2001, Walker et al. 1999, Cloutier et al. 2002). In addition "Estimates of sexual abuse are even higher when surveying female patients with unexplained or functional pain (e.g., irritable bowel syndrome [IBS], pelvic pain of unknown origin), psychiatric illness, and substance abuse (Leserman 2005)." Statistics also show that population-based surveys have repeatedly shown higher rates of sexual abuse among women when compared to men . However, research indicates that Whites and Blacks tend to have the similar amounts sexual abuse prevalence have (Tjaden 1998). However research has shown that cases of sexual abuse tend to be higher amongst Native Americans (Tjaden 1998). Additionally "two population-based studies showed no differences in education between abused and nonabused, whereas 3 large probability surveys showed that sexually abused had more education, and 1 showed they had less education (Wise et al., 2001; Leserman, 2005)."

Indeed sexual abuse is a widespread problem that can have devastating results for the victim and society as a whole. The following paragraphs will discuss the impact of child sexual abuse.

The Impact of sexual Abuse

Sexually abused children can suffer from wide range mental, emotional and physical issues. These issues are often first apparent with the context of school performance. Children who have experienced abuse may experience problems in school associated with attention, focusing and behavioral problems. Dowling & Mullers (2008) explain that long-term effects include post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), and behavior problems including withdrawal, sexualized behavior and acting-out. Issues in relation to depression, anxiety, suicidal ideation, bipolar disorder, violence and substance abuse also follow child sexual abuse (CSA).

According to the American Psychological Association, re-victimization is a common behavior exhibited by children who have been sexually abused. Although sexual abuse is an experience and not a diagnosis, the experience of being sexually abused may lead to some diagnosable disorders. The difficulty associated with maturation is compounded when children have been subjected to abuse. It is extremely necessary for practitioners, researchers, educators and parents arm themselves with knowledge of signs and symptoms of sexual abuse. The effects of sexual abuse are long lasting and often require intense therapy and treatment for children to heal and over come the trauma associated with sexual abuse.

In addition to psychological issues associated with sexual abuse, there are also physical issues that can occur as a result of sexual abuse. According to Leserman (2005) over the past ten years many studies have found that people who were sexually abused as children have higher incidences of physical health problems (907). In some cases these physical problems occur long after the abuse has occurred (907).

Leserman (2005), also explains that studies involving clinics, HMOs and primary care facilities have found links between sexual abuse and higher levels of reported gastrointestinal problems and abdominal pain (McCauley et al. 1997;Walker et al. 1999;Hulme 2000). In fact in most of these studies people who were sexually abused reported gastrointestinal problems at twice the rate of people who had not been sexually abused. In fact as early as a decade ago McCauley et al. (1997)

"found that among women who were abused inchildhood, 46% reported abdominal pain, 36% had diarrhea, and 39% had constipation in the past 6 months compared with 28%, 24% and 26% of the nonabused, respectively. In a random sample of women HMO members, those with sexual maltreatment reported more nausea (8%) and abdominal pain (22%) compared with those with no maltreatment (4% and 14%, respectively); diarrhea and constipation did not differ between groups (Walker et al., 1997). In a random survey of Los Angeles women, the sexually assaulted had about twice the risk of reporting gastrointestinal symptoms (41%) such as vomiting, nausea, abdominal pain, diarrhea, and bloating compared with the nonassaulted (26%) (Golding 1994; Leserman 2005)

The author also explains that women who were sexually assaulted as children reporter greater incidences of painful sexual intercourse (dyspareunia), pelvic pain, painful menstruation (dysmenorrhea), vaginal infection, and other gynecologic problems (Leserman 2005). Studies have also found that women who were sexually abused were twice as likely to report pelvic pain and vaginal discharge when compared to women who had not been abused (Leserman 2005).

All of the aforementioned problems that can occur as a result of child sexual abuse are treatable. Given the proper interventions those that have been abused are able to cope with the stigma, psychological and physical problems that may arise. The following section of this discussion will focus on the interventions that are often utilized to assist people who have been sexually abused.

Interventions for victims

Indeed people who have been sexually abused suffer from various trauma, disorders and/or illnesses as a result of their abuse. There is no single intervention that serves as a cure all. As such individualized treatment is necessary in order to address the specific needs of each child. For this reason, there are numerous interventions that are commonly used to assist in the treatment of children who have been sexually abused. Treatment for these children can range from art therapy and play therapy, to group and individual therapy and cognitive behavioral therapy. The type of therapy used will depend largely on the type of behavioral, emotional, and mental disturbances that the child is experiencing. Another factor in the treatment selection is age and mental capacity of the child (Brown, 2005). A comparison and contrast of art therapy, play therapy, cognitive-behavioral therapy and pharmacologic therapy will be provided in the following paragraphs

Art Therapy

Art therapy has recently emerged as a viable type of intervention for victims of sexual abuse. It may be inclusive of any form of the arts including music, visual arts, acting and writing. Art therapy is believed to be beneficial for sexual abuse victims because it can assist in the reestablishment of self-esteem. According to Brooke (1994), the visual arts are particularly useful in the regard. The author explains

"To create something and ultimately confront that creation, even if it represents traumatic material, allows one to reabsorb the event in a restructured form.

Viewing these self-directed visual solutions demonstrates that internal chaos can be formed and redefined often without overwhelming the client. Self mastery, empowerment and assertiveness become possible as the ego recognizes victory over once elusive and frightening internal forces (Brooke 1995, 498)."

According to this assertion art therapy is useful in treating victims of child sexual abuse because it gives them the power to confront their fears through artistic expression. In other words art allows them the cathartic release necessary to confront the psychological issues that are present because of the abuse.

Art therapy can be used for the purposes of storytelling, short-term trauma resolution, in play therapy and forensic investigations (Liebmann, 2003). In addition art therapy is most often utilized with people who are dealing with Attention Deficit Hyperactivity Disorder, sexual abuse, Autism, medical art therapy, adolescent depression, eating disorders, bereavement, severe mental illness, addictions and many other situations (Liebmann, 2003). Art therapy is a unique way that children can express their thoughts and feeling and disclose some of trauma that was experienced as a result of their abuse.

As a result of having a limited vocabulary and an inability to articulate what has happened to them, it is often hard for children to discuss the details of their abuse. Art therapy gives an outlet, and meets the children on their level. Rankin (2003) affirmed that the purpose of art therapy is to address the major affects of trauma on the child's life. Additionally, Rankin (2003) stated that art interventions begin with self-management, then proceed with safety planning, telling the trauma story, grieving traumatic losses, self-concept and world view revision and finally ends with self and relational development. Treatment progress and outcomes will vary from patient to patient, as therapy is an individualized process.

Although the amount of empirical research regarding art therapy is limited, the use of art therapy has been confirmed as a means for victims to express how they feel and find some closure. Art therapy has also become a type of intervention that is used in combination with other interventions. With this understood, the preceding section of this discussion will focus on play therapy as an intervention.

Play Therapy

Play therapy is a long-established and highly effective treatment method used in working with children who are experiencing various conflicts, contrasting role expectations, or dissociated feelings (Weber, 2009). These concepts are enacted in play, and brought to conscious awareness by the therapist's comments (Weber, 2009). Play therapy is a very heterogeneous type of therapy that permits the therapist and patient to have a freedom of expression that is different from that of traditional counseling. Clinicians who utilize play therapy use a variety of props and settings when meeting with clients. Some of the items used include anatomically correct dolls, puppets, stories, sand boxes, toy cars and trucks, games, and various forms of art (Gil, 1991).

According to Crenshaw and Hardy (2007) the purpose of play therapy is to assimilate what goes on around the child into his or her present scheme of knowledge and assisting the patient in mastering self and the environment. Play therapy is also designed to assist the victim in overcoming the situation, increase relatedness and express feelings. As with other types of intervention, play therapy is also designed to improve self-esteem.

Like art therapy, play therapy is often yields high levels of success with children because it allows them the ability to express themselves in a form more conducive to their cognitive and developmental abilities. Traumatized children had more intense play, play disruptions, repetitive play, avoidant play behavior, and negative affect. Now that the research has examined art therapy and play therapy, the intervention known as Cognitive Behavioral Therapy will be examined.

Cognitive Behavioral Therapy

As one might assume, cognitive behavioral therapy (CBT) offers a combination of strategies from cognitive and behavioral theories. According to Nicholaichuk and Yates (2002), this treatment approach is based on the premise that cognitive and affective processes and behavior are linked, and that cognitions, affect, and behavior are mutually influential. The National Association of Cognitive Behavioral Therapist offers a simple explanation for CBT: according to McGrath et al. (1998), CBT typically includes targeting deviant sexual behavior and interests and a wide range of social skills/relational deficits. In addition CBT addresses the issue of cognitive distortions, which permit the offender to justify, rationalize and/or minimize the offending behavior (McGrath et al., 1998).

As it pertains to the use of CBT in addressing the issue of child sexual abuse, the United States Department of Health and human services has developed and implemented a Cognitive Behavioral Therapy intervention specially designed for Child Sexual Abuse. According to a report published by the government agency

"Cognitive Behavioral Therapy for Child Sexual Abuse (CBT-CSA) is a treatment approach designed to help children and adolescents who have suffered sexual abuse overcome posttraumatic stress disorder (PTSD), depression, and other behavioral and emotional difficulties. The program emphasizes the support and involvement of no offending parents or primary caretakers and encourages effective parent-child communication. Cognitive behavioral methods are used to help parents learn to cope with their own distress and respond effectively to their children's behavioral difficulties. This CBT approach is suitable for all clinical and community-based mental health settings and its effectiveness has been documented for both individual and group therapy formats ("Cognitive Behavioral

Therapy for Child Sexual Abuse")."

This particular program is designed to assist abuse victims from the ages of 3 to 18 who suffer from post traumatic stress disorder ("Cognitive Behavioral

Therapy for Child Sexual Abuse"). The program can be used in private or public clinics ("Cognitive Behavioral Therapy for Child Sexual Abuse"). The program has proved to be a successful intervention fro children of all races and ethnicities regardless of socioeconomic backgrounds. In most cases those that participated in the program were treated at medical school campuses and public clinics. However, this particular intervention has been implemented by therapist in community setting ("Cognitive Behavioral

Therapy for Child Sexual Abuse").

The report further explains that intervention is composed of parallel sessions involving the child and the nonoffending parent(s), in addition to joint parent-child sessions during other therapy sessions. Also, the treatment interventiion can be effective with 12 sessions. This form of intervention has also been utilized in both groups and individual sessions. The goals of the treatment consist of educating the children as it pertains to child sexual abuse and healthy sexuality. This intervention also teaches children how to cope with their feelings. To this end children are taught various techniques including relaxation, expression of emotion, and cognitive coping. The intervention is also geared toward assisting children in processing the traumatic memories and reminders they may encounter. Children are also taught how to protect their bodies from sexual predators.

Additionally "Parents are also provided with behavioral management training to strengthen children's positive behaviors while minimizing behavioral difficulties ("Cognitive Behavioral Therapy for Child Sexual Abuse"). Joint parent-child sessions are designed to help parents and children practice and utilize the skills learned, while also fostering more effective parent-child communication about the abuse and related issues ("Cognitive Behavioral Therapy for Child Sexual Abuse")."

The report also explains that outcomes of this intervention have been positive. According to the report those who participated in the program experience a 41% decrease in depression levels among children and a 23% decrease in the amount of acting out demonstrated by the children ("Cognitive Behavioral Therapy for Child Sexual Abuse"). The report also explains that there was a 45% increase in the children comfort level as it pertained protecting their bodies against sexual predators ("Cognitive Behavioral Therapy for Child Sexual Abuse"). In addition, to the positive outcomes of children, parents also experienced positive outcomes. For instance there was a 26% decrease in the emotional distress of parents and a 45% decrease in the parents though concerning the abuse that their children had endured. • 63% reduction in children's PTSD

symptoms

CBT can be used in family-based, group, and individual treatment settings and at varying developmental levels. CBT empowers adolescent clients by giving them a voice in setting treatment goals that is equal to that of their parents and by teaching them to better regulate their own thoughts and feelings by means of psycho education Ehrenreich et al. According to Kendall (2000), CBT can be either therapeutic, preventative, or enhancement focused. Enhancement-focused interventions are focused on improving quality of life, rather than targeting individuals who are at risk for a problem or who have a problem (Kendall, 2000).

Pharmacological Treatment

As a result of behaviors such as anger, depression, aggression and grief, that may be associated with sexual abuse; many physicians may utilize medication in order to stabilized and/or treat clients. Medications may also be utilized to treat co morbid conditions, such as attention deficit hyperactivity disorder, major depression, obsessive -- compulsive disorder, or posttraumatic stress disorder (Weber, 2009). Using medication for treatment of youths and adults who have gone through significant trauma has become a generally accepted practice throughout the world today.

There are several theorists who believe that many symptoms that arise as a result of sexual abuse occur due to chemical imbalances and/or changes in the brain. The medication prescribed would be used in order to treat specific symptoms, rather than treating sexual abuse. For example, Cohen et al. (2002) assert, children who suffer from post-traumatic stress disorder may experience over reactivity of the amygdala, over reactivity of the medical prefrontal cortex, elevated levels of dopamine, increased activities of the orepinephrine/epinephrine (adrenergic) system, elevated endorphine levels, dysregulation of the HPA axis, decreased hippocampal and corpus collosum size and low levels of serotonin. This statement speaks of the types of chemical imbalances that may occur and require the use of medication. It is important to note that the medication does not fix the problems, nor does it cure the patient. It only provides hormones that will help to balance chemicals in the brain that may bring on unwanted symptoms of abuse, such as depression, aggression, paranoia and agitation.

Comparisons and Contrast of Interventions

Play therapy, art therapy, cognitive-behavioral therapy and pharmacological therapies are all used to treat children who have been sexually abused. In order to determine which intervention will be used to treat a sexual abuse survivor, it is important for clinicians to become aware of various treatments. Knowledge of a variety of interventions enables clinicians to compare the components of one intervention against that of another and chose what works best for the client.

Play therapy and art therapy are similar theories. Play and art therapies are forms of therapy that are familiar and fun activities for children. These approaches take away the pressure that may arise when a child is forced to talk about and/or relive their abuse.

Because of their cognitive level of development, elementary school-aged children are unable to work through personal struggles through verbal expressions. Play therapy has been widely recognized as the developmentally appropriate way to therapeutically relate with children (Myrick & Holden, 1971). The same holds true for art therapy.

Contrasts

Although there are many comparisons that can be made as it pertains to the different types of interventions, there are also some contrasts. For instance, play therapy, art therapy, cognitive behavioral therapy and pharmacological therapy are all used to treat children and they are all different, respectively. Play therapy uses props such as dolls, trucks and blocks. Through play, therapists may help children learn more adaptive behaviors when there are emotional or social skills deficits (Pedro-Carroll & Reddy, 2005).