Therapeutic group intervention effectiveness for sexually abused preschool children

Validating the Effectiveness of Participation in a Time-Sensitive Closed Therapeutic Group for Preschool Aged Children Allegedly Sexually Abused

This paper will review existing research on allegedly sexually abused preschool aged children. The traumatic psychological effects of the abuse including low self-esteem, poor peer relationships, behavior problems, cognitive functioning and physical/mental health will also be evaluated.

The author notes the paucity of available material on sexually abused children. Very little therefore is known of the effectiveness of psychotherapy to assist in the treatment of the problems of this particular group of abused children - a population of 40 selected children with a mean age of 45, with their parents (either father or mother) and/or caregivers attending sessions in another session hall at the same time the children are undergoing therapy.

This proposed study will therefore focus on how mental health services are provided to preschool children with ages ranging between 4 and 6 who have been allegedly sexually abused and the extent to which poor social skills and low self-concept affect this population.

The sample will be from Bethesda Alternative, a non-profit agency in Norman that specializes in the treatment of sexually abused children, their non-offending caretakers, and the suspected perpetrators of sexual crimes against children.

The information acquired will be integrated into sexual abuse literature and provide additional insight into the delivery of mental health services to the allegedly sexually abused preschool children.

Chapter I

INTRODUCTION

Childhood sexual abuse is one of society's major problems today. It is not germane to a particular race, gender, age or socioeconomic status. In far too many cases, it will be noted that children who were sexually abused in their early years identify with the abusers and become abusers in themselves in later years. They also indulge in many deviant behavior. The effects of childhood sexual abuse are thus magnified as more adults disclose an early sexual abuse history.

Because of these disclosures, concerned educators, policy makers, psychiatrists, clinicians, nurses, guidance counselors and religious groups have agitated for an effective treatment for sexually abused children. This is clearly an indication of the need for the problem to be addressed in a more dynamic, more effective and more thorough fashion.

What indeed is childhood sexual abuse? In this paper childhood sexual abuse will be defined as any "forced or coerced sexual action or behavior imposed on a child or any sexual activity between a child and a much older person whether or not obvious coercion is involved."

The sexual behavior may include non-contact abuse, including exposing the child to indecent suggestions and exhibitionisms and/or contact abuse, including any sexual touching, genital contact, involving either the perpetrators or victim's genitals and/or abuse involving actual penetration." It may also mean inappropriate sexualized behavior, sexually acting out, characterized by a feeling of low self-esteem, and regressive behavior in the child victim.

Because of the increased number of sexual abuse cases among preschool aged children, clinicians, teachers, parents, school programs are intensifying and expanding their activities and capabilities to address this issue.

There is empirical evidence that the rate of spontaneous recovery is high following the disclosure of sexual abuse. (Benther Williams and Zetzer, 1994) although other authorities dispute this recovery frequency (Adams, Tucker, 1984).

Results are often described as having consequences that can be felt throughout an individual's life (Newberger and Devos, 1988). The validity of current treatments need to be established.

Depending on the criteria used, the prevalence of sexual abuses ranges from 150,000 to 200,000 cases reported per year (Reid-Alter, Gibbs, Lachenmeyer, Sigal and Massoth, 1996). Treatments tend to focus on the negative behavior of the sexually abused child. Major treatment modalities used for the sexually abused child include cognitive behavior therapy, psychodynamic therapy, play therapy and various allied therapies. These common treatments attempted to reduce negative behaviors and assist the child to relive the experience in a supportive environment. These interventions however fail to treat concomitant deficits associated with the effects of sexual abuse on the preschooler. The so-termed co-marked deficits include low self-esteem, inadequate special skills, labile mood, limited frustration tolerance, temper, tantrums and outbursts, chronic school failure and academic underachievement that often results in an emotional and behavioral disorder (EBD) label. Evaluative reports on treatments for sexual abuse among preschool aged children have focused on the aforementioned treatment modalities associated with the individual experience.

Research studies related to sexual abuse make extensive references to the difficulties faced by preschool aged children who have allegedly been sexually abused. Children who have been sexually abused tend to suffer from low self-esteem, have difficulty with impulse control issues and have difficulty developing poor relationships.

Similarly psychotherapy has been found effective in the treatment of low self-esteem, impulse control and poor peer relationships. In contrast, there is very little research material in psychology on the treatment of children, specifically pre-school-aged who have been allegedly sexually abused. This in spite of the fact that psychotherapy has been found effective in intervention modalities. There is very little available research on how mental health treatment is provided to preschool aged children.

Purpose of the Study

It is the purpose of this study to evaluate the effectiveness of a structured, time sensitive, closed therapeutic program for allegedly sexually abused pre-school children whose median age is five years. Despite the psychological aspects of the problem, there is no treatment study which has been conducted which evaluated the effectiveness of the therapy which has been applied to this particular population of preschool children allegedly sexually abused. This study therefore is intended to provide the preliminary investigation concerning the delivery of mental health services to a structured, closed, time sensitive preschool-aged group and the benefits of psychotherapeutic treatment for low self-esteem, impulse control and poor peer treatments.

Statement of the Problem

What is the nature and process of mental health counseling for preschool aged children who have been allegedly sexually abused? What behavioral changes occurred in the children upon completion of the structured, time sensitive, closed therapeutic program?

Methodology

The independent variables will be measured by changes in social skills, self-esteem, impulse control and sexualized behavior.

An empirical analysis will be used by the researcher to describe the nature and process of the counseling mental health program. She will describe in detail each aspect of change in behavior in each of the 40 child participants in the program. A description of the sessions held for parents/caregivers will also be done by this researcher and the corresponding assessment will be included.

A structured interview will be presented and analyzed to determine the appropriateness for participation in the program.

To validate the effectiveness of the VOCA-funded mental health therapeutic program, the researcher proposes to use the Chi Square -Multiple Samples method.

Chapter II

REVIEW OF RELATED LITERATURE

When a child acts in a disorderly, disconnected manner, his nervous force is under a great strain." (Montessori, 1949 p. 64)

Over the years, Maria Montessori has studied children, observed them, cared for them, formulated ways by which they can best learn skills and enhance them. When the children's actions and attitudes are discordant, when he is confused, disoriented, when he doesn't know what to do, then he is laboring under great stress and his parents, caregivers, teachers must try to ferret out the reasons behind the unseemly, unusual actions and attitudes and institute ways by which he can be brought back to normalcy.

More often than not, the uncoordinated child has been traumatized by an event or incident he is powerless to cope with. The parent/caregiver/teacher/clinician should provide a framework to better recognize and manage this impact of a traumatic incident or event.

Marsha L. Shelov (Children and Trauma; the Role of Parents) thinks that a very important point to consider is how we can identify children who have actually experienced such a trauma. For her a traumatic situation "occurs when sudden or extraordinary external event over-whelms a child's capacity to cope, producing the inability to master or control the feelings caused by the event. The condition in which the child is exposed to a terrifying event either as a victim or a witness can cause intense feelings of fear and helplessness, an emotional terror. The trauma may be a one-time event or the result of a repeated exposure to traumatic stressors.

Sexual abuse is an example of a traumatic experience. The child's mind become flooded with impressions of both the attacker's aggression and the anguish of the victim's emotional and physical suffering. The severity, duration and proximity of an individual's exposure to the traumatic event are the most important factors affecting the child's experience of the event.

Children's responses to trauma:

According to Shelov, "the first reaction of the child is often an increased sense of fear of further immediate trauma and thus the loss of a child's usual sense of immunity to such danger. Instead of facing life with a typical sense of openness, a traumatized child may retreat defensively. Mild or severe, a traumatically frightening experience matters deeply to a child and even when the parents wish to forget what has happened to their child, the child remembers."

Shelov says that the healing process calls for a child to remember over and over, detail by detail. Children remember through retelling, through play, and through their post traumatic fears, dreams and unusual behaviors. All of these varied forms of remembering are indications of the trauma's force but which are also part of the child's internal struggle to heal and master the trauma.

Shelov stresses that trauma causes psychological wounds. Healing from the wounds requires time and can be influenced by understanding parents and other caregivers. Different children manifest different signs of psychological trauma. There is a correlation between particular aspects of the trauma itself and all that is special and characteristics about the child to bring about a child's particular response to the trauma. Parents and caretakers should be very observant during the following weeks and months to discover the effect of the experience on the child. We must remember that young children may not be able to discuss what has happened and may communicate what they have experienced through play and changes in normal routine behavior.

Children don't react to psychological trauma in the same way and at the same time. Some children react to psychological trauma immediately, some within a few days after the assault. However, some children don't show any signs of immediate reaction; they appear untouched, unaffected, unfazed, they appear to show no signs of fear. Some studies show though that these unaffected children will manifest distress signs as delayed reactions over time. Children's distress will appear in unusual behavior and reactions, some of which are the following:

Fears and anxieties. Persistent fearfulness, specific phobias, unspecified fears, heightening distress over separation from caretakers, and sudden and swift reaction to loud noises

Behavioral regression. Children's reaction are manifested by a temporary setback in skills and behaviors expected of their age level. They may show lack of developmental skills, they tend to lose control over aggression and inability to control themselves.

Children may imagine unwanted images and thoughts. They may repeatedly describe disturbing images of the trauma in their minds.

Inability to enjoy pleasurable activities

Repetition in describing the trauma, replaying the trauma

Withdrawal from parents, caretakers, friends, playmates

Sleep-related difficulties

Changes in personality

Complaints of aches and pains

Accident-proness and recklessness.

These are signs of trauma and stress to watch out for. These may be the only indicators of a child's distress. The child's behavior indicates a problem that the child is trying to cope with. The child's success in coping with the trauma is often dependent on a parent's or caregivers ability to accept the symptoms of the problem and remedy them. Once the behavior and attitudes are understood and accepted, the child's recovery becomes clearer and easier.

Shelov insists that the kind of trauma generally has a direct impact on the severity of a child's reaction. Single traumatic events of short duration that do not involve interpersonal violence or threat often have less serious and brief effect than events that result in physical harm, lasting disfigurement, major changes in the child's family and life circumstance or other constant reminders of the trauma.

Shelov describes the healing process that should be prescribed for a child who feels that the mantle of protection on his being has been destroyed. For a while he loses his prior sense of security from harm. It is not just fantasies and bad dreams that haunt him, it is real life that must be feared. Threatened children undergoing a psychological trauma look towards his protective parents and trusted adults for reassurance and support. Sometimes, parents too are traumatized and they feel that they have little to give to the child by way of reassurance and support. They first need to be treated themselves.

Shelov lists down ways by which children may be helped.

1. Following a child's encounter with trauma, for many months, children need lots of comforting and reassurance. Infants and young children need to be nursed, rocked-cuddled, sung to. They need stories to listen to and to quickly read. The child needs to return to those comforting rituals that soothed it when it was younger. Older children's needs and likes must be considered when parents try to comfort them. Parents know what is particularly soothing to their child. Children need to be calmed and special comforting at bedtime is called for, maybe an extra story, a massage, a nigh light, imagining good dreams to have, a favorite music on a tape recorder or favorite stories. Comfort and reassurance are needed by children having nightmares. The source of terror should be directly addressed and eliminated.

2. Children should be given basic information about what happened to them. Information that could be understood by the child told simply and honestly, questions answered directly and truthfully.

3. Tolerance for regression behavior. Parents' response when a child regresses needs to match the needs of the child. The child should be made to feel that the parents understand that the child is undergoing difficulty and that the parents and child can handle the problem together until the child is stronger again.

4. Respect a child's fears. The fears should be acknowledged, that they will be less frightening overtime and that you will be present to help them. There is the danger of giving a child's fears too much support. Out of fear and concern, parents can miss signs that the child is ready to move on. Finding the middle course between over-protectiveness and excessive expectations is the most difficult but the best route.

5. Children who are undergoing flashbacks and panic reactions can be comforted by immediate reassurance and education. Children must be brought to the present. The parents can talk to the child about the here and now, making the child feel that the danger is over and that she is not alone. Children should be reminded that they are safe now.

6. Opportunities should be provided about talking about feelings. Children very often exhibit strong feelings, many of them unpleasant and upsetting. Telling and talking about the unpleasant incident is definitely part of the healing.

7. Opportunities should be provided for play. Playing out the trauma is necessary for many children. Appropriate toys and props should be available to the child for play experiences.

8. Be ready for difficult behavior. Children's own controls fail them. They cry over little things, make angry demands, show more aggression and test limits and rules. It is difficult for parents to respond to this behavior. Parents should show understanding and caring while maintaining the rules and limits of the home.

9. Follow the normal routine as quickly as possible. Children find comfort when they returning to normalcy.

10. There should be physical outlets for children having difficulty in controlling their aggressiveness.

11. Focus on images of strength and survival. Both parents and children should be reminded of their strengths and competencies. Let them be reminded of difficulties they have overcome in the past.

When is the time to seek professional help?

There are definite signs that call for immediate professional help. Shelov lists them down as follows:

1. A child's post traumatic behavior endangers herself and others.

2. A child reacts to the trauma by talking about being dead, dwelling on the issues of death and dying or threaten to commit suicide.

3. The child loses all prior grasp on the line between fantasy and reality.

4. There are disruptions in daily life and age-appropriate behaviors.

Indicators which can be expected during the initial stage of coping with trauma become causes for worry if they persist or intensify. The following behaviors lasting beyond six weeks are reasons for seeking professional help:

1. The child continues to experience extremes of fear, nightmares, flashbacks, and separation anxiety.

2. The child's regression to the behavior of a younger child shows no sign of decreasing over time.

3. The child continues to experience more than one nightmare per week or shows no decrease in other sleep disturbances originating at the time of the trauma.

4. There is no decrease in social withdrawal, listlessness or lack of pleasure in routinely enjoyable activities over six weeks.

5. The child complains continuously of physical pain or illness for which no medical explanation can be found. This can mean underlying unexpressed emotional pain.

6. A child continues to undergo vivid terror in response to trauma-related sensory triggers with no decrease in intensity or frequency of these reactions.

7. A child's distractibility interferes with attention and learning at school.

8. Overall changes in the child's personality dating from the time of the trauma that are dramatic and worrisome to parents and others.

9. The child's post-traumatic reaction or behavior even if mild, is particularly upsetting or bothersome to the child.

Time is of the essence in seeking professional help. The earlier the traumatized children go for professional help, the better the chances that these children will benefit from the help. The importance of early professional intervention is related to children's internal process of healing from trauma. Immediately after a trauma, disturbing and confused memories and feelings are fully available to a child. In time, the child should be able to resume normal functioning. Very often, the children should find ways to encapsulate or isolate the disruptive aspects of the trauma over time, perhaps pushing them to a dark corner of the psyche where they will not have to face them so often. Children are not aware that they are doing this, pushing the trauma into a corner of their being. This gives them some belief from the immediacy of disruptive images and feelings. Parents too notice the child distancing himself from the trauma and feel relieved that a child is "forgetting" about it. It is important to remember that most children do heal from traumatic experience. There is always help available and seeking the help of experienced professionals can provide assurance and treatment.

Fortunately, most children do not undergo traumatic experiences but parents should be alert to the subtle exposure to trauma from television, newspapers, magazines which show frightening experiences from natural disasters, child abuse and child violence. Young children should be shielded from this and older children need to have help in putting these events in the right perspectives.

Beverly James in her book Treating Traumatized Children provides specific guidance and tools for treating children who have been traumatized by physical and sexual abuse, other forms of child abuse, disaster, divorce or witnessing violent events.

James assesses the impact of trauma and develops specific treatment plans. She outlines creative exercises and techniques to guide clinicians to join children in slowly and carefully reviewing their experiences and helping them understand and accept their feelings related to the trauma. James makes use of art, play, and drama techniques presented in a sophisticated yet straightforward manner, very useful to clinicians with specialized training in these techniques or those using them for the first time.

Therapists are singularly challenged when the traumatized event has been deliberate such as that which occurs in sexual abuse. Situations like this calls for knowledgeable practice by a seasoned psychotherapist who will not send out improper messages to the child or to his caregivers.

According to James one needs to develop a relationship with the child, thus deliberately take her back through her painful experience. Our natural inclination is to shield the child who must undergo a painful medical procedure. The clinician or therapist must act in an unnatural manner so that the child will experience a reality.

The basic principle which James proposes is that healing will not happen until the child has worked through the trauma. Repressing the trauma simply holds it in abeyance where it can easily surface again and cause bigger problems later. Doors should be reopened to terrible and frightening experiences to help the child go through the trauma and therefore exposes himself through the stories and descriptions of these events. Never should a child, his parents and caregivers get the feeling that even inured professionals cannot face the intensity and depth of the trauma that the child has suffered. The child must be made to feel that he is now in a safe environment in which he can face the realities of life, realize that he has survived and move on.

So that he can be effective and avoid inflicting greater harm, the therapist must 1) be equipped with a clear theoretical foundation; 2) have at his fingertips a very wide range of techniques he can draw from any moment; 3) be conscious of the commitment needed in time and energy; 4) be able to work sensitively and directly on the child's trauma while dissociating himself objectively from the overwhelming effects of the trauma and 5) be able to consult and learn from the experience and knowledge of trusted colleagues.

James provides readers and researchers with specific ways to deal with the child's trauma, some very simple, some very intense and serious. Techniques are outlined in a clinical framework intended to help the clinician understand the treatment needs of the children.

James urges the therapists and clinicians not to simply adopt but to study carefully what others have learned, blend those ideas with their own theoretical foundations and experiences, make adaptations to their own styles, skillfully apply what has been isolated, observe outcomes, and then decide whether or not to incorporate what they have learned into their store of knowledge.

Each child must be considered individually. Some are able to deal easily and heal fast. If the child is particularly sensitive and fragile, if early on in life he has experienced only deprivation of human ties, or some other deeply rooted emotional condition exists not directly related to the traumatic event, some measures may not work at all. But some children are stronger than others and can easily deal with life's difficulties. Some children have indeed benefited from life's challenges, some learn the art of compassion and emerge strong. Respect, acknowledge, and utilize a horrible event for the purpose of healing.

Traumatized children need the genuine care of committed professionals whose accumulated knowledge learning expertise and experience will facilitate the children's progress through their suffering, sot that they may accept their pain, their losses and gains and move on with their lives.

James' book may also be used for adults who were also traumatized during childhood. Adults may also reexperience their past as the helpless children they once were.

When we go to the nitty gritty of the subject, James' definition of trauma is culled from Webster's New Collegiate Dictionary. Trauma as paraphrased by James "is an emotional shock which creates substantial, lasting damage to an individual's psychological development." It also refers to overwhelming, uncontrollable experiences that psychologically impact victims by creating in them feelings of helplessness, vulnerability, loss of safety, and loss of control. Some emotional states may exist and be uncovered by a therapist. The child victim may exhibit severe psychiatric symptoms or may superficially appear symptom-free.

Research proves that the impact of trauma on a child may have lifelong psychological consequences, depending on the development stage of the child at the time of trauma, his coping abilities, and the meaning of the event to the child. Further research and studies reveal that we may expect new ways of treatment that will assist the clinician in working with children.

Critical Aspects of Treatment

The treatment of traumatized children requires special applications, James stresses. This has not been given special attention by clinicians. These aspects according to James are the following:

1. There is a need for the child to acknowledge and explore his pain while undergoing therapy so that he may integrate his experience.

2. A serialized course of treatment rather than one uninterrupted stretch of therapy is often needed. In this manner, he becomes responsive to developmental vulnerabilities that arise from the trauma.

3. The needs of the child cannot be effectively met by a clinician who works alone. He must be supported by the caregivers. Their active participation is needed.

4. To be able to elicit material from the child that is not likely to surface spontaneously and that the issues are not really shameful and can be dealt with directly.

5. Intense positive clinical messages have to be received and felt through the child's defenses. The process should be fun-filled and enjoyable for both the child and the treatment team to counteract the hard work being done.

6. The therapeutic program should include attention to the physical, cognitive, emotional and spiritual characteristics of the child considering that the damage affects all these areas.

7. Children exhibit behaviors that are secret and dysfunctional and this continues long after the traumatic event. Dissociation and deviant sexualized behavior which occur after the traumatizing event are not likely to be brought to light after the traumatizing event unless a determined effort is made to discover them by an experienced clinician.

8. Working with traumatized children involves gross, sometimes horrible situations and may have a strong personal impact on the therapist and this impact may interfere with treatment.

James thinks that helping children to acknowledge and accept the realities of painful events in their life is an essential part of treatment. If the children do not accept the reality, children continue to put enormous amounts of energy into avoiding what they find overwhelming and frightening often by invoking defense mechanisms such as splitting, dissociating and suppressing which can impede their development. Children avoid anything that reminds them of what they want to forget. Defense mechanisms include extreme withdrawal, constricted physical and emotional expression, dangerous risk- taking, and aggression.

James observes that traumatized children who have not come to terms with what has happened to them may be afraid to play, fantasize/or dream because unbroken memories or thoughts might emerge. There might be within them an intense hunger to achieve, because they feel worthless. Academic achievement for instance counteracts their profound sense of worthlessness, but their intense reactions to both internal and external stresses often produce learning problems which confirm their perceived inadequacies.

This failure to address the realities and consequences of the event may render it impossible to bring to light the misperceptions that exist or are likely to develop which can be buried along with the actual circumstances of the trauma. The buried erroneous information festers like an unhealed wound and like a geological hot spot can erupt without warning.

James notes that some more examples of critical aspects of treatment are when:

The child believes that a knife was left in his body after surgery child believes that his mother's body was still inside the crushed car six months after she was killed in an accident.

The child believes that the devil lived in his stomach.

The child believed that wearing her pink nightie caused her grandfather to sexually molest her

The child believed that he had AIDS

James proposes a developmentally sequenced treatment. She says that with sexual abuse the child may experience physical excitement initially and the expectation of a reward or heightened stature as a result of sharing a secret with an adult. At some stage he may have guilt feelings for having enjoyed or not having resisted the experience. He may feel shame, feeling guilty over having caused a person's removal from his home. He may long for the abusive parent, having feelings of shame and stigmatization; believe he is gay, gross, perverted, or that he is only a sexual object; he is so afraid that it may be found out or that he will abuse others.

The therapist is usually aware that there are other clinical issues which must be attended to but he has to wait for its appearing develop-mentally. The therapist should foresee what could develop sequentially and be prepared to deal with later developments.

There should be a thorough assessment of both child and family as preliminaries to forming a sequential treatment plan. The clinicians must know:

The child's past and present situation

The specific traumatic events leading to the situation for which treatment is needed

The experience and meaning of the events to the child

The child's strengths and weak and problem areas

Hidden Trauma-Reactive Behavior

James writes of hidden trauma-reactive behavior which may be discovered by detailed, skillful probing. If not dealt with, the behavior becomes entrenched and more complex and feelings of guilt and alienation may increase. These behaviors are post-traumatic stress disorder, dissociative behaviors including multiple-personality disorders and paraphilia behaviors.

Dissociative disorders appear in traumatic experiences during childhood. Children with a genetic predisposition to dissociate under stress, when undergoing what they feel to be a life-threatening event, with no sense of having adult protection will react to the experience by entering a dissociative state. Dissociation is resorted to so that one may be able to cope with the initial trauma and also to deal with subsequent events that bring back memories of the original event or that which may be threatening.

Dissociation events have implications for the treatment of traumatized children:

Clinicians should be observant of instances of dissociation in children.

Diagnosis must include an assessment of the possibility of dissociative responses by the child.

Treatment objectives will not be met if the child has isolated a part of his personality from awareness and from treatment.

Dissociation behavior should be evaluated at the beginning of therapy and at different points in the treatment process.

Paraphilia Behaviors

Terr's (1981) research showed that traumatized children engage in post traumatic play that is secret and ritualistic, with a driven quality to it. Some sexually victimized children engage in post-traumatic sexual behaviors that are deviant or inappropriate. These behaviors, referred to as "paraphilia" behaviors include exhibitionism, obscene telephone calls, humiliating or dangerous self-stimulating sexual behaviors, sexual abuse of animals or younger children, and the pursuit of adult sexual contact. These behaviors may serve some emotional need or be an attempt to master the situation or may be conflict resolution. Because of the drama and excitement and orgasmic reinforcement, the behavior takes on a life of its own and becomes part of an addictive cycle rather than just meeting a specific need. Left untouched by the treatment process, paraphilia behaviors can so escalate that the victim can become a victimizer of others.

Professionals and caregivers have a great difficulty in dealing with children's sexual children. We feel that we are not prepared to believe that children are also sexual beings. We do not want to see the evidence of the child's having seen damages, and we fear that it may make matters worse. If we ignore the behavior, we hope it will go away. We really don't know what to do and so we ignore this aspect of the treatment.

The therapist should always remember that the victim has been sexually assaulted. Sexual molestation is not limited to overt molestation but includes sexual over stimulation, threats of sexual abuse, child pornography, witnessing violent or aberrant sexual behaviors, and other related events or situations.

Points which James believes clinicians should remember are:

Care should be taken so that there won't be any categorization into victim/good guys and perpetrators/bad guys. If the child has been engaging in actual or imagined paraphilia behavior, he will not bring this out in the open or he may be considered bad.

Caregivers should be made to understand that these behaviors are not unusual in children who have been sexually traumatized. This does not mean either that the child will grow up to be a sexually perverted individual. Caregivers become free to discuss this issue with the clinician so that treatment may be prescribed for it.

The therapist must develop the expertise to address these issues with the child so that he, the therapist can intervene clinically.

The child should not be made to feel that the therapist hates person's who traumatized him. He may be a person the child loves and may cause feelings of shame and guilt. This creates a chasm between the child and the therapist.

Anger may be expressed by the therapist after the following conditions have been met:

The child and the therapist have formed a therapeutic bond

Work has been done to acknowledge positive interactions between the child and the offending adult.

The child can differentiate between feelings toward a person and feelings about a person's behavior.

There is acknowledgment by the child that what happened was not his fault.

James concludes that specific treatment or approach may be used in therapy for children, many of the strategies cannot be used in isolation. Traumatized children must form a relationship with their therapists so that they may be able to relive their traumatic experience and fully understand what has happened to them. The therapist should work openly, directly, intensely yet playfully and have fun with the child-victim; making the child accept his/her past and present feelings and change behaviors that are dysfunctional. A team approach may work workers so that the child undergoes cognitive, emotional, physical and spiritual recovery. A developmentally sequential process provides for return to therapy and consequently to recovery with different perspectives.

Pre-School Sexual Abuse Program

We analyze the therapy to be used with the 40 preschoolers who are subjects of this paper. This particular program has three phases. Phase 1, groups 1-5 builds trust, establishes rapport and sets the stage to attain the groups objectives. Phase 2, groups 6-8 provides for the working through of the trauma effectively. Phase 3, groups 9-12, looks forward to termination and tries to put the children together again by enhancing their self-esteem and recaps the safety and educational features of the group in an effort to prevent the recurrence of future abuse.

Group 1 - the primary objective is to establish rapport and trust. The children introduce themselves and talk about their family and siblings. The four basic rules are discussed (can't hurt yourself, can't hurt anybody else, no destruction of property and confidentiality) as well as minor rules (sharing, asking permission, staying in your seats, etc.) Artwork consists of free drawings and drawing a person. The last 15 minutes are used to read a safety book, cleaning up and snack time.

Group 2 - It focuses on establishing trust and rapport. There is reinforcement of rules as well as sharing information about their families. Therapists encourage expressions of feelings. Artwork consists of family and free drawings. Cleanup and snacks at the end of the session.

Group 3 - The idea is to set the reason for the grouping. Children who are able are encouraged to tell what happened to therapy. How to stay safe is the basic tenet and the group may discuss the good and bad features. Art work consists of a magical castle as a metaphor for their own homes with danger on the outside. Children are motivated to work through feelings of helplessness, fear and anger through fantasy and artwork. This exercise promotes group cohesiveness and improve self-esteem. Artwork is hung up for display. Cleanup and snack time at the end.

Group 4 - Objectives focus on group requests for information about the abuse. Artwork involves filling in various feelings (scarred, sad, angry, etc.) and eliciting different samples of each. More discussion about good and bad touches along with feelings. Cleanup and snacks at end.

Group 5 - this group has the same goals as those of Group 4 and Group exercise "Touch Me, Touch Me Not" where children place band aids on body parts where it's not okay to be touched. Asking permission for touches and saying no to bad touches is reinforced as well as boundaries and appropriate touching. Cleanup and snacks at the end.

Group 6,7, 8 - All three of these groups focus on the children expressing their feelings and what happened to them symbolically through their artwork. In Group 6, the children fingerpaint, in Group 7 they use clay and Group 8 paints with brushes. All of the activities elicit regressive behaviors and it is in this stage that parents / caregivers note more infantile and acting out behaviors at home. Children who cannot verbalize the abuse are allowed to act out the abuse and work through it nonverbally.

Group 9 - Trust should be well entrenched as well as a nurturing relationship between the therapists and the children. Dolls which are automatically accurate are used by letting children explore them, show what happened to them or act out whatever happened to them. Alternate exercises would be body outlines, which the kids color" and fill in a positive body image is reinforced, as well as roles and boundaries. Snacks and clean up end the session.

Group 10 - Children are still motivated to either draw the abuse or draw a "monster" who represent the molester symbolically. Therapists help in making cages for the monsters with keys for the kids. Emphasis is empowerment and being in control. Children often express ambivalent feelings towards the molester/monster and this is explored with the idea of separating the child from the behavior. This is the point when termination of the program is discussed during the clean up and snack time.

Group 11 - The subject of termination is discussed at once and a recap is made on what was learned in the group about safety, good and bad touching and who to tell it to. Free art with structured material (markers, pencils) is encouraged and therapists continue to promote goodwill and esteem. A safety book may be read at cleanup and snack time.

Group 12 - In this session graduation party is held with special refreshments. Kids are given diplomas with special skills/talents or message. Reinforcement is made during termination and names are mentioned as to whom to talk with if they have problems in the future. Feelings about leaving and saying goodbye are disclosed.

The program dwells on activities for the abused children. Therapists, clinicians, parents and caregivers are supposed to be very observant, wary about reactions or withdrawals, reluctance to participate, still some expression of fear, anger and suspicion. Therapy employing advanced strategies may be resorted to again. Still, to refer to James from whose work we have drawn much of the related literature, therapy may be a lifelong continuing process.