Sexual abuse: developmental differences in children's behavior and self-perception

Clinical Stakes of Sexual Abuse in Adolescent Psychiatry

BACKGROUND

The extent and nature of sexual abuse (SA) and its consequences in psychiatry are still poorly described in adolescence.

OBJECTIVE

This article describes the frequency of SA reported in an adolescent population hospitalized in psychiatry, and assesses its links with the severity of mental disorders and the medical issues of these adolescents.

METHODS

The study includes 100 patients for whom SA has been mentioned, among all patients aged 13 to 17 years old hospitalized for about 4 years. The characteristics of sexual abuse were correlated with the medical severity of the patients, as well as the number, the duration of their hospitalization(s), and the time until disclosure.

RESULTS

The results show the central place of SA in adolescent psychiatry, with a prevalence of 28.5% and a cumulative hospital stay which is five times longer than average. Correlations have been observed between the number of suicide attempts and the number of abuses reported. The medical severity of patients is significantly increased when the named aggressor is an adult. The number of hospitalizations is positively correlated with the number of reported abuses, as well as with the intrafamilial and adult status of the perpetrator. Finally, an early age of onset, repeated abuse, and the intrafamilial nature of the abuse are associated with a longer time to disclosure.

CONCLUSIONS

The severity of adolescent psychiatric situation is statistically in favor of a history of SA, which should therefore be actively explored during care.

The Psychiatric Consequences of Child and Adolescent Sexual Abuse

INTRODUCTION

The purpose of this study was to investigate the psychiatric consequences of sexual abuse and its associated factors in children and adolescents referred to our child and adolescent psychiatry clinic from official medico-legal units.

METHODS

All victims of sexual abuse (n=590) aged 1-18 (mean: 13.56±3.38) referred from forensic units to Ondokuz Mayis University Child and Adolescent Psychiatry Clinic over a period of 2 years [boys: 83 (14.1%); girls: 507 (85.9%)] were included. Child and adolescent psychiatry and forensic medicine specialists evaluated all the cases. The Wechsler Intelligence Scale for Children-Revised Form (WISC-R) and the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version-Turkish Version (K-SADS-PL-T) were applied.

RESULTS

Abuse-related psychiatric diagnoses (of which 45.9% were major depressive disorder and 31.7% were post-traumatic stress disorder cases) were made in 75.2% of the cases. In 80.3% of the cases, the perpetrators were known to their victims [incest, n=91 (15.1%)], and intercourse took place in 48.8%. Although gender and age were not significantly associated with the appearance of any psychiatric disorders, severity of abuse (e.g., intercourse; p=.006), additional physical assault (p<.001), and incest (p<.001) had a significant correlation with psychiatric disorders. To explore the predictive value of multiple factors in the appearance of any sexual assault-related psychiatric disorder, a logistic regression model was used to determine the best linear combination of age, gender, abuse severity, incest, involvement of any other victim, additional physical assault, and length of time from first abuse to first psychiatric evaluation. This combination of variables (occurrence of incest, additional physical assault, and a long duration from first abuse to first psychiatric evaluation) significantly predicted the appearance of a psychiatric disorder of any kind (χ²=55.42; df=7; n=522; p<.001).

CONCLUSION

Our findings reveal that the occurrence of incest, additional physical assault, and a long duration from first abuse to first psychiatric evaluation predict higher rates of sexual abuse-related psychiatric disorders.

A systematic review of the emotional, behavioural and cognitive features exhibited by school-aged children experiencing neglect or emotional abuse

BACKGROUND

Interventions to minimize the long-term consequences of neglect or emotional abuse rely on prompt identification of these children. This systematic review of world literature (1947-2012) identifies features that children aged 5-14 years experiencing neglect or emotional abuse, as opposed to physical or sexual abuse, may exhibit.

METHODS

Searching 18 databases, utilizing over 100 keywords, supplemented by hand searching, 13,210 articles were identified and 111 underwent full critical appraisal by two independent trained reviewers.

RESULTS

The 30 included studies highlighted behavioural features (15 studies), externalizing features being the most prominent (8/9 studies) and internalizing features noted in 4/6 studies. Four studies identified attention deficit hyperactivity disorder (ADHD) associated features: impulsivity, inattention or hyperactivity. Child difficulties in initiating or developing friendships were noted in seven studies. Of 13 studies addressing emotional well-being, three highlighted low self-esteem, with a perception of external control (1), or depression (6) including suicidality (1). A negative internal working model of the mother increased the likelihood of depression (1). In assessing cognition or academic performance, lower general intelligence (3/4) and reduced literacy and numeracy (2) were reported, but no observable effect on memory (3).

CONCLUSIONS

School-aged children presenting with poor academic performance, ADHD symptomatology or abnormal behaviours warrant assessment of neglect or emotional abuse as a potential underlying cause.

Social relationships in sexually abused children: self-reports and teachers' evaluation

This study aimed to explore the social relationships of child victims of sexual abuse using both self-reports and teachers' ratings. Participants were 93 child victims of sexual abuse and a comparison group of 75 nonvictims. Teachers' assessments revealed that sexually abused children displayed greater social skill problems compared to same-age, nonabused peers and were more likely to display social difficulties nearing clinical levels. Analyses indicated that sexually abused children presented lower levels of interpersonal trust in people surrounding them yet a marginally higher level of trust in peers compared to nonabused children. Sense of loneliness and feeling different from peers did not differ between groups.

A Review of Physical and Mental Health Consequences of Child Abuse and Neglect and Implications for Practice

This article provides an overview of mental and physical health outcomes of child maltreatment to help health care providers identify the consequences of maltreatment and consider treatment options. Child maltreatment is associated with a variety of negative physical and mental health outcomes that affect the individual throughout the lifespan and place a substantial burden on both victims and the population as a whole. The review begins with an overview of the role of physicians in identifying abuse and neglect in the clinic setting. Next, current research findings on physical and mental health outcomes in children, adolescents, and adults are reviewed. Finally, opportunities for primary prevention of abuse and neglect are discussed. Primary prevention strategies can avoid risk for maltreatment, and subsequent interventions for victims have the potential to greatly improve their health.

True and false recall and dissociation among maltreated children: the role of self-schema

The current investigation addresses the manner through which trauma affects basic memory and self-system processes. True and false recall for self-referent stimuli were assessed in conjunction with dissociative symptomatology among abused (N=76), neglected (N=92), and nonmaltreated (N=116) school-aged children. Abused, neglected, and nonmaltreated children did not differ in the level of processing self-schema effect or in the occurrence and frequency of false recall. Rather, differences in the affective valence of false recall emerged as a function of maltreatment subtype and age. Regarding dissociation, the abused children displayed higher levels of dissociative symptomatology than did the nonmaltreated children. Although abused, neglected, and nonmaltreated children did not exhibit differences in the valence of their self-schemas, positive and negative self-schemas were related to self-integration differently among the subgroups of maltreatment. Negative self-schemas were associated with increased dissociation among the abused children, whereas positive self-schemas were related to increased dissociation for the neglected children. Thus, positive self-schemas displayed by the younger neglected children were related to higher dissociation, suggestive of defensive self-processing. Implications for clinical intervention are underscored.

Factors linked to outcomes in sexually abused girls: a regression tree analysis

Children who report sexual abuse (SA) have been found to display a range of internalizing and externalizing behavior problems. In the present study, a tree-based analysis was used to derive models predicting the variability of internalizing and externalizing behavior problems as well as dissociation symptoms in SA girls. Participants were 150 girls aged 4 to 12 years referred to a specialized pediatric clinic after disclosure of SA. The potential predictors taken into account included sociodemographic and abuse-related variables as well as maternal and family characteristics. The models obtained point to prior abuse as a salient variable in predicting outcomes of SA girls. Implications for the treatment for children disclosing SA are discussed.

Parental knowledge of child sexual abuse symptoms

The purpose of this study was to investigate parental knowledge of symptoms of child sexual abuse (CSA), and to determine the factors associated with that knowledge. A total of 150 parents listed symptoms of CSA in the following areas: physical/medical, emotional, sexual behavior, and behavior towards others. Results suggest that, although most parents are familiar with some of the symptoms of CSA, they are more likely to know emotional or behavioral reactions which could be suggestive of many other life stressors. Parents with higher socioeconomic status listed more symptoms, but race and parenting experience were not significant factors. Results suggest the need to inform parents of more indicative physical or sexual symptoms, and to target parents of lower SES background in awareness efforts. doi:10.1300/ J070v15n04_01.

Stressors and child and adolescent psychopathology: evidence of moderating and mediating effects

This paper reviews studies that have tested for moderators or mediators of the relation between stressors and child and adolescent psychopathology. Many studies have tested for moderation, but results of research studying moderators have been inconclusive. There have been few theory-based studies and there have been few consistent findings. Far fewer studies have tested for mediation effects, but these studies have generally been theory-driven, have more often built upon one another in an incremental fashion, and have yielded consistent results. In particular, there is substantial evidence for the mediating role of family relationship in the relation between stressors and child and adolescent psychological symptoms. Future studies should integrate moderator and mediator research by testing for specific mediators in relation to particular moderating contexts, so that we can better understand the complex ways in which stressful life experiences affect the well-being of children and adolescents.

Treatment outcome research with the non-offending parents of sexually abused children: a critical review

Potentially deleterious effects arise from the experience of childhood sexual abuse, but maternal supportiveness has been identified as a crucial mediator. Consequently, a body of knowledge has begun to develop on interventions designed to improve the supportiveness and adjustment of the non-offending parent. The present paper attempts to provide a critical review of the treatment outcomes reported for these new interventions. Studies have been organized according to the sexually abused child's stage of development: preschool, school-aged, and adolescence. Recommendations for service delivery and research follow.

Social self-efficacy and behavior problems in maltreated and nonmaltreated children

Investigated the relations among child maltreatment, children's social self-efficacy, and behavioral adjustment. Data were collected on 305 maltreated and 195 non-maltreated children from low-income families (ages 5 to 12 years) who were assessed on perceived social self-efficacy and evaluated by camp counselors on internalizing and externalizing symptomatology. Younger (< 8 years) maltreated children exhibited inflated levels of perceived self-efficacy in confictual peer interactions compared to younger nonmaltreated children. Younger maltreated children with higher levels of social self-efficacy showed significantly less internalizing behaviors compared to younger maltreated children with lower levels of social self-efficacy. For older children (> 8 years), regardless of maltreatment status, higher levels of perceived social self-efficacy in conflict situations were related to lower levels of internalizing symptomatology. The results are discussed as suggestive of the role of children's social self-efficacy as a protective factor in the link between maltreatment and internalizing symptomatology.

Stress and psychopathology in children and adolescents: is there evidence of specificity?

Research on the relations between specific stressors and specific psychological outcomes among children and adolescents is reviewed. Specificity, the notion that particular risk factors are uniquely related to particular outcomes is discussed from a theoretical perspective, and models of specificity are described. Several domains of stressors are examined from a specificity framework (e.g., exposure to violence, abuse, and divorce/marital conflict) in relation to broad-band outcomes of internalizing and externalizing symptoms. Studies that tested for specificity conducted within the past 15 years are examined, and definitional problems are highlighted. Little evidence for specificity was found. Methodological problems in the literature and the lack of theory-driven specificity research are discussed, and directions for future research are identified.

Profiles of child sexual abuse cases in Ireland: an archival study

OBJECTIVE

This study aimed to profile subgroups of CSA cases referred for assessment at two national CSA assessment centers in Ireland.

METHOD

Historical and clinical data for 150 CSA cases were drawn from records of two Dublin-based national specialist sexual abuse assessment and therapeutic centers. Three main comparisons were made involving: (1) 113 confirmed CSA cases and 37 unconfirmed CSA cases, (2) 55 confirmed CSA cases that displayed clinically significant behavior problems, and the 56 confirmed CSA cases without significant adjustment difficulties, and (3) 19 confirmed CSA cases in which violence was a central feature, and 79 confirmed cases in which violence was not a central feature.

RESULTS

There were three main findings. (1) More unconfirmed cases were male; had single or separated parents; and a father with a criminal history. As a group, the confirmed cases were largely youngsters who had been abused by male adults or adolescents outside their nuclear family and who subsequently were well supported by one or two parents. (2) Poorly adjusted CSA victims had a history of coercive violent abuse while better adjusted children were victims of nonviolent abuse. (3) Victims of violent CSA were more likely to have experienced penetrative abuse and to display more externalizing behavior problems.

CONCLUSIONS

Confirmed and unconfirmed CSA cases, well and poorly adjusted CSA cases, and victims of violent and nonviolent CSA referred for assessment at two national CSA assessment centers in Ireland had distinctive clinical profiles.

Relationships between maternal adult attachment security, child perceptions of maternal support, and maternal perceptions of child responses to sexual abuse

This study assessed the relationships between maternal adult attachment style, children's perceptions of maternal support following disclosure of sexual abuse, and maternal perceptions of children's behavioral and emotional responses to sexual abuse among African-American child sexual abuse victims aged 4 to 12 (n=96) and a comparison group of non-abused subjects (n=100). Mothers with insecure attachment styles reported significantly higher rates of internalizing behaviors in their sexually abused children than did securely attached mothers. Among mothers of non-abused children, those with insecure adult attachment styles reported significantly higher rates of externalizing behaviors shown by their children in comparison with mothers with a secure adult attachment style. Mothers with insecure adult attachment styles also reported higher rates of overall behavior problems in their non-abused children that approached statistical significance. Sexually abused children's perceptions of maternal support were not related to maternal attachment style nor to child functioning. Contrary to our prediction, mothers of sexually abused children did not show lower rates of secure attachments when compared to mothers of non-sexually abused children. Our findings indicate that fostering parent- child attachment is important in order to decrease the risk for behavior problems and symptomatology in sexually abused children.

Extended forensic evaluation when sexual abuse is suspected: a multisite field study

A subset of children referred due to suspected sexual abuse require more than one interview for professionals to reach an opinion about the veracity of allegations. The National Children's Advocacy Center's forensic evaluation model was designed for that specific group of children. The multisite study of the model reported here followed a 2-year pilot study. Professionals in 12 states adopted the model and collected data for 2 years on a total of 147 participants. In 44.5% of the cases, a credible disclosure was obtained, with 73% of these cases supported in the legal system. The forensic evaluation procedure yielded clear information to be used in child protection and prosecutory decisions in 64% of the cases (combining cases with credible disclosures and abuse unlikely findings). Finally, the study examined the effects of the length of the evaluation and of the case and child characteristics on evaluation outcomes.

The effects of family and community violence on children

This review examines theoretical and empirical literature on children's reactions to three types of violence--child maltreatment, community violence, and interparental violence. In addition to describing internalizing and externalizing problems associated with exposure to violence, this review identifies ways that violence can disrupt typical developmental trajectories through psychobiological effects, post-traumatic stress disorder (PTSD), cognitive consequences, and peer problems. Methodological challenges in this literature include high rates of co-occurrence among types of violence exposure, co-occurrence of violence with other serious life adversities, heterogeneity in the frequency, severity, age of onset, and chronicity of exposure, and difficulties in making causal inferences. A developmental psychopathology perspective focuses attention on how violence may have different effects at different ages and may compromise children's abilities to face normal developmental challenges. Emphasis is placed on the variability of children's reactions to violence, on outcomes that go beyond diagnosable disorders, and on variables that mediate and moderate children's reactions to violence.

Coping strategies and social support as mediators of consequences in child sexual abuse victims

OBJECTIVE

The main objective of this study was to evaluate the mediator role of coping strategies and social support on the adaptation of children following CSA. Empirical studies indicate that short-term consequences of child sexual abuse (CSA) are multiple and varied (Kendall-Tackett, Williams, & Finkelhor, 1993; Wolfe & Birt, 1995). While abuse-related characteristics were first studied to explain the variability of CSA outcome, more recently, the influence of other variables such as coping strategies and social support have been considered.

METHOD

Fifty sexually abused children aged between 7 and 12 participated in this study. The Child Behavior Checklist (Achenbach, 1991) and the Perceived Competence Scale for Children (Harter, 1985) were used to measure victims' adjustment. Coping strategies were evaluated by the Self-Report Coping Scale (Causey & Dubow, 1992) and the children completed the Perceived Social Support (Harter, 1985). A French version of the History of Victimization (Wolfe, Gentile, & Bourdeau, 1987) was used to gather abuse-related characteristics from medical records.

RESULTS

Results indicate that sexually abused children exhibit internalizing and externalizing behavior problems following CSA. Coping strategies and social support exert direct effects on victims' adjustment instead of the mediator influences originally expected. Among abuse-related variables, only the perpetrator's identity is directly related to internalizing symptoms.

CONCLUSIONS

The absence of mediational effects of coping and social support is discussed in light of the measures used and the cross-sectional nature of the study. Results highlight the importance of parental implication and the consideration of coping strategies in designing therapeutic interventions with this population.