A. Effects of sexual abuse
1. Sexually abused children vary widely as to how the abuse affects them. Some children
are relatively unaffected, some show short-term effects, some are more seriously affected.
2. Research on the effects of sexual abuse generally use clinical samples which cannot
be generalized to the entire population of sexually abused children.
3. Contrary to what most people believe, the long-term effects of sexual abuse are not
nearly as severe as is often assumed (Levitt & Pinnell, 1995; Rind & Harrington,
a. The effects of physical abuse and neglect are likely to be more serious and generate
more long-term damage (Ney, Fung, & Wickett, 1994).
b. When family dysfunction is controlled, the effects of sexual abuse wash out. This is
because both extrafamilial and intrafamilial sexual abuse are closely associated with
families that are dysfunctional and pathological (Alexander &
Lupfer, 1987, Beitchman
et al., 1991, Levitt & Pinnell, 1995; Nash et al., 1993).
3. Some factors seem to be associated with greater harm.
a. Because of the difficulties mentioned above, this does not in any way establish a
direct cause and effect link (Nash, Zivney, & Hulsey , 1993).
b. Also, there is no contributing factor that all studies agree on as being
consistently associated with greater harm.
c. Many studies report greater harm with use of force, genital as opposed to other
types of contact, sex with the father or stepfather, and long duration of repeated abuse.
d. Studies assessing the effect of age of onset have contradictory results.
4. A supportive environment, including a supportive, functional family, is associated
with less harm.
B. Treatment for sexually abused children
1. Role of the therapist vs. role of the evaluator
a. The professional conducting the evaluation as to whether abuse happened should not
be the professional who provides treatment for sexual abuse. The roles are different and
are contradictory in many respects.
b. Therapy should never be used to make a determination as to whether, in fact, abuse
c. A child should not be given therapy for sex abuse until there is a determination
that abuse has occurred (Ceci, 1994; Gardner, 1992; Wakefield & Underwager, 1988). If
the child needs treatment before a judicial determination, any treatment should address
whatever behavioral problems the child is having, but not focus on sexual abuse.
d. If a child is in therapy prior to such a determination, the child may ask questions
or talk about sexual abuse. Give careful responses that will not contaminate the child's
memory and answer questions honestly. Remember that the goal of therapy is to restore the
child to normal developmental growth as quickly as possible. This can be done without
focusing on abuse.
2. Begin with a careful individual and family assessment.
a. Children react to abuse differently. There are no typical symptoms of the sexually
abused child. Some children may need only reassurance and support, but not long-term
therapy. There is no such thing as a child sexual abuse syndrome that is diagnostic of
children who have been sexually abused.
b. The assessment should include some assessment of the child's developmental level,
descriptions from the parents as to problem behaviors, and information about the nature of
c. Emphasize measurable, objectively described behaviors and not hypothesized internal
d. Evaluate the extent to which the child's problems are the result of the
investigation process and the child's family's reactions to the disclosure. This includes
interviews by law enforcement and social services, foster home placement, genital
examinations, publicity about the case in the media which results in the child's peers
knowing about the abuse, foster home placement, and termination of contact with a parent.
e. In intrafamilial abuse, assess the degree of danger for future abuse. In the United
States, this is not likely to be a problem since either the perpetrator or the child will
be removed from home.
f. Assess the family system and the strengths and problems. This can be done through
behavioral observation of the family in interaction as well as through individual
assessments of all members of the family. Stress and rely upon valid and reliable
statistical and actuarial methods as much as possible. These measures may include
personality, intellectual functioning, and strengths and resources.
3. Include standardized measures of the child's problems.
a. For example, the Child Behavior Checklist (Achenbach &
Louisville Behavior Checklist (Miller), and the Personality Inventory for Children
et al). These are parent-report checklists that differentiate between children with
psychopathology from children in the general population and provide descriptive
information of the child's assets and problems.
b. Do not use drawings for anything other than interview aids and conversation
starters. There is no evidence that the symbolic sign approach to children's drawings is
reliable or valid.
4. Do not convey to the parents or the child that the child is likely to be seriously
and perhaps permanently damaged by the abuse.
a. The exaggerated emphasis on the harmful effects of abuse can leave the family
hopeless, fearful, and anxious. This can become a self-fulfilling prophecy.
b. If long-term, intensive therapy is given to a child who does not need it, a
relatively brief, although unpleasant event, in the child's perception, may be blown up
into a major catastrophic event. Misguided therapy may teach a child to be a lifelong
5. If a careful assessment indicates no problems, do not give the child long-term
intensive therapy. Reassure the child and be in a monitoring role with the child and
parents. If problems appear later, they can be addressed.
6. Family involvement is essential.
a. With incest, treatment of the child must be coordinated with treatment for the
offending and nonoffending parent.
b. In extrafamilial abuse, the parents and other family members should be actively
involved whenever possible. Do not treat the child apart from the parents.
c. With younger children, the focus should be on helping the parents learn effective
ways of responding to the child's problem behaviors.
d. Parents may attend to problem behaviors that they believe were caused by the abuse.
This often has the effect of increasing the frequency of the behaviors. Therefore, it is
important to work with the parents on effective ways to respond to problem behaviors.
7. The type of therapy for children which has demonstrated efficacy is
cognitive-behavioral (Casey & Berman, 1985; Weitz et al., 1987, 1995; Weitz &
a. Specific problems are targeted and strategies are developed for working on them.
b. The treatment strategies will involve step-by-step, daily activities that help the
child and the parents address the child's problems.
8. Child therapy as is practiced in most clinics in the United States is not effective
according to the outcome research (Weitz et al., 1992; Weisz, Donenberg et al., 1995;
Weitz & Weiss, 1993)
9. Play therapy
a. This is the most frequent approach used in the United States. Sometimes, it is
termed "disclosure-based, play therapy."
b. Children are encouraged to express their feelings and act out the abuse in play
sessions. The therapists may use drawings, dolls, puppets, and sand tables. Their play, in
turn, is interpreted as reflecting actual things that have happened to them.
c. There is no research on play therapy that supports its use with sexually abused
children (Campbell, 1992a; White & Allers, 1994).
10. View the child as an active participant in solving her problems and help the child
modify her behavior.
a. Do not treat the child as a passive victim.
b. Give the child the message that, although she is not responsible for the abuse, she
is responsible for knowing right from wrong and for getting help if she is abused again.
c. The child can learn more effective ways of dealing with whatever problems she now
10. Cognitive-behaviorally focused group therapy can be helpful with older children,
since meeting other children who have been abused can be helpful.
11. Children may show opposition and resistance to therapy (Haugaard, 1992). This
should be handled by exploring and then gently challenging false beliefs about therapy
that the child may have. These false beliefs include:
a. The child may think she was brought to therapy because of a personal defect or
illness she has that caused the abuse.
b. The child may see therapy as a type of punishment. "Why must I come here when
it was my father who did everything wrong."
c. The child may believe he must go to therapy because people think he will become a
child abuser himself later in life.
12. Family therapy is recommended
a. This was the first approach used to respond to sexual abuse.
b. The Child Sexual Abuse Treatment Program (CSATP) was developed by Giarretto (1980)
in Santa Clara County, California beginning in 1971. It succeeded admirably. 90% of the
children were returned home within the first month and 95% eventually. There was no
recidivism reported in more than 250 families.
c. Unfortunately, as the emphasis in the United States shifted to prosecution and
demonization of alleged perpetrators, this established and demonstrated program dropped
out of use. It combined individual treatment, family therapy, and marriage therapy and
emphasized the positive contributions strengths can make to growth.
d. This was the approach Dr. Underwager first used in 1953 when he encountered a case
of incest. We also used this approach with the cooperation of the authorities until about
1977 when it became difficult to pursue family therapy and reunification of families.
e. The advent of a systematized child protection system and the emergence of a corps of
protection workers moved treatment n a different direction.
13. Major premises of family therapy
a. The family is viewed as an organic system. Family members assume behavior patterns
to maintain system balance (family homeostasis).
b. A distorted family homeostasis is evidenced by psychological/physiological symptoms
in family members.
c. Incestuous behavior is one of the many symptoms possible in troubled families.
d. The marital relationship is a key factor in family organic balance and development.
e. Incestuous behavior is not likely to occur when parents enjoy mutually beneficial
f. A high self-concept in each of the mates is a prerequisite for a healthy marital
g. High self-concepts in parents help to engender high self-concepts in children.
h. Individuals with high self concepts are not apt to engage others in
hostile-aggressive behavior. In particular, they do not undermine the self-concept of
their mates or children through incestuous behavior.
i. Individuals with low self-concepts are usually angry, disillusioned, and feel they
have little to lose. They are thus primed for behavior that is destructive to others and
j. When such individuals are punished in the depersonalized manner of institutions, the
low self concept/high destructive energy syndrome is enforced. Even when punishment serves
to frustrate one type of hostile conduct, the destructive energy is diverted to another
outlet or turned inward.
14. Overall the continuing research shows that family dysfunction is the major issue in
causation of abuse, physical, emotional or sexual, and any long-term negative effects.
Children growing up in intact, functional and supportive nuclear families are
significantly less likely to report any form of abuse (Gaudin et al., 1990; Mullen et al.,