Chapter 13

Effects from Sexual Abuse and

Posttraumatic Stress Disorder

SYMPTOMS

Joline Kennington was a 12-year-old Caucasian female referred to treatment by

her mother, Mrs. Kennington, and a social worker from a state family services
department. A female clinical psychologist who specializes in youths who have
faced traumatic circumstances saw Joline. Joline's circumstances involved alleged
sexual abuse by her father who was incarcerated. Mrs. Kennington and the social
worker thought Joline should receive therapy to address her current trauma and
loss of her father.
The psychologist tried to speak with Joline individually during the initial
interview. Joline was reticent and made little eye contact, however. Joline first
responded briefly to questions that had nothing to do with the recent abusive
situation. She talked about her dog and her favorite television shows and foods.
The psychologist tried to develop good rapport with Joline and asked about recent
events. Joline cried softly and would not speak. The psychologist comforted Joline
and thanked her for coming in. She also secured a promise from the girl to meet
again the following week.
The psychologist interviewed Mrs. Kennington and found that she had much
to say about the current situation. She said Joline's father sexually abused his
daughter 10 months earlier. Mrs. Kennington was apparently suspicious of her
husband when he would go into Joline's bedroom, shut the door, and stay there
for long periods. Mrs. Kennington insisted she only noticed her husband's odd
behavior just before calling the police. She said she asked Joline about the situation
and that her daughter started crying and said "Daddy keeps touching me in bad
places." Mrs. Kennington said she immediately called the police who in tum
contacted the family services department. Following interviews with Mr. and Mrs.
Kennington and Joline, the father was arrested on charges ofchild molestation and
was in jail awaiting trial.

148
 E FF E C T 5 FRO M 5 E X U A LAB USE AND POST T R A U MAT Ie 149

Mrs. Kennington broughtJoline for counseling because the girl was upset that
her father was to go to trial the next week and that she, Joline, might have to
testifY. Mr. Kennington vigorously denied the charges, but Mrs. Kennington said
he was a "pathological liar" who would "say anything to save his skin." The
psychologist noticed that Mrs. Kennington was more concerned about Joline's
performance on the witness stand than her daughter's emotional state following
the performance. Mrs. Kennington was concerned about how Joline would look
to the jury, whether she would appear credible, and whether her father would

~ and
intimidate her.
The psychologist saw that Mrs. Kennington had a detached relationship with
her family. She and her husband experienced deep marital problems for several
years and often argued about finances, child rearing, and sex. Mrs. Kennington
described her husband as abusive, brutish, and coarse. Mrs. Kennington was also
unaware of many of Joline's daily activities, such as her schoolwork. She was
effusive in her praise for Joline, however, and insisted that she and her daughter
had a close, loving relationship. Mrs. Kennington was not close either to her two
sons, both of whom reminded her of her husband. Her sons, 17- and 19­
years-old, were not living at home when their father was arrested. They had no
knowledge about recent family events, but "the boys," Mrs. Kennington said,
"will be on their father's side."
) treatment by The psychologist also spoke with the family services social worker in charge of
family services Joline's case. The social worker, Mrs. Tracy, provided a more balanced view of the
lths who have situation. Mrs. Tracy said the entire situation was cloudy and that the police and
lvolved alleged family services department acted largely on Joline's self-report after her mother
I and the social called police. Joline said her father was entering her bedroom and fondling her.
~nt trauma and He was allegedly caressing his daughter's body and asking her to do the same to
him. Mrs. Tracy stated that Joline said her father touched her genital area and
ring the initial asked her to fondle his. No kissing, vaginal penetration, or oral sexual contact was
ver. Joline first initially reported, however.
recent abusive Mrs. Tracy asked Joline how often and how long the fondling took place, but
::>ws and foods. Joline did not give a clear answer. She initially said the abuse lasted since her
~d about recent 10th birthday. When re-interviewed before her mother, however, Joline said the
>mforted Joline abuse lasted one month. Joline also reported more thorough abuse during the
he girl to meet second interview byadding extensive kissing and oral sexual contact. Exactly what
happened was thus unclear. Joline's accounts of events wavered even more during
t she had much subsequent interviews, but she insisted her father caressed her and asked her to do
ally abused his the same. In recent interviews, she said she could not remember whether kissing
spicious of her and oral contact occurred.
, and stay there Mrs. Tracy conveyed her suspicions that Mrs. Kennington influenced her
husband's odd daughter's answers. Mrs. Kennington seemed to want to punish her husband for
,ut the situation past offenses by encouraging Joline to magnifY ilie seriousness of the alleged abuse.
ling me in bad Mrs. Kennington was also minimizing the length of the alleged abuse to avoid
e who in tum blame for reporting delays. What actually happened to Joline, if anything, was now
h Mr. and Mrs. unclear. Mrs. Tracy said her "gut reaction" was that abuse occurred, but ilie nature
nolestation and of the abuse was unknown. Mrs. Tracy expressed concern that different accounts
of what happened might jeopardize the district attorney's chances for a conviction.
150 C H A PT E R 1 3

Mrs. Tracy also said Joline had other problems in recent months. Her
schoolwork suffered dramatically; her B average slipped to D and F grades. Joline
also had enormous guilt and sadness over the loss of her father as well as anger
toward him and her mother. Joline told the social worker her mother "waited too
long" and ignored her complaints about her father. Mrs. Tracy suspected Mrs.
Kennington called police only after a major argument with her husband about
another issue. Joline was also quite nervous about the possibility of testifying in
court.
The psychologist completed her initial assessment by interviewing Joline's
schoolteacher with Mrs. Kennington's permission. The teacher, Mrs. Ecahn, said
Joline was a bright child who was having trouble concentrating on her work. She
also appeared agitated and occasionally cried during class. Mrs. Ecahn and other
school officials were aware ofJoline's situation so they made accommodations to
assist her. The teachers gave her substantial emotional support and after-school
tutoring. Based on information from all these sources, the psychologist suspected
that abuse had occurred and that Joline was suffering from its effects. The psy­
chologist suspected Joline had symptoms of posttraumatic stress disorder (PTSD).

ASSESSMENT

The essential feature of PTSD is characteristic symptoms following exposure to an

extreme traumatic stressor involving direct personal experience of an event that
involves actual or threatened death or serious injury, or other threat to one's
physical integrity; or witnessing an event that involves death, injury, or threat to
the physical integrity of another person; or learning about unexpected or violent
death, serious harm, or threat of death or injury experienced by a family member
or other close associate [American Psychiatric Association (APA) , 2000, p. 463].
A person's response to the trauma must involve intense fear, helplessness,
horror, or, in youths, disorganized or agitated behavior (APA, 2000, p. 463).
Other PTSD-related symptoms that may occur in those sexually abused include
self-destructive and impulsive behavior, somatic complaints, shame, depressive
behaviors, social problems, feeling "damaged" or threatened, and personality
changes (APA, 2000, p. 465).
A key aspect ofPTSD is that a traumatic event is constantly reexperienced in
the form of memories, dreams, a sense of reenactment, or physiological or psy­
chological distress when a person faces cues that remind her of the trauma. Young
children may also relive trauma through repetitive play and believe their lives will
be shortened or that they can foresee negative events. Someone with PTSD
generally experiences increased arousal and avoids stimuli linked to the traumatic
event. These symptoms must last longer than one month and must cause signifi­
cant impairment in functioning. PTSD is chronic if symptoms last longer than
three months (APA, 2000).
Joline appeared to meet some diagnostic criteria for PTSD. The reported
abuse involved a threat to physical integrity - Joline told the social worker she felt
 E F FEe T S FRO M SEX U A LAB USE AND POST T R A U M AT I C 151

nt months. Her endangered and "dirty" as a result. She reportedly felt helpless during the abusive
i F grades. Joline episodes, daring not to resist her large father. JoJine also had nightmares about the
as well as anger abuse and anxiety when confronted with the fact she might have to face her father
ther "waited too in court. She often avoided talking further about the abuse, was disinterested in
( suspected Mrs. activities that used to make her happy, and was detached from others. Symptoms
r husband about of PTSD were also evident in Joline's anger and concentration problems. These
y of testifying in symptoms affected Joline's social and academic functioning so a consideration of
PTSD seemed warranted. About 29-39% of sexually abused youths later develop
viewing Johne's PTSD (Molnar, Buka, & Kessler, 2001).
Mrs. Ecahn, said Assessing youths who have endured sexual abuse and who experience
n her work. She symptoms of PTSD usually involves an interview. For obvious reasons, inter­
:lcahn and other viewers usually focus on the child and must do so carefully and without force­
ommodations to fulness. An interviewer must develop rapport with the child and provide a safe,
and after-school confidential environment where the child feels comfortable expressing personal
)logist suspected issues. Joline's psychologist met withJoline and the social worker, who already
:ffects. The psy­ had a special rapport with the girl. Joline said she felt comfortable talking with the
lisorder (PTSD). psychologist individually about her abuse after a few sessions. In the meantime, the
legal case against Mr. Kennington was delayed because ofJoline's unwillingness to
testify.
The psychologist's first task was to clarifY whether abuse occurred and, if so,
what type. Mter much discussion and reassurance about confidentiality, Joline re­
peated her original version of events. She said her father entered her bedroom at
?; exposure to an night for several months, talked to her about her day, and began some form of
:)f an event that physical contact. This initially involved body massages, but later progressed to full­
threat to one's body caressing. Mr. Kennington later told Joline to reciprocate and directed her
.lry, or threat to hand to his genital area. As these events progressed, Mr. Kennington told his
ected or violent daughter not to tell anyone about their "special time together." He made no overt
family member threats, however.
2000, p. 463]. Joline said no kissing or other activity took place. She admitted lying to
ar, helplessness, police after her mother told her to "make the story as painful as possible." She
2000, p. 463). complied, but later confused her accounts of these nonexistent events. Joline also
abused include claimed she told her mother several times what was going on before the police
ame, depressive came, but her mother took no action until the night of her big argument with
and personality Mr. Kennington.
Clinicians also use rating scales to assess PTSD and related symptoms caused
eexperienced in by sexual abuse. An example is the Trauma Symptom Checklistfor Children,* which
:)logical or psy­ contains items related to anxiety, depression, anger, posttraumatic stress, dissoci­
trauma. Young ation, and sexual concerns (Briere, 1996). Sample items from this measure include:
e their lives will
• Bad dreams or nightmares
ne with PTSD
o the traumatic • Remembering things that happened that I didn't like
1st cause signifi­ • Feeling scared of men/women
ast longer than
• Reproduced by special pemlission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida
. The reported Avenue, Lutz, Florida 33549, from the Trauma Symptom Checklist for Children by John Briere, PhD., Copyright 1989,
worker she felt 1995 by PAR, Inc. Further reproduction is prohibited without pemussion of PAR, Inc.
152 CHAPTER 13

• Can't stop thinking about something bad happening to me

• Feeling afraid somebody will kill me
Assessing children following disclosure of abuse should focus on several ele­
ments (Crooks & Wolfe, 2007; Wolfe, 2007):
• Behavior patterns that may lead to future revictirnization (e.g., delinquency,
school absences)
• Symptoms of PTSD and general anxiety
• Sexual and peer relationships
• Causes and feelings about the past abuse
• Level of general disorganization
• Current family atmosphere
Joline had no disruptive behaviors, substance use, stealing, or aggression.
Depressive symptoms of social withdrawal, guilt, and suicidal ideation were
present, however. J oline said she felt her classmates looked at her "funny," that she
caused her father's legal trouble, and that the family "might be better off if [ was
dead." The psychologist developed a verbal contract with Joline to ensure that she
would speak to the psychologist if she had suicidal thoughts or before any suicide
attempt.
Joline was also anxious about going to school and testifying in court. This
persisted for so long that Joline eventually refused to testify and the charges against
Mr. Kennington were dropped (he moved out of state thereafter and had no
further contact with JoIine or Mrs. Kennington). The psychologist suspected
Joline refused to testify as well because of her guilt about the situation. Joline
blamed herself for some aspects of the abuse, even saying her father would not
have faced legal trouble if she did not live in the apartment.
The psychologist also discussedJoline's current relationship with her peers and
family members. Joline said her friends and people at school were supportive, but
she felt uncomfortable given recent media attention about the case. Her rela­
tionship with her mother was strained because Mrs. Kennington was upset that
Joline would not testify in court. Joline also remained angry at her mother for
waiting so long to do anything about the abuse. The psychologist believed Joline
was learning to adjust to the major changes in her life, but that she would have to
work through many of her negative feelings.
Assessing sexually abused youths may include anatomical dolls. A therapist
may use the dolls in cases where a child is unwilling or not verbal enough to
describe abusive events. The child learns to draw the human body and identify
different body parts. The doll is then introduced to the child who answers dif­
ferent questions about what an offender mayor may not have done. Use of dolls
facilitates memory for details of abusive events, but is not helpful if a child
completely forgot what happened. The use of dolls may reveal aggressive and
sexual play among those sexually abused. The use of dolls does not appear to
entice children to make up stories of abuse, a source of great controversy in this
area (Faller, 2005). Dolls were not used for Johne.
 E F FEe T 5 FRO M 5 E X U A LAB USE AND PO 5 T T R A U M AT I C 153

RISK FACTORS AND MAINTAINING VARIABLES

No child is immune from abuse, but some factors may precipitate sexual abuse
IS on several ele­ (Hilyard & Wolfe, 2002; Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003).
These factors include low family income, isolated families, marital conflict,
parental substance abuse, presence of a stepfather, patriarchal attitudes on the part
.g., delinquency,
of the father, lack of social contact on the part of the child, sexually restrictive
family attitudes, and a poor mother-child relationship. This relationship may have
several features:
• A past situation in which a child lived away from her mother
• Emotional detachment on the part of the mother
• Poor supervision of the child
• The mother's punitiveness regarding her child's sexual development
g, or aggressIOn.
Some of these characteristics did not apply to Joline and her family. The
II ideation were
family's socioeconomic status was middle class, Mr. Kennington was Joline's
"funny," that she
natural father, Joline did have several close friends, Joline and her mother were
oetter off if I was
never separated, and the family was not isolated from others. The family lived in
to ensure that she
an urban environment and interacted regularly with other families. Whether the
.efore any suicide
family as a whole had sexually restrictive attitudes was unclear, though this did
seem to be true for Mrs. Kennington.
19 in court. This
Some of the other listed characteristics did apply to Joline and her family.
le charges against
Mr. Kennington was reportedly traditional and conservative regarding family
Ifter and had no
structure. He disapproved of his wife's career and time spent away from home and
ologist suspected
fought a lot with his wife about their lack of sex and affection. Joline and her
, situation. Joline
mother clearly had a problematic relationship as well. The social worker believed
father would not
Mrs. Kennington resented her husband's affection for his daughter and postponed
calling the police about the abuse to deliberately poison the father-daughter re­
vith her peers and
lationship. Mrs. Kennington also seemed nervous about her daughter's potential
:e supportive, but
sexual development, telling the social worker at one point she felt uncomfortable
e case. Her rela­
talking to Joline about dating and sex.
m was upset that
Several preconditions often set the stage for sexual abuse (Wolfe, 2007). First,
.t her mother for
the perpetrator must be motivated to abuse a child sexually. Many people believe
1st believed Joline
sexual abuse is about sexual gratification, but it often relates to desire for power
he would have to
and need to humiliate others. Joline's psychologist believed Mr. Kennington's
recent occupational difficulties, loss of the older sons from the house, and argu­
dolls. A therapist
ments with his wife may have created a sense of lack of power assuaged by con­
verbal enough to
trolling his daughter. No one interviewed Mr. Kennington, however, so no direct
)ody and identify
evidence existed of this need for power or desire to humiliate Joline.
who answers dif­
A second precondition for sexual abuse is that the perpetrator must overcome
lone. Use of dolls
inhibitions regarding sexual activity with a child. The person may engage in al­
lelpful if a child
cohol use, deny negative consequences of the abuse, accept child pornography as a
:al aggressive and
legitimate medium, attribute the behavior to poor self-control, or believe a parent
)es not appear to
may do as he wishes with a child. The last condition certainly applied to Joline, but
ontroversy in this
no evidence was available regarding the other factors. Whether Mr. Kennington
154 C H A PTE R 1 3

believed sexual interactions with his daughter involved affection and were not
abusive was unknown.
A third precondition for sexual abuse is that the perpetrator must overcome
external obstacles to the sexual behavior. Major obstacles include discovery and
arrest. This was not initially difficult for Mr. Kennington because his wife allowed
him to spend considerable time alone with Joline and did not listen to Joline's
complaints about the sexual activity. Mr. Kennington also apparently thought,
wrongly so, that his appeals to Joline to remain silent about their "special time
together" would prevent any trouble.
Finally, a perpetrator must overcome a child's resistance to sexual contact.
Mr. Kennington took advantage ofJohne's initial confusion about the difference
between normal parent-child affection and exploitation. The extra attention he
gave Joline may have placated the girl for some time before she reported the abuse
to her mother.
Researchers have also developed etiological models of PTSD. Continual
avoidance of thoughts associated with trauma may exacerbate PTSD symptoms
(Tull, Gratz, Salters, & Roemer, 2004). A person must fully assimilate these thoughts
into her psyche for PTSD symptoms to abate. This model may have applied to Joline,
who was initially hesitant about sharing her account of sexual events. Others claim
traumatic events trigger feelings of shame and guilt from self-blame (Leskela, Die­
perink, & Thuras, 2002). These feelings may then trigger symptoms ofPTSD such as
physiological arousal and negative views about the future. Joline had many of these
feelings that the psychologist thought maintained her PTSD symptoms.
Other etiological theories of PTSD involve a more integrated approach.
Fletcher (2003) outlined a model for childhood PTSD etiology that includes
traumatic events, emotional and biological responses, attributions, individual
characteristics, and characteristics of the social environment. A traumatic event
would typically involve death, injury, loss of physical integrity, suddenness, un­
predictability, uncontrollability, chronic or severe exposure, close proximity, and/
or social stigma. Several of these certainly applied to Joline.
Emotional responses ofPTSD include fear, horror, and helplessness, whereas
biological responses include changes in neurotransmitters, such as norepinephrine,
dopamine, serotonin, and acetylcholine. Attributions linked to PTSD include an
appraisal of a traumatic situation as inescapable, belief that one's safety will always
be threatened, or an attitude that one's future will forever be tainted by trauma
(Fletcher, 2003). These beliefs were evident to some extent in J oline.
Individual characteristics that may help cause PTSD include a biological
predisposition to negative reactivity to stressful events, psychological vulner­
abilities based on past experiences, and inability to cope with stressors. Char­
acteristics of the social environment may lead to PTSD as well. These
characteristics include negative family reactions to trauma and to the person, poor
community support, and financial difficulties.
Joline's coping skills were quite good given her circumstances, though she
continued to display negative emotions and poor school performance. She also
became upset about new changes in her life and remained upset for long periods.
Joline's condition was aggravated by her strained relationship with her mother and
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EFFECTS FROM SEXUAL ABUSE AND POSTTRAUMATIC 155

1 and were not the family's problematic financial situation. Positive community support from
school officials, the family services department, Joline's friends, and the psychol­
must overcome ogist likely prevented the development of some long-term PTSD symptoms,
e discovery and however.
.1is wife allowed
isten to Joline's
rently thought, DEVELOPMENTAL ASPECTS
ir "special time
Researchers have examined short- and long-term consequences ofabuse in youth,
sexual contact. and these appear to differ from age to age. From infancy to age 2.5 years, children
.t the difference who face general trauma (e.g., from a natural disaster) may show sleeping and
tra attention he toileting problems, exaggerated startle responses to loud noises, fussiness and de­
lorted the abuse pendent behavior, loss of important developmental skills regarding speech and
movement, sudden immobility, intense fears of separation, avoidance of cues that
'SD. Continual remind the child of trauma, and social withdrawal or lack of responsiveness to
TSD symptoms others Oohnson, 2004; Miller-Perrin & Perrin, 2007; Monahon, 1993).
e these thoughts Reactions among very young sexually abused children may include inap­
.pplied toJoline, propriate touching of other children, unusual attention to one's genital area (e.g.,
ts. Others claim massaging), demonstration of sexual knowledge highly advanced for a child's age,
e (Leskela, Die­ or genital pain or sexually transmitted disease. The last symptom, of course, may
)fPTSD such as occur at any age. A child's play may also involve reenactment of abusive trauma
:i many of these and the child, if verbal enough, may suddenly discuss issues surrounding the abuse.
1n.1$. Children aged 2.5-6 years who face general trauma may show separation
:ated approach. anxiety, social withdrawal, nightmares, magical thinking to explain "bad" events,
y that includes somatic complaints, unpleasant visual images, regressions in language and self-care
ons, individual skills, retelling of the traumatic event, involvement of traumatic events in play and
:raumatic event with playmates, changes in mood and personality, and fear that trauma will recur.
uddenness, un­ A child may become more sensitive to anniversaries that remind her of trauma.
)roximity, and/ Sexually abused children in this age group may show sexualized play, sudden and
specific fears of a particular gender or place, aggressive touching of others, and
:ssness, whereas overconcern with masturbation and their genital area. Children aged 2.5-6 years
LOrepinephrine, have better memories of traumatic events than younger children Oohnson, 2004;
~SD include an Miller-Perrin & Perrin, 2007; Monahon, 1993).
fety will always Children aged 6-11 years who face general trauma may reenact the trauma in
:lted by trauma detailed stories and play. These children have specifIC fears and unwanted visual
lne. images, distractibility, poor concentration, guilt about their role in the traumatic
je a biological event, and sensitivity to parental reactions. The reactions mentioned for younger
logical vulner­ children may also apply to 6-11-year-olds. Sexually abused children in this age
;tressors. Char­ may show overt sexual behaviors, hint about their own sexual experience, verbally
s well. These describe abuse, or act like younger sexually abused children. They have better
Ie person, poor recall than preschoolers so their memories of abuse are more detailed and long
standing Oohnson, 2004; Miller-Perrin & Perrin, 2007; Monahon, 1993).
es, though she Adolescents who face general trauma can have several reactions that include:
lance. She also
lr long periods. • Delinquent, reckless, or risk-taking behavior
.1er mother and • Accident proneness
156 C H A PTE R 1 3

• Vengefulness
• Shame and guilt
• A sense of humiliation
• Intense memories
• Depression and pessimism
• Problems in interpersonal relationships
• Extreme social involvement or withdrawal
Joline's most prominent reactions were guilt, social withdrawal, embarrass­
ment, depressive symptoms, and sexual repression. Joline was clearly uncomfort­
able talking about sexual issues, though this is often normal for a 12-year-old. She
also had a tense relationship with her mother, wanted to skip school, and some­
times avoided social outings with her friends. Joline continued to blame herself for
her father's absence and occasionally thought about suicide.
Traumatized and sexually abused adults tend to marry and have children at a
younger age than the general population, leave school, fear independence, and
seek a different social group. Common long-term problems include anxiety and
depression, feelings of isolation, substance abuse, sexual problems, poor self­
esteem, and eating and sleeping disorders. Sexually abused women are at greater
risk of revictimization through rape or spousal abuse (Gladstone et al., 2004).
Key developmental aspects of PTSD may indicate how severe the disorder
will be. A child's level of cognitive and social development is certainly critical.
Children with more advanced cognitive development may appraise an event as
more traumatic, have more self-defeating thoughts, be more susceptible to de­
pression, fear more abstract consequences of the trauma, and have better memories
of the trauma than younger children. Older children and adolescents with better
cognitive development also tend to have better coping skills, however. Younger
children with poor social skills may not develop a wide support network or ef­
fectively communicate their fears and worries about the future. Conversely,
adolescents with good social skills can soften PTSD symptoms by talking with
their friends and escaping aversive family situations.
Developmental differences can also influence how a child reacts to traumatic
events. Children react worse to traumatic events because they have less control
(and less perceived control), more disorganized behavior, and greater sensitivity to
reminders of the event than adolescents (Fletcher, 2003). Younger children are
better at dissociating themselves from a traumatic event, however, and this may
protect them somewhat from developing PTSD. This may also explain why se­
verely abused children sometimes develop dissociative identity (multiple person­
ality) disorder.
Joline's cognitive and social development was generally good. This proved to
be a double-edged sword, however. Her cognitive skills allowed her to under­
stand that the sexual abuse was not her fault and that her mother, though not
blameless, was a victim of these circumstances. Joline also came to fear men in
general, however, regarded sexual behavior and activity as somewhat repulsive,
and continued to have unpleasant memories of the abuse. Johne's positive social
 EFFECTS FROM SEXUAL ABUSE AND POSTTRAUMATIC 157

development allowed her to build coping skills, rely on a support network, and
become more self-reliant than before. Joline's ongoing attachment with her
friends, however, came at the expense of a continually strained relationship with
her mother and less concern for her academic perfonnance.

TREATMENT

rawal, embarrass­ Clinicians who treat abused children often focus on the parents and child. Clini­
early uncomfort­ cians often target the remaining parent because the other has been removed from
12-year-old. She the family. Parent-oriented treatment often involves building better methods of
:hool, and some­ discipline through modeling, role-playing, and instructions regarding time-outs
, blame herself for and appropriate positive reinforcement. Other parent treatment components in­
clude cognitive therapy to modify irrational thoughts about a child's behavior,
lave children at a anger and self-control training, and general coping skills training (Cohen,
dependence, and Deblinger, Mannarino, & Steer, 2004). Joline's psychologist did not emphasize
:lude anxiety and parent training because Mrs. Kennington had not engaged in overt abuse toward
llems, poor self­ Joline and because she did not want to be an active participant in therapy. Some
len are at greater might argue that Mrs. Kennington's neglect ofJoline's trauma was abusive itself,
et al., 2004). however, and worthy of intervention.
vere the disorder Child-oriented treatment for maltreated youths, especially those sexually
certainly critical. abused, depends largely on a child's age. Play therapy may be most useful for
lraise an event as preschool children without fully developed cognitive or social skills. Play therapy
usceptible to de­ involves having a child interact with different recreational items that allow for
~ better memories expression in a comfortable setting. Examples of such items include dollhouses,
cents with better puppets, paints, clay, and building materials. Play therapy is effective for over­
lwever. Younger coming resistance to therapy, enhancing communication about certain events,
t network or ef­ promoting creative thinking and fantasy, and releasing emotions (Schaefer &
ure. Conversely, Kaduson, 2007). As a child engages in pretend play, a therapist can raise questions
by talking with about hypothetical scenarios (e.g., inappropriate requests from others) and how
the child might protect herself (e.g., tell others about "bad" touches).
:acts to traumatic Treatment for sexually abused preschoolers can also focus on having a child
have less control talk about traumatic events. This helps lower a child's apprehension and identify
ater sensitivity to people a child can trust. Emotive imagery techniques help address nightmares. A
1ger children are therapist asks a child to imagine teaming up with a favorite superhero to battle a
-er, and this may nightmare villain. A therapist may also educate a child about what touching
explain why se­ behaviors are inappropriate and how to reject unwanted touches. These latter
multiple person­ techniques were not necessary for Joline, however.
For school-age children who have been sexually abused, child-based treat­
1. This proved to ment focuses on impulse and anger control, emotional expression, problem­
:d her to under­ solving training, gradual exposure to feared stimuli with relaxation training,
:her, though not improving self-esteem, increasing social activity to reduce isolation or depression,
~ to fear men in and cognitive therapy. Education about sexuality, sexual abuse, and personal safety
ewhat repulsive, is also important (Putnam, 2003). Group therapy may be helpful for education,
:'s positive social emotional expression, and building social support. Another treatment technique is
158 C H A PTE R 1 3

to have a child write letters to hypothetical victims or family members to describe

her feelings and achieve mastery of the feelings (Boriskin, 2004).
Joline's psychologist asked her to write a letter to a hypothetical 12-year-old
girl abused by her father. The psychologist askedJoline to write about her feelings
and give advice to the other child. Joline wrote several short letters about her
feelings of guilt and sadness and fortunately told the other child she should not
blame herself for abuse. She also gave advice about how to talk with friends, see a
therapist, and live life "one day at a time." As Joline wrote the letters, the psy­
chologist talked to her about her feelings and helped ease her guilt and anger.
A more controversial topic that arose during therapy was Joline's desire to
write a letter to her father. Mrs. Kennington adamantly opposed this idea and
insisted Joline have no contact with Mr. Kennington. The psychologist offered a
compromise, suggesting Joline write the letter, but send it to the psychologist
instead of her father. Joline agreed and wrote a long, rambling letter about her
anger toward her father, her hopes that he was okay, and her wish to see him again
at some future time. Mrs. Kennington said Joline took several days to complete
the letter, during which time she often cried. Mrs. Kennington saw this as a
destructive process, but the psychologist knew Joline needed to express these
feelings to put the abusive events behind her. Joline's overall mood did improve
somewhat following the letter-writing exercise.
Treatment with J oline also focused on her feelings of isolation, general fears
of men, and questions about dating and sex. The psychologist engaged in cog­
nitive therapy to reduce Joline's interpretation of others' actions as threatening
or mean. This applied especially to others who were close to her, including her
peers and her mother, and was a natural result of her father's betrayal. Joline
often felt her friends looked at her strangely and did not want to interact with
her. Joline came to recognize that others were perhaps uncomfortable around
her because they did not know what to say. The psychologist suggested that
three of Joline's close friends attend therapy and this issue regarding her peers
was largely resolved. Therapy did not help improve Joline's relationship with her
mother, however.
The psychologist also helped Joline identifY "good" men in her life to help
her see that abuse was not a part of every man's nature. Joline identified her
brothers, pastor, and school guidance counselor as positive role models. The
psychologist also answered Joline's questions about dating and sex and discussed
appropriate and inappropriate sexual contacts at length.
The initial treatment of youths with PTSD symptoms involves ending trauma
and helping a child recover in a safe environment. Subsequent treatment may then
resemble components for sexually abused children, including emotional expres­
sion, family therapy, and exposure to thoughts and cues surrounding the trauma.
Joline persistently avoided the old apartment where her father molested her.
When the psychologist thought Joline was ready, they toured the old apartment
together. Joline identified different aspects of the place and entered her old bed­
room last. She cried for an extended period, but eventually became calm. Joline
wrote another unsent letter to her father following this experience, but kept this
one confidential.
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EFFECTS FROM SEXUAL ABUSE AND POSTTRAUMATIC 159

~mbers to describe The long-tenn prognosis for those abused or with PTSD depends largely On
). their degree of emotional expression (catharsis), level of family and social support,
etical 12-year-old exposure to cues that remind a person of trauma, and coping skills. Joline
about her feelings remained in therapy for seven months after which she and her mother moved to a
letters about her different city. By the end of treatment, Joline's grades at school improved and she
ld she should not adjusted well to past events and to her new life. The psychologist thoughtJoline's
with friends, see a long-tenn prognosis was probably good.
e letters, the psy­
uilt and anger.
Joline's desire to
DISCUSSION QUESTIONS
.sed this idea and
hologist offered a
1. About one in four girls and one in six boys are sexually abused by age 18
the psychologist
years. Why do you think sexual abuse is so prevalent?
~ letter about her
:1 to see him again 2. Ifyou were to interview a severely abused child, what themes would be most
days to complete important to cover first? What characteristics about yourself should you think
:on saw this as a about when talking to an abused child?
to express these 3. What types of trauma are most likely to lead to PTSD? Why do some people
,ood did improve experience PTSD following a terrible event and others do not? Explore
personal, family, and social issues to address this question.
ion, general fears 4. What events in your life might you describe as traumatic? What about the
engaged in cog­ event made you feel that way?
ns as threatening
5. Given Mrs. Kennington's behavior, do you feel Joline should stay with her
er, including her
mother after her father left? Explore advantages and disadvantages of this
s betrayal. Joline
situation.
: to interact with
nfortable around 6. If you could speak to Joline about her situation, what would you most like to
st suggested that say? If you were a therapist and were abused in the past, would you self­
;arding her peers disclose this as part of therapy to help your client? Defend your answer.
:ionship with her 7. Can memories ofpast abuse be repressed and later remembered? Support your
answer. What are judicial and other ramifications of this phenomenon?
1 her life to help 8. Explore the utility or desirability of self-help groups for treating people who
:1e identified her have been sexually abused. Discuss the pros and cons of using support groups
)le models. The rather than a trained professional who never experienced abuse personally.
;ex and discussed

es ending trauma
atment may then
notional expres­
ding the trauma. InfoTrac® College Edition
~r molested her.
Ie old apartment Explore InfoTrac College Edition by going to http://infotrac.thomsonleaming.com.
red her old bed­ Hint. Enter these search terms: child maltreatment, sexual abuse, posttraumatic stress
arne calm. Joline disorder, exposure therapy.
,ce, but kept this