A Treatment Planning Overview for Children with Sexual Abuse History

The impact of sexual abuse can range from no apparent effects to very severe ones. Typically, children who experience the most serious types of abuse—abuse involving family members and high degrees of physical force—exhibit behavior problems ranging from separation anxiety to posttraumatic stress disorder. However, children who are the victims of sexual abuse are also often exposed to a variety of other stressors and difficult circumstances in their lives, including parental substance abuse. The sexual abuse and its aftermath may be only part of the child’s negative experiences and subsequent behaviors. Therefore, correctly diagnosing abuse is often complex. Conclusive physical evidence of sexual abuse is relatively rare in suspected cases. For all of these reasons, when abuse is suspected, an appropriately trained health professional should be consulted.

Children and adolescents, regardless of their race, culture, or economic status, appear to be at approximately equal risk for sexual victimization. Statistics show that girls are sexually abused more often than boys are. However, boys’ and, later, men’s, tendency not to report their victimization may affect these statistics. Some men even feel societal pressure to be proud of early sexual activity (no matter how unwanted it may have been at the time). It is telling, however, to note that men who have been abused are more commonly seen in the criminal justice system than in clinical mental health settings.

Studies on who commits child sexual abuse vary in their findings, but the most common finding is that the majority of sexual offenders are family members or are otherwise known to the child. Sexual abuse by strangers is not nearly as common as sexual abuse by family members. Research further shows that men perpetrate most instances of sexual abuse, but there are cases in which women are the offenders. Despite a common myth, homosexual men are not more likely to sexually abuse children than heterosexual men are.

What are the Effects of Child Sexual Abuse?

In an attempt to better understand the ill effects of child abuse, psychologists and other researchers have studied what factors may lessen the impact of the abuse. More research needs to be done, but, to date, factors that seem to affect the amount of harm done to the victim include the age of the child; the duration, frequency, and intrusiveness of the abuse; the degree of force used; and the relationship of the abuser to the child.

Children’s interpretation of the abuse, whether or not they disclose the experience, and how quickly they report it also affects the short- and long-term consequences. Children who are able to confide in a trusted adult and who are believed experience less trauma than children who do not disclose the abuse. Furthermore, children who disclose the abuse soon after its occurrence may be less traumatized than those children who live with the secret for years.

Some researchers have begun to look at the question of whether someone can recover from sexual abuse, and, if so, what factors help in that recovery. Children and adults who were sexually abused as children have indicated that family support, extra-familial support, high self-esteem, and spirituality were helpful in their recovery from the abuse.

It is important for victims of abuse to relinquish any guilt they may feel about the abuse. Victims also report that attending workshops and conferences on child sexual abuse, reading about child sexual abuse, and undergoing psychotherapy have helped them feel better and return to a more normal life. Research has also shown that often the passage of time is a key element in recovery.

Counseling and other support services are also important for the caregivers of abused children. One of the strongest predictors of the child’s recovery from the abuse experience is a high level of maternal and family functioning. (This, of course, assumes that the abuser was not a member of the immediate family or, if so, is not still living within the family.)

SEXUAL ABUSE BEHAVIORAL DESCRIPTORS:

1. Vague or unclear memories of inappropriate childhood sexual abuse that can be corroborated by significant others.
2. Clear memories of being sexually abused with clear, detailed memories.
3. Inability to recall a time periods of time or periods of his or her life.
4. Physical signs of sexual abuse, blood in the underwear, swollen genitalia, tear in vagina or rectum, constant rashes etc.
5. Unable to enjoy any close contact with significant others.
6. Unexplainable feelings of anger, rage, when coming into contact with a close family relative or family friend.
7. Unexplainable feelings of fear when coming into contact with a close family relative or family friend.
8. A history of promiscuity or tendency towards promiscous behavior.
9. Views relationships with others on sexualization basis.
10. Low self esteem related to the experience of sexual abuse.

LONG TERM GOALS SEXUAL ABUSE:

1. Explore the issue of being sexually abused with an better capacity for intimacy in relationships.
2. Start the healing process from sexual abuse with gaining a new enjoyment of appropriate sexual contact.
3. Successfully work through the issues related to being sexually abused with a greater understanding and better control of feelings.
4. Learn to recognize and accept the sexual abuse without sexualization of relationships.
5. Determine whether sexual abuse occurred.
6. Help minor move away from being a victim of sexual abuse and become a survivor of sexual abuse.

SHORT TERM GOALS FOR SEXUAL ABUSE:

1. Implement a clear plan to protect minor or other minors in the family from any future sexual abuse.
2. Allow minor time to describe the entire story of the abuse.
3. Develop clear intimacy boundaries within the family.
4. Identify any family stressors or dynamics that contributed to the sexual abuse.
5. Assess the type of abuse, frequency, and duration of the abuse.
6. Help minor identify and express the feelings connected to sexual abuse.
7. Identify a support system of key family member or individuals who will be helpful in aiding the process of resolving the issue.
8. Increase knowledge of sexual abuse and its effect.
9. Increase the ability to talk openly about the abuse, reflecting acceptance of the abuse.
10. Eliminate the secrecy in the family by informing key non-abusive members about the sexual abuse.
11. Eliminate feelings of shame and guilt by allowing minor to verbally affirm self as not responsible for abuse.
12. Clarify any vague memories of the abuse.
13. Allow expression of any feelings about the perpetrator, including the impact the abuse when it occurred and currently.
14. Use art work to allow minor to express feelings about the abuse.
15. Help minor verbalize that the perpetrator of the abuse is responsible and minor.
16. Use story telling to allow minor to develop a picture of the abuse.
17. Encourage non abusive parent to spend more quality time with minor.
18. Express examples on how the sexual abuse has impacted his or her life.
19. Explore any family pattern of broken boundaries through physical contact or verbal suggestiveness.
20. Assign reading information that assists in overcoming shame.
21. Lower statements of victimization and increase statements that reflect personal empowerment.
22. Encourage minor to identify self as a survivor of sexual abuse.
23. Explore the positive aspects of being able to forgive all those involved with the abuse.
24. Increase forgiveness level of self, perpetrator, and others connected with the sexual abuse.
25. Increase level of trust by allowing more socialization and greater intimacy tolerance.
26. Encourage an increased ability to accept and initiate appropriate physical contact with others.

INTERVENTIONS FOR SEXUAL ABUSE:

1. Confront and challenge any denial of sexual abuse within the family.
2. Implement a clear plan to protect minor and other children from any further sexual abuse.
3. Teach minor how to empower herself or himself to protect himself or herself.
4. Explore family dynamics and identify any stress factors that contributed to the sexual abuse.
5. Assess whether perpetrator needs to be remove from the home.
6. Encourage minor to verbally express facts and clarify any feelings associated with the sexual abuse.
7. Use anatomically dolls to have minor described how the abuse happened, without leading the minor.
8. Report sexual abuse to appropriate child protection agencies.
9. Consult with other agencies, doctors, or other witness to verify the sexual abuse.
10. Instruct minor to draw a picture of his or her house, then have minor depict what is like to live in that house.
11. Instruct minor to draw a picture of his or her house, then have minor indicate where the abuse happened.
12. Probe for any family history of prior sexual abuse.
13. Use guided fantasy to help minor express any repressed feelings, not guiding minor.
14. Help minor explore and express any guilt or shame feelings associated with the abuse.
15. Help minor develop awareness of how sexual abuse has impacted his or her life.
16. Identify key family members to offer support and nurturance to minor.
17. Increase family knowledge on sexual abuse impact, and develop appropriate ways to help minor recover from sexual abuse.
18. Conduct a session to allow perpetrator apologize from the abuse to family and minor.
19. Encourage minor or parent can help minor, write a forgiving letter to perpetrator.
20. Help minor draw and color different emotions. Then have minor describe which emotions he or she experienced during and after the sexual abuse.
21. Refer minor to sexual abuse survivor group for minors, to help minor understand that he or she is not alone in experiencing abuse.
22. Teach minor how to meet his or her needs using non-sexual appropriate adaptive ways.
23. Use role playing and modeling to prepare minor to face the court process or legal process.
24. Help minor understand that underlying painful emotions (fear, sadness, hurt, anger) and the experience of the sexual abuse.
25. Increase parental and family time spend on leisure activities as a family.
26. Build the level of trust with the minor using consistent eye contact, unconditional positive regard, and warm acceptance to help increase ability to identify and express feelings.
27. Explore the sexual abuse experience gently without pressing early for unnecessary details.
28. Allow the minor to draw the house in which he or she was raised, complete with where everyone slept.
29. Encourage, and support minor in verbally expressing and clarifying feelings associated with the abuse.
30. Assist minor identify individuals who would be supportive and encourage him or her to ask for their help.
31. Encourage attendance to a support group for survivors of sexual abuse.
32. Assign minor or non abusive parents to read books such as, The Courage to Heal (Bass and Davis), Betrayal of Innocence (Forward and Buck), or Outgrowing the Pain (Gil), and to discuss key concepts with therapist.
33. Assign minor to complete a weekly written exercise from The Courage to Heal Workbook weekly, (Davis).
34. Encourage open in talk about the abuse without shame or embarrassment remind that she or he was not responsible for the abuse.
35. Role play with minor the empty chair conversation exercise with a key figure connected to the sexual abuse (such as, perpetrator, sibling, or parent) telling them of the sexual abuse and its effects.
36. Hold conjoint therapy session where minor tells family of the abuse.
37. Conduct family sessions with minor assisting and supporting minor reveal the abuse to parent(s).
38. Assist minor identify, express and process any feelings of guilt linked to feelings of physical pleasure, emotional fulfillment, or responsibility connected with the sexual abuse.
39. Confront and discuss with minor any statements that reflect self-responsibility for the abuse or indicate feelings that he or she is a victim. Then help minor develop feelings of empowerment by working through the issues and letting go of the abuse.
40. Refer minor or conduct hypnosis with minor to uncover or clarify the nature and extent of the abuse.
41. Increase recall of the details of the abuse by encouraging minor to keep a journal about the incident.
42. Assign minor to write an angry letter to the perpetrator and to process it with therapist.
43. Hold conjoint therapy sessions to allow minor confront the perpetrator of the abuse.
44. Define a symptom development line connected to the abuse.
45. Allow minor to make a list of the ways sexual abuse has affected his or her life and to process the list in therapy.
46. Complete genogram to identify key family patterns of broken boundaries related to sex and intimacy.
47. Give and discuss reading sections from books such as, Healing the Shame That Binds You (Bradshaw), Shame (Kaufman), and Facing Shame (Possum and Mason) and to process key points in therapy.
48. Complete an exercise that identifies the positives and negatives of being a victim and the positives and negatives of being a survivor.
49. Recommend that minor or parents read Forgive and Forget (Smedes), and process key point in therapy
50. Assign minor to write a forgiveness letter and complete a forgiveness exercise (see Forgiving by Simon and Simon) and discuss and process in therapy.
51. Teach share-check method (such as, sharing and then checking to be sure that the shared data is treated respectfully, kindly, and share more freely) of building trust in relationships.
52. Use role-playing and modeling to establish reasonable personal boundaries that are neither too porous nor too restrictive.
53. Explore how to give and receive appropriate touches, helping minor define what is appropriate.
54. One or two times a week minor practices initiating touching or a touching activity (such as, hugging a family member or friend, etc.)