Child sexual abuse: a marker or magnifying glass for family dysfunction?

Child sexual abuse: a marker or magnifying glass

for family dysfunction?

Abstract

A report of child sexual abuse leads to a multi-agency investigation that often reveals other

maltreatment and dysfunctional behaviors within the farnily. Due to recent developments in this field, the

emphasis of the investigation has shifted to the child’s history rather than information from the parent or

accused, or the presence of injuries. In the last 10 years C’hildren’s Advocacy Centers have become a central

component to the investigation of child sexual abuse and provide a means for long-term follow-up

of referred families. The idiosyncrasies of this investigative and advocacy system have provided an

in-depth view of the families of sexually abused children.

Four family types emerge: safe and secure, safe and insecure, unsafe and enmeshed, and unsafe

and insecure. The characteristics of child sexual abuse, the response to the child’s disclosure of abuse,

and the prognosis for the child victim vary among the -different family types. An innovative long-term

program of wrap-around services for sexually abused children and their families provides counseling,

peer activities, family mentoring, and child mentoring while tracking the symptoms and behaviors of the

child victims. The identification of a child victim of sextial abuse can be a tragic crisis and an opportunity

for intensive and timely intervention.

1. Introduction

How can sexual abuse be a marker or magnifying glass for family dysfunction? The answer

lies in part with legal definitions and with the unique way that child sexual abuse cases are

investigated. All 50 states have laws mandating the

report of suspected child abuse to authorities,

usually law enforcement or child protection agencies. Of the four types of child maltreatment,

sexual abuse is most clearly recognized by society and most clearly defined by laws. Most

Americans would agree that when an adult touches the genitals of an 8-year-old girl in a sexual

manner it is inappropriate and unlawful.

Some would agree that when a father strikes his 8-year-old daughter in the buttocks with a

belt and leaves bruises that it is perhaps excessive and inappropriate, but fewer would agree that

the act merits criminal prosecution. Few would agree that if a father yelled at his 8-year-old

daughter and repeatedly called her an “ugly idiot,” or left her alone for 4 hr at night that either

incident should be reported for emotional abuse or neglect and the father prosecuted for his

actions.

The laws are generally vague and unhelpful in defining what constitutes “abuse” in our society.

For example, in the Texas Family Code Section 261.001 (ref.) physical abuse is defined by

such terms as “substantial harm … excluding reasonable discipline by a parent,” and emotional

abuse is “mental or emotional injury … that results in observable and material impairment in

the child’s growth, development, or psychological functioning.” The latter definition is flawed

by the fact that “mental injury” can rarely be attributed specifically to some “observable and

material impairment” in the child’s functioning over a period of time that would effect his

growth and development. Both definitions are hampered by subjective terms that leave the

decision to report abuse up to the reporter and his or her personal threshold for what is tolerable.

What is “substantial harm?” What is “reasonable discipline?” A number of parents are

unreasonable when they mete out punishment, but the definitions refer more to the outcome

of such acts (the injuries received by the child) rather than the parent’s state of mind when

the punishment is rendered. To these unreasonable parents, the discipline they give is entirely

reasonable and they are usually unwilling to admit that they exercised poor judgment unless

the injury results in death or devastating injury. The definition of neglect does not include age

guidelines for when children may be left unsupervised but relies on the reporter to determine

when a child is “exposed to substantial risk of physical or mental harm” or when a child is in

a situation “that a reasonable person would realize requires judgment or actions beyond the

child’s level of maturity. . .” In contrast, sexual abuse definitions in the Texas Family Code are

primarily referenced to the Penal Code Sections 22.021 and 43.01 and provide more concrete

parameters for what constitutes sexual abuse. Examples from these sections include:

‘Touching of the anus, breasts or any part of the genitals … with intent to arouse or gratify the

sexual desire of any person’; ‘penetration of the anus or female sex organ of a child by any

means’; ‘penetration of the mouth of a child by the sex organ’ of another person; and ‘causing

the sexual organ of the child to contact or penetrate the mouth, anus, or sexual organ of another

person.’

While terms such as “female sex organ” are somewhat vague and the “intent to arouse or

gratify the sexual desire of any person” depends primarily on the sexual offender’s confession,

these definitions are far more specific than those for physical or emotional abuse. While definitions

for physical and emotional abuse depend more on adult definitions of what is “reasonable”

or “substantial,” sexual abuse definitions rely on the child’s report that specific types of sexual

contact have occurred.

Not surprisingly, the system responses to a report of sexual abuse generally differ from

the responses to a report of suspected physical abuse, emotional abuse or neglect. While

Child Protective Services receives the bulk of all child maltreatment referrals, very few of

the physical abuse, emotional abuse and neglect cases are criminally investigated or prosecuted.

While the threshold for reporting abuse is a “suspicion,” the threshold for a criminal

conviction is “beyond a reasonable doubt.” Victims of severe physical abuse and neglect are

usually very young children incapable of testimony due to their developmental immaturity or

the severity of their injury. Without the key testimony of the child, abusers rarely feel compelled

to admit guilt. A criminal prosecutor must prove that a specific person “knowingly and

willingly” caused the injury(s) in the child. This is often problematic when several people

have cared for the child during the time frame of the injury. Unlike sexual abuse cases, investigations

of physical abuse, emotional abuse, and neglect are hampered by questions of

intentionality which can be definitively answered only by the suspected abuser, and questions

of parental rights to render what they consider to be “reasonable discipline.” Due to these difficulties,

abusers rarely admit to their acts and rarely agree to accepting services to modify their

behavior.

Sexual abuse victims are generally older children and fully capable of providing statements

and testimony. Sexual abuse investigations rely primarily on the child’s statements since

physical injuries and evidence are generally laclcing (refs.). Since information critical to the

investigation is more readily available, most sexual abuse investigations involve both Child

Protective Services and law enforcement. One role of Children’s Advocacy Centers is to facilitate

and coordinate joint investigations between these two agencies, and to provide a means for

follow-up and monitoring of sexual abuse cases. As a result, sexual abuse cases tend to be more

straightforward than other types of abuse and mnore effectively investigated. With the added

long-term involvement of child advocacy centers, issues of family dysfunction and violence

often surface. The purpose of this paper is to describe the families of sexually abused children

within the context of the child victim’s experience, disclosure, immediate responses to disclosure,

and long-term effects of abuse. This discussion will provide the rationale for an innovative

long-term intervention and prevention program provided to sexually abused children and their

families.

2. Literature review/background

Sexual abuse is a common childhood problem. National U.S. statistics (Wang & Dara, 1997)

indicate that more than 200,000 children are reported to Child Protective Services each year

for suspected sexual abuse. Estimated numbers are much higher; the more conservative figures

indicate that as many as one female in four and one male in six will experience sexual abuse

prior to their 18th birthday (Hopper, 1997; Lechner, Vogel, Garcia-Shelton, Seichter, & Steibel,

1993; Lewin, 1997). The discrepancy in reported and estimated numbers suggest that child

sexual abuse remains a significantly underdetected and underreported problem.

A primary reason for underdetection is that a significant number of child victims do not

disclose their abuse. Approximately 90% of child sexual abuse cases are first detected when

a child discloses to someone; the remainder arc: detected when the abuse is either inadvertently

witnessed or discovered in the victim’s diary or pornographic photographs (Kellogg &

Menard, 2002). In a study of young adults that were sexually abused as children, only 75%

disclosed their abuse during childhood (Kellogg & Hoffman, 1995). In addition, health professionals

rarely detect physical signs of sexual abuse since more than 80% of examinations

are normal (Berenson, Wiemann, & McCombs, 2001; Kellogg & Adams, 2002) and because

general practitioners rarely have the knowledge or expertise to detect the subtle signs of trauma

associated with sexual abuse or assault. While schools may encourage disclosure with various

preventative programs, one study (Kellogg & Huston, 1995) found that children first disclose

to school personnel in only 10% of cases.

Reasons for underreporting to authorities are often linked to adult responses when a child

first discloses sexual abuse. Adults may believe the child and report promptly, believe the child

but delay or avoid reporting, or not believe the child and not report. In one study (Kellogg &

Huston, 1995) only half of the child victims that disclosed abuse were helped in a way that

terminated the abuse. In another study (Kellogg & Menard, 2002) the response to disclosure or

discovery of sexual abuse was supportive in 63% of cases. In these cases, the abuse was reported,

the nonabusive custodial adult believed and supported the child victim and the perpetrator was

denied access to the child victim. In 18% of cases the response to disclosure or discovery of

abuse was not supportive: the child was not believed and the abuse was either not reported or

the abuse was reported but the child victim was not believed. In some of these cases, the child

first told a family member, family member did not report, and the child later told a nonfamily

member who did report. In other cases, the child was punished for disclosing abuse. The

remainder (17%) of responses to disclosure or discovery of abuse were neutral; it was unclear

whether the nonabusive adult caretakers supported or believed the child victim.

The first adult family member that the child discloses to is frequently the mother. The mother

of the sexually abused child not only plays a pivotal role in the child’s likelihood of disclosure,

but also in the risk factors that give rise to the abuse. Sexual abuse is not considered a random

event. Well-documented risk factors include:

(1) Presence of a step-father or other father figure.

(2) Living without the mother at some interval.

(3) Lack of matemal education (did not finish high school).

(4) Lack of emotional closeness to the mother.

(5) Sexually repressive mother.

(6) Lack of physical affection from the father.

(7) Family income less than ,000 per year.

(8) Fewer than three friends in childhood (Finkelhor, 1979).

These risk factors are cumulative such that each additional factor increases the child’s

vulnerability by 10-20%. All but one of these factors involve the mother or mother’s choice

of partner(s). Considering that most sexual offenders of children are adult family members

(Burge, Katerndahl, & Kellogg, 2001; Kellogg & Hoffman, 1995), the mother’s decisions in

life and role within the family are integral to the safety and well-being of her children.

In one study (Burge et al., 2001) of 100 adult female survivors of childhood sexual abuse,

the families of origin were characterized by dysfunction and loss. Half experienced a loss of a

biological parent through divorce or death at the average age of 7 years (median 5 years). During

elementary school years parental loss may disturb the achievement of normal developmental

goals at this age that include self-esteem, autonomy, and the identification and adaptation of

appropriate role models, primarily family members. Seventy percent of adult survivors of child

sexual abuse experienced the death of a family member prior to turning 18; 15% experienced

the death of their father. Among those who experienced sexual abuse during the elementary and

middle school years, the prevalence and severity of adult psychopathology was greater than in

those experiencing sexual abuse in later childhood years (Katemdahl, Burge, & Kellogg, 2001).

It may be that the dissolution of the family structure through divorce or death potentiates the

effects of child sexual abuse or creates greater risk of exposure to sexual offenders of children.

In this study, 68% were victimized by family members and more than two-thirds of these

perpetrators lived with the child.

The effects of sexual abuse are similar to emotional abuse rather than physical abuse. Given

that most sexual offenders desire a relationship with their child victims, deception and threats

are commonly used to gamer the cooperation and secrecy of their victims. Children are taught

and expected to obey the significant adults in their life and these adults are assumed to be

protective and moral. Depending on the approach of the abuser, the child victim may experience

either confusion or fear at the onset of abuse. If the sexual offender approaches the child with

deception and enticement the child may be unable to reconcile the expected protective and moral

role of the adult with his or her actions. Depending on the age and individual characteristics of

the child, abuse factors, and family circumstances. the child may either redefine the adult role

and accommodate (“I have to do whatever my father says”) or redefine the adult role and report

(“Even if his is my father, he is doing something wrong”). If the sexual offender uses threats

to gain sexual access to the child, most children feel helpless and comply with the demand for

secrecy. The importance of secrecy is evident in the fact that most sexual offenders explicitly

or implicitly warn their victims not to “tell” after the first episode of abuse.

As the abuse continues, the threats become more specific and ominous and the child’s sense

of helplessness deepens. These threats often reflect the family dysfunction and the child’s

greatest fears: “Don’t tell or I’ll beat up your morr and come back to kill you all”; “Don’t tell

,cause your mom won’t believe you anyway”; “Don’t tell or they’ll take you away from your

mom”; or “If you tell I’ll go to jail and your little sister won’t have a daddy.” These threats are

often effective and may delay or deter the child’s diisclosure. In one study (Kellogg & Huston,

1995), sexually abused children and adults abused as children waited an average of 2.3 years

(median 5-6 months) before disclosure. The reasons child victims delay disclosure reflect the

effectiveness of their abuser’s threats.

Fear of perpetrator* 34%

Fear of getting in trouble 21%

Fear of not being believed 13%

Fear of effects on family 10%

Fear of effects on perpetrator 8%

No reason specified 8%

Did not know it was wrong 2%

Liked it 2%

Embarrassed 2%

* This response was more common in subjects from violent homes (p <

.05).

3. Findings: a proposed model of family types

Families can protect or harm, by active choice or by passive neglect. Protection can be

primary: parents that do not maltreat their children; or secondary: parents that promptly

report their child’s maltreatment and who believe and support them. Families that protect

their children by choice are child-centered; they have relatively stable family structures,

little adult dysfunction, and good parental-child bonding. Families that are unintentionally

neglectful and lapse in protecting their children are impaired by adult-centered

issues: lack of stable family structure, lack of parental-child bonding, overwhelmed by adult

mental health problems, criminal behavior, alcohol or drug addictions and intrafamilial

violence.

Four types of families emerge from Table 1: safe, secure (child-centered, stable, protective

family); safe, insecure (nonabusive but dysfunctional adults who place their children at risk

for abuse); unsafe, enmeshed (enmeshed abusive family); and unsafe, unstable (abusive and

dysfunctional adults).

3.1. Safe, securefamilies

Based on studies of child sexual abuse victims, most do not live within families that lack

dysfunctional, unprotective, and abusive behaviors. In one study more than half of child sexual

assault victims reported adult domestic violence in their homes and only 20% reported they had

never lived with a violent or sexually abusive adult male (Kellogg & Menard, 2002). In another

study of 100 females that were survivors of child sexual abuse only 15% reported that none of

their immediate or extended family members were heavy drinkers, drug abusers, arrested for

drug or alcohol-related crimes, arrested for assault or diagnosed with a mental health problem

(Burge et al., 2001).

In a study of sexually abused children, 63% indicated that the adult response to their disclosure

of abuse was supportive: the abuse was reported, the nonabusive custodial adult believed

and supported the child victim, and the perpetrator was denied access to the child

victim (Kellogg & Menard, 2002). While this result is encouraging, it is prejudiced by the

fact that children in this study would not have been identified if their abuse had not been

reported by some supportive adult. Not surprisingly, another study of young adults sexually

abused as children found that while most victims did disclose in childhood, only half of

those that did disclose indicated that the abuse stopped after disclosure (Kellogg & Huston,

1995).

Children in safe and secure families that do suffer sexual abuse tend to experience

less severe forms (nonpenetrative sexual acts). Maternal and paternal bonding, lack of

drinking problems in the father, and lack of violence by the mother against the father are

all related to lower severity of sexual abuse against the child (Burge et al., 2001). Less

adult psychopathology in survivors of child sexual abuse is associated with lack of

family (of origin) alcohol abuse and lower frequency of abuse (Katerndahl et al., 2001).

Safe, secure, and child-centered families appear to protect children from abuse, moderate

the severity of abuse and ensure a more favorable prognosis for the child’s recovery from

abuse.

3.2. Safe, insecurefamilies

A safe, but insecure family poses a considerable risk to children for abuse. This type of family

is insecure for children because the adult dysfunctional behaviors overshadow the bonding,

nurturing, and protection of children. These families may be characterized by loss: 40% of

adult survivors of child sexual abuse have lost a parent due to divorce and 17% have lost

a parent due to death during their childhood (Burge et al., 2001). Several documented risk

factors for child sexual abuse concern family problems or challenges, including the presence

of a step-father or other father figure and living without the mother at some interval (Finkelhor,

1979). Dysfunction in families of sexually abused children is common and takes many forms:

61% of fathers and 32% of mothers are described by their children as heavy drinkers or drug

users, having been arrested for drug or violence-related crimes, or having mental health illnesses

(Burge et al., 2001). Half of the adult survivors of child sexual abuse report that their fathers

hurt their mother and a third did so while drinking; 18% of beaten mothers visited a physician

for treatment of their injuries. In the same study, 22% of adult survivors of child sexual abuse

indicated that their mother hurt their father, and 6% did so while drinking; 4% of the beaten

fathers visited a physician for treatment of their injuries (Burge et al., 2001).

Family dysfunction appears to increase the risk of child abuse by either compromising the

protective skills of the caretakers and/or by increasing access of perpetrators to children. Child

victims of multiple perpetrators are more likely to come from families characterized by spousal

violence or by at least one adult with an alcohol or drug problem when compared with children

victimized by only one perpetrator (Kellogg & Hoffman, 1997). Substance abuse may impair

parental supervision of children. Since many sexual offenders of children are substance abusers

(Edwall & Hoffman, 1988; Faust, Runyan, & Kenny, 1995). many children of substance abusing

parents may be more accessible and vulnerable to sexual offenders their parents are acquainted

with.

Family dysfunction may also impair the parent’s ability and willingness to respond appropriately

when their child discloses abuse. Most sexually abused children first disclose to a peer

rather than an adult (Kellogg & Huston, 1995). Children in dysfunctional homes may be less

inclined to disclose abuse to their parents when there has been less optimal parental-child

bonding.

3.3. Unsafe, enmeshed families

The unsafe and enmeshed family is a stable but isolated family that is controlled by an

abusive father figure. The children, and other adults, typically the mother, are integrated into

a rigid system of functioning determined entirely by the abusive head of the family, usually

the father or a father figure. There are no known dysfunctional behaviors among the controlled

adults primarily because the abuser does not allow such information to be shared. It is not

unusual for the “subordinate” adult to have considerable mental health problems but it is

unusual for that adult to have any opportunity to seek any form of help. Adults in families of

victimized children are more likely to have poor communication skills, confused roles, and

difficulty with problem-solving (Alexander, 1985; Courtois, 1988; Finkelhor, 1979; Hoagwood,

1990). Such families may also be remote from other means of social support (Ray, Jackson, &

Townsley, 1991). Mothers may be ineffectual due to their partner’s abusive behavior and

control and their own mental health problems stemming from their maltreatment. Wife battery

significantly increases the risks for child sexual abuse (McCloskey, Figueredo, & Koss, 1995)

and is associated with child physical abuse as well (Saunders, 1994; Stacey & Shupe, 1983).

The children in the enmeshed family may be bonded to the mother because they view her as

a safe haven from the father or because they wish to protect her from the father. The mother, in

turn, may become pathologically dependent on her children’s love to counterbalance the stress

of her adult relationship. The children sense that the mother is ineffectual in her dealings with

the controlling father figure. They may doubt her ability to respond to a disclosure of sexual

abuse by the father. This doubt is weighed with other fears. They may fear that disclosure will

result in severe punishment of all family members. They fear their mother will side with the

abuser since she too seems helpless to his whims. Because they are closely bonded with her,

some child victims will opt to disclose to their mother. The mother, out of dependence or fear

of the perpetrator will typically attempt ineffective alternatives to reporting in order to stop the

abuse. She may arrange for a lock on the child’s bedroom door or “never leave her alone” with

the perpetrator. Often, the child’s fears and doubts of the mother’s response to their disclosure

results in considerable delay of their disclosure.

As may be expected, the prognosis for children in an enmeshed family with a father figure

perpetrator depends primarily on the mother’s response to their disclosure of sexual abuse. If

the mother believes, supports and protects her children, then the prognosis for recovery is good

as long as the mother does not succumb to the apologies and pleas for family reunification that

commonly follow when the perpetrator is controlling and manipulative. If the mother reacts to

the disclosure with ineffective measures, disbelief, or ambivalence, the children are more likely

to recant. Unfortunately, children in enmeshed families often do not disclose to adults outside

their home because of a strong sense of entrapment and general lack of adult relationships and

friendships outside the home.

3.4. Unsafe, insecure families

The unsafe, insecure, and adult-centered family is comprised of a mother who has multiple,

short-term volatile relationships with various men and may have children with different fathers.

The adult relationships are characterized by the same dysfunctions as the safe, insecure

family: drug/alcohol abuse, violence, crime, low education, unemployment, and mental health

problems. The difference is that the adult males are abusive to the children and frequently to

other adult family members as well. This abuse may be physical and/or sexual, and is invariably

emotional. The difference between unsafe insecLire families and unsafe enmeshed families is

that both the mother and father figure in the unsafe insecure family are typically abusive and

dysfunctional but in the enmeshed family the father is the only abuser and adult dysfunction

is minimized or covert.

Children in a sexual abuse clinic were surveyed about all the adult males that had ever lived in

their home. While the most common response was that no father figure had been physically or

sexually abusive to any household member (20%c), 19% indicated they had lived with at least

one father figure that was sexually and physically violent to all the children and physically

violent to their mother (Kellogg & Menard, 2002). Less common were father figures that

were either physically violent or sexually abusive to the children or adult females. The adult

relationships are often short-term and sometimes terminated when one partner is incarcerated

for a crime but more often because the relationships are based on self-serving pleasure rather

than commitment. This self-serving need may be drugs, crime, or sexual variety.

Children living in unsafe, unstable families may be victims of sexual and/or physical abuse by

multiple adults living with them throughout their childhood. Because the adult relationships

are volatile and short-term, the abuse of the children may be short-term but repetitive and

variable. They may be victims of neglect as infants, physical abuse as toddlers, sexual abuse as

school-age children, and emotional abuse all their lives. They are not bonded with any adults in

their home and have not learned to trust any adults outside the home. Disclosure of abuse may

be accidental; a child may tell a peer of their maltreatment without expecting a reaction or even

recognition that such incidents are inappropriate. Some of these peers may inform an adult who

then makes a report to authorities. Abused children in unstable homes may panic and recant

their statements because they fear unforeseen consequences and because they feel they have no

other haven, safe or unsafe. Those that recant are unlikely to “let it slip out” again when they

are abused by another adult. The mother in an unsafe, unstable family may indicate her abused

child is known to be a “liar” and “never liked him (the abuser) anyway.” Because the mother

often has the prior experience of being reported to child protective authorities for physical

abuse or neglect, she is usually defensive and uncooperative when the sexual abuse is reported.

She may have little remorse when her children are taken into protective custody, and may feel

more freedom to pursue her own needs. She chooses her adult partner over her children. These

children confront one of two dismal outcomes: stop the abuse and lose their mother (disclose)

or keep their mother and continue the abuse (don’t disclose). Many children forego or delay

disclosure in favor of the latter option. Regardless, the prognosis for psychological recovery

in these children is fair to poor.

4. Discussion: intervention strategy

Intervention for sexually abused children must incorporate the family and be initiated at

an appropriate interval. Dysfunctional families may use excessive or inappropriate corporal

punishment and provide role models that promote the development of delinquent behaviors,

substance abuse, and unsafe sexual practices in the children. When do these behaviors in

children and adolescents begin? In a study of 166 pregnant or parenting adolescents, more than

half (54%) indicated they had a forced sexual encounter or a sexual encounter with a person

more than 4 years older during their childhood or teen years (Kellogg et al., 2000). In this latter

group, they indicated when they were first subjected to a variety of behaviors and activities.

Behavior Age first occurred (years)

Hit or hurt by a family member 11.5

Age first forced or illegal sexual experience* 11.6

Hit in the face by a family member 12.7

Hit with a fist by a family member 13.4

Use of illegal drugs 14.1

Alcohol intoxication 14.4

Runaway 14.5

Age first wanted sexual experience 14.9

First pregnancy 16.0

* Illegal sexual experience is a sexual experience with a person 4 or more years older that

was not coercive from the subject’s perspective (Kellogg et al., 2000).

This timeline indicates that, on average, most child maltreatment begins during the late

childhood/early adolescent years and occurs over a relatively narrow time frame of 3-4 years

such that by mid adolescence the sexually abusecl child has engaged in many of the health

risky behaviors. Because the sexual abuse occurs early in this timeline and because most (80%;

Alamo Children’s Advocacy Center data) sexually abused children presenting for evaluations

are under the age of 13 years, intervention during childhood years is optimal.

Based on the foregoing discussion, a report of child sexual abuse can provide a magnifying

glass for family dysfunction. The identification of a child victim of sexual abuse can be a tragic

crisis and an opportunity for intensive and timely intervention. This intervention should be

multifaceted, targeting nonabusive adults, children and victims for several months or years.

Provided services should be individualized to the needs and problems of each family.

The Child Abuse Resource Enhancement (CARE) Project in San Antonio, Texas is an

example of a long-term, multifaceted intervention program for sexually abused children and

their families. This program is based on the following premises:

(1) Most (80%) children and adolescents presenting for sexual abuse evaluations are under

13 years of age.

(2) Most dysfunctional and health risky behaviors in abused children appear by age 14.

(3) Risk factors for sexual abuse include family factors such as dysfunction and methods

of discipline.

(4) The child victim’s perception of the parents’ reaction to their abuse impacts their tendency

to disclose abuse and their recovery.

(5) The choices a custodial parent makes with regards to partners and support of their

children impact the child’s risk for abuse, use of illicit substances, and health risky or

delinquent behaviors. These risks in childhood impact the child’s capacity to become a

protective and secure parent.

The goals of the CARE Project are to (1) reduce the likelihood of future substance abuse,

adolescent pregnancy, and other high-risk behaviors with adverse health and legal consequences

for girls and boys, age 6-12, that have been sexually abused, (2) enhance the protective and

parenting skills of the nonabusive custodial parent; and (3) maximize the potential for sexually

abused children to become protective and secure parents to their own future children.

The specific project objectives include:

(I) Provide new long-term services to sexually abused children; the point of contact for

these children will be the Alamo Children’s Advocacy Center when they are referred

by Child Protective Services or law enforcement for medical evaluations.

(2) Increase the number and duration of services received by sexually abused children and

their family members beyond the current short-term medical and counseling services.

(3) Through therapy and mentoring, reduce the trauma experienced by abused children, as

measured by the diminution of symptoms of anxiety, depression, dissociation, anger,

and post-traumatic stress.

(4) Through various counseling, mentoring, and peer activities, provide abused children

and their families with the support, knowledge and social skills necessary to develop

healthy and appropriate relationships with family members and others.

(5) By establishing mentoring relationships with carefully screened adults, provide abused

children with individual support and positive role models.

(6) Increase the resiliency of abused children and enhance their resistance to destructive

and unhealthy behaviors in adolescence.

(7) Conduct a prospective long-term study of outcomes in sexually abused children enrolled

in this program, identify which interventions enhance child resiliency and family

stability, and develop an intervention/prevention model for abused children and their

families that can be incorporated readily into other communities.

Utilizing many community agencies, four broad categories of services are offered to sexually

abused children and their families: counseling (family and child), medical services (child),

mentoring (family and child), and peer activities (child). The collaborating agencies include

the battered women’s shelter, Boy’s Club, Girl and Boy Scouts, YMCA/YWCA and Big

Brothers and Sisters. Interventions are clinic-, home-, and school-based, and include both

in-person and telephone contacts. Services are tailored to the needs and capabilities of the

family, are offered over 4 years, and vary through time with the changing needs and desires of

the family and children. CARE Project personnel provide case management, coordinate case

review among collaborating agencies, collect and analyze data, provide some of the medical,

counseling, and mentoring services, and conduct in-service training for all the collaborative

agencies. Data collected includes: demographic information, number and types of services

utilized, length of time services were utilized, family paychosocial data (gathered from the

mother), child psychosocial functioning (gathered from the child), reactions to abuse (child

and parent), use of physical discipline (child and family), and the Trauma Symptom Checklist

for Children, a reliable and valid instrument developed by Dr. John B riere. The latter instrument

is administered to children and repeated over 3-6 month intervals.

As of September 2001, the CARE Project has been offering these services for 30 months.

Some preliminary results and observations include:

(1) There has been at least one adult substance abuser in 44% of the homes of sexually

abused children.

(2) Fifty-six percent of the mothers of sexually abused children have been victims of intimate

partner physical and/or sexual violence and 44% suffered physical and/or sexual

violence as children. Approximately two-thirds of the sexually abused children have

been disciplined by physical means.

(3) Nearly 30% of sexually abused children felt some degree of blame for the abuse and

about a third did not think their nonabusive parent believed their disclosure of abuse

completely.

(4) About 85% of the 456 children and families that enrolled and participated in CARE

utilized more than one of the services offered; only 23% that enrolled in CARE did not

participate. The combination of counseling and peer activities is the most commonly

utilized cluster of services.

(5) On the Trauma Symptom Checklist for Children, 21% of sexually abused children worsened

in at least one of the symptom groups through time; 51% improved or stabilized

and 29% had both improvement and worsening in different symptom groups. About

15% had suicidal ideation at some time.

These preliminary results suggest that the fami]ies enrolled in CARE are characterized by

dysfunction and violence but nonetheless have high participation rates in the services offered

through this project. Many of the sexually abused children feel guilt and suffer from symptoms

of anxiety, stress, depression, dissociation, and anger but in most children these symptoms

do improve with time. When the study is complete, comparisons between the outcomes in

families that participated in CARE and those that idid not will enable the researchers to make

recommendations for effective intervention.

5. Conclusions

Due to the idiosyncrasies of the law and investigation, a report of child sexual abuse often

reveals family dysfunction and instability. The mandated nature of the investigation provides

an opportunity to begin intensive and long-tern intervention for both child victims and family

members. When such intervention is effective parents of sexually abused children become more

protective and sexually abused children have a better prognosis for recovery and for parenting

their own future children.

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