November 19, 2010
Charles W. Sanders, Ph.D. LMFT, LMHC, LCSW, School
Psychologist, Sanders and Associates, LLC, Indianapolis, IN
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Identifying Childhood Sexual Abuse
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Using Projective Drawings with Sexually Abused Children
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Treating Childhood Sexual Abuse
Clinical Symptoms of Sexually Abused Males
Clinical Symptoms of Sexually Abused Adult Females
Clinical Symptoms of Sexually Abused Children
Sexual Abuse in Families
Factors that Limit Reporting of Child Sexual Abuse
Testing Measures Used to Identify Childhood Sexual
Abuse
Summary
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Symptoms that you may see when children have been sexually abused:
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Signs of social withdrawal
There is fear of going to school
You will see some generalized anxiety
The child will have nightmares, sleep
disturbance
They will start having learning
problems
There will be bodily complaints,
especially urinary problems, pelvic
pain
They will do aggression, where they
will start bedwetting, thumb sucking,
clinging to the caretaking parent
You will see fear of men or strangers
or they will be afraid of males
Sometimes there is an increased
number of baths and showers
Preoccupation with being dirty; they
have to continually take baths to clean
themselves
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Children will also become sexually
aggressive with other children; they
will reproduce the sexual abuse that
was done to them upon siblings near
their own age or children who are
younger than they are
These children will exhibit sexual
knowledge and preoccupation with
sexual thoughts and statements that
are far beyond his or her age; their
knowledge of sex is far beyond what
they should know
Children sometimes get sexually
transmitted diseases
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Clues that you may see when adolescents have been sexually abused
as children:
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Decline in school performance
Difficulty concentrating
Sleep disturbance
Adolescents will have pseudomaturity; they will act more like a
30 or 40 year old
Poor peer relations
Poor social skills
Depression
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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A generalized lack of trust in
relationships among their peers
and adults
Runaway behavior
Behavior problems
Alcohol or drug use
Suicide ideation
Suicide attempts
Increased numbers of baths and
showers; preoccupation with
being dirty and making
themselves clean.
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Clues to identifying childhood sexual abuse in adults:
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The adult will have a lot of shame
and stigmatization
Increased drug or alcohol abuse
Low regard for themselves
Encounter difficulty in
maintaining intimate
relationships, especially sexual
relationships
Unable to protect themselves in
dangerous situations
Often will live with or marry an
abusive partner
Suicide thoughts or attempts
Anxiety
Unexplained panic attacks
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Flashbacks
Sleep disturbance
Nightmares
Chronic sense of sadness and
depression
Problems maintaining
relationships and marriage
Problems in childbirth
Inability to trust
Repressed anger and hostility
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 The
Draw-A-Person, House-Tree-Person,
and Kinetic Family Drawing are among
the 10 most frequently used projective
tests by clinicians with children.
 Projective drawings can be a therapeutic
tool in giving the child a voice to
describe the abuse that has happened to
him.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 There
has been an increasing focus in the
literature on the use of projective drawings
with sexually abused children.
 Drawings of explicit sexual features not only
indicate sexual knowledge beyond an
expected age-appropriate level, it also
indicates preoccupation with sexual
thoughts and sexually explicit material.
 Studies have found that sexually abused
children either exaggerate or minimize
sexual features in their drawings.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Drawings
done by victims of a child sex
ring were filled with failure, death, and
the trees that were drawn were dead or
dying.
 The preoccupation with sexually relevant
concepts significantly differentiated the
sexually abused children across both
genders.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Art
work drawn by abused children
which “showed trees that look like erect
penises with testicles, which the authors
suggested would reflect sexual abuse.
 Also, the drawings had elongated necks,
breasts, and ‘phallic bananas,’ which are
also indicators of sexual abuse and
sexual preoccupation”.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
posttraumatic stress symptoms caused
by childhood sexual abuse are best
alleviated through cognitive-behavioral
therapy.
 This therapy is most effective when the
nonoffending mother participates in the
child’s therapy.
 If the mother participates, the posttraumatic
stress, depression, aggressive behaviors,
and sexualized behaviors are alleviated.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Childhood sexual abuse controls every facet of a
person’s life.
 When you are treating someone who has been
sexually molested as a child, the first thing you,
as a therapist, have to do is get the client to tell
their story, to admit that they have been sexually
molested and to begin to tell their story,
acknowledging the areas where they need
healing.
 Clients tend to rationalize or minimize the sexual
abuse situation, basically pretending that
whatever happened was not really that bad, and
explain the abuse away.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Research
says that these women come for
help between the ages of 35 and 40. My
experience over the years has been usually
ages between 30 and 40.
 It is important for therapists to allow the
man or woman who has come for treatment
to feel protected and safe within the
treatment process, and give assurance that
their traumatic experience of childhood
sexual abuse will be understood at an
individual level.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 For
a client to heal, they must believe that
they were sexually abused as a child and
that they were the victim and that the abuse
really did happen.
 Helping your client to accept the fact that it
was not their fault or their responsibility,
that this was not something that they wanted
to happen, is the task of a good therapist.
 It is important to help the sexually abused
client to begin to trust themselves.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
childhood sexual abuse has totally
put them in a state of non trust of the
world.
 The therapist must help those who have
been sexually molested to learn to trust
and to learn that this world is and can be
a safe place for them.
 The therapist should help the sexual
abuse victim to grieve and mourn the
childhood that they lost.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Those
who have been sexually molested have a
lot of anger, and the anger will come out
somewhere. It is important that they use this
anger to help themselves heal.
 Victims will criticize themselves persistently
and continue to devalue themselves. You, the
therapist, will have to teach your clients to love
themselves again, to accept themselves, to see
that they are a loveable, capable, successful,
happy person.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Clients
need to face their abuser, but this
does not have to be face-to-face
confrontation.
 When your client wants to confront the
abuser, the child molester, as a therapist
there are many things that you have to
take into consideration to help the client
to be realistic about the kind of negative
responses they might get from the family
system
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
last thing that a victim needs to move
through is resolution: moving on from the
pain, the hurt, the guilt, the anger, the
anguish, and to live a somewhat normal life,
whatever is normal for them.
 Sexual abuse survivors will hold onto the
hope that the person that has molested them
will admit it or the people who didn’t
protect them and didn’t care about them will
admit that they weren’t a good parent and
apologize for it.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 As
the therapist, you have to help your client
to find a safe place.
 One of the things you need to address when
you treat those who have been sexually
molested as children is to help them change
their life themes.
 People who have had childhood sexual
abuse in their history have very destructive
life themes.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Unless
the therapist challenges these life
negative themes, by helping the client to
rewrite and change these life themes, the
client will continue to not have happiness in
their life, not have love in their life, not have
acceptance and care and safety in their life,
not have all the positive things in their life
that they want to have because the negative
life themes prevent them from having these
important things that they need in theirs
lives.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 One
of the best ways to deal with negative
life themes is to counter it with positive,
supportive statements.
 Muscle relaxation works well with this
population.
 Because they don’t fall into the deeper
levels of REM sleep, then the clients end up
with all kinds of health problems because
they are not getting the kind of sleep and
rest that the body needs.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Next
you as a therapist should move from
muscle relaxation right into the thematic
imagery.
 Thematic imagery involves picturing
relaxing situations. Therapists use this
technique to reduce stress, to help the client
to feel safe and secure and loved and
accepted.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Studies with sexually abused males using the
MMPI indicated that the sexually abused male
group demonstrated significantly more
pathology than the clinical control group.
 The sexually abused male group had high levels
of conflict with society, criminal behavior
tendencies, compulsions, antisocial
characteristics, schizophrenia, mental confusion,
thinking disorders, paranoia, anxiety, low selfesteem, and moodiness.
 A Sexual Abuse Survey sent to sexually abused
men indicated a much higher risk to have had
sexual intercourse with an adult female against
her will.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Sample studies have “characterized Sexually abused
male as having extensive psychiatric histories.”
 Clinical symptoms of sexually abused males include:
aversion to sexual intimacy, sexual preoccupation,
aggressive sexual behavior, extreme guilt, low selfesteem, feeling of isolation, depression, impaired
ability to trust others, anxiety, family problems, and
marriage problems.
 Sexually abused boys have more severe short- and
long-term symptoms than sexually abused girls.
 A male who experiences childhood sexual abuse has
a much higher possibility than nonsexually abused
males of displaying aggression and hostility to
others.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Women
who seek treatment for childhood
sexual abuse tend to fall into one of three
groups:
Women who seek treatment for remembered
sexual abuse;
2. Women who seek treatment for other disorders
such as depression or anxiety, but without
awareness of the childhood sexual abuse; and
3. Women who have repressed memories as a result
of denial and dissociation, and seek treatment for a
variety of reasons.
1.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 These
women may experience perceptual
disturbances, thought disturbances, and other
symptoms such as somatic complaints,
depression, anxiety, social avoidance, and
passive-aggressive personalities.
 Childhood sexual abuse and rape are the most
common causes of PTSD in women, and women
have twice the possibility of developing PTSD
than men.
 Anxiety, depression, lack of trust, attempted
suicide, and posttraumatic stress are normal
responses to childhood sexual abuse.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Women’s
initial reaction of dealing with the
childhood sexual abuse through therapy are
low self-esteem, shame, guilt, insomnia,
posttraumatic stress disorder, and sexual
problems.
 The psychiatric diagnoses have been
indicated among childhood sexual abuse
survivors include major depression,
obsessive-compulsive disorders,
generalized anxiety, and posttraumatic
stress.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Some coping strategies of adult female survivors
that are used to cope with childhood sexual
abuse are alcohol abuse, drug abuse, risky
sexual behaviors, and smoking.
 Childhood sexual abuse has been linked to
eating disorders, anorexia nervosa, bulimia, and
hypertension.
 Studies have indicated that survivors of
childhood sexual abuse overeat, smoke
cigarettes, drink alcohol, do not use seatbelts in
motor vehicles, smoke crack cocaine, and are
homeless.
 Childhood sexual abuse survivors also report
self-mutilation, cutting one’s own skin.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
sexually abused children scored
significantly lower on the combined
individual measures of school achievement,
and yet no IQ differences were found.
 The profile of the elementary school-aged
sexual abuse victim is that of a girl who is
experiencing depression, achieving below
expectations, having difficulties with peer
relations, and presenting hyperactive,
acting-out, and aggressive behaviors at
school and at home.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
impact of childhood sexual abuse divides
children into two categories:
(1) those who have posttraumatic stress
disorder and (2) those who will experience
revictimization, promiscuity, distrust of others,
and a distorted view of other people’s
motivation for their behaviors.
 The other common effects of childhood sexual
abuse include sexual problems, guilt, poor selfesteem, and suicide ideation.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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The effects of childhood sexual abuse include
poor social functioning, self-esteem, and
development of psychopathology.
 Studies indicate that sexually abused children
are likely to develop “anxiety, depression, (low)
self-esteem, (poor) impulse control, and
dissociative disorders” in adulthood.
 Other diagnoses include: Attention Deficit
Hyperactivity Disorder, Conduct Disorder,
Oppositional Defiant Disorder, Learning
Disorder, Borderline Psychosis, and Personality
Disorders.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
sexually abused child may also display
spacing out and truant behaviors.
 They often do not learn the materials taught
in the public school classroom.
 Clinical reports have consistently indicated
that the sexual abuse of children
significantly delays cognitive development,
social development, emotional and
psychological development, and interferes
with overall adaptive functioning.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
developmental difficulties that have
been identified in sexually abused
individuals include negative self image,
muted sensory-perceptive response, the
inability to trust, inability to distinguish
between thought and action, and feeling
and doing and inability to trust.
 The effects of childhood sexual abuse have
three outcomes: (1) psychiatric disorders,
(2) dysfunctional behaviors, and
(3) neurological dysregulation.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
clinical symptoms of children are much
more severe when the sexual abuse was
done by a parent. Those clinical symptoms
range from major depression, acute anxiety,
posttraumatic stress, low self-esteem, and
suicide ideation.
 The National Institute of Justice shows that
sexually abused children experience the
same problems as adults: guilt, shame,
anxiety, fear, depression, transmitted
diseases, and somatic problems.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Children
who were sexually abused
demonstrate significant deficits in
attention, reasoning, executive
functioning, and distraction.
 Child Protection and Welfare agencies
found that in 80% of child abuse cases,
that the parents are the alleged
perpetrator of child abuse and neglect.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
functioning of a sexual abuse family
has higher degrees of conflict between
family members, an authoritarian family
structure, poor family loyalty between
family members, lack of psychological
warmth in the family, bonding problems
between children and adults, social
isolation, higher marital conflict, role
reversal, and higher degree of
alcoholism.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 There
is no example of healthy relationships
demonstrating respect, love, and mutuality.
 Studies on the impact of childhood sexual
abuse consistently find that sexual abuse
committed by a parent is the most damaging
form of abuse.
 The best chance for a sexually abused female
to recover is if she is not blamed or accused of
seducing her father and is supported and
accepted by her mother.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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When the abuse is revealed within the family
system, some mothers blame the sexually
abused child for destroying their marriage.
 Some mothers detach themselves from their
daughters and view them as rival females
competing for their husband’s attention, doing
nothing to stop the childhood sexual abuse.
 Mothers who were sexually abused themselves
fail to see that there is even a problem with the
abuse, and may think it is not a big deal or that it
is how people learn about sex.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
long-term outcome is poor for the
sexually abused child if she is accused of
causing the sexual abuse or taken out of
the home and sexually revictimized ,
sexually abused families are
dysfunctional in a number of ways.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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A
British study indicated that witnessing
domestic violence within the family
lowers children’s IQ more than chronic
exposure to lead.
 When fathers are identified as the child’s
molester, the negative consequences to
the family are decline in monetary
income, anger, anxiety, depression, and
guilt.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Many perpetrators intimidate children to
continue victimization.
 Perpetrators seek out vulnerable children; these
children may be socially isolated, have low selfesteem, have only one parent, lack supervision,
and have physical or intellectual disabilities.
 These children will often have a lack of faith that
law enforcement agencies, Welfare Department,
or Child Protective Services will believe their
reporting of the childhood sexual abuse.
 Children may fear being accused of false
reporting.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
psychological effects of abuse often
make the children confused, dissociate,
and repress their memories of abuse.
 These psychological effects often cause
the child’s allegations to not be believed
and their reporting to be inconsistent and
unclear.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Even
though every state now has laws
requiring professionals to report childhood
sexual abuse, the laws still vary in detail
from state to state.
 Some of the reasons professionals have
given for not reporting childhood sexual
abuse include: concerns about
confidentiality, the abuse or neglect was not
serious enough to report, the situation
resolved itself, or it had already been
reported.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
Louisville Behavior Checklist (LBC)
measures three factors: (1) internalizing
behavior problems, (2) externalizing
behavior problems, and (3) antisocial
behavior problems.
 The Child Behavior Checklist (CBCL) has
also been used to distinguish between
sexually abused children and nonsexually
abused children.
 The Sexual Abuse Symptoms Checklist
(SASC) to study sexually abused children in
a short-term psychiatric hospital.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The Trauma
Symptom Checklist (TSC) is
a 54-item self-report measure that
measures depression, anxiety,
posttraumatic stress, sexual concerns,
dissociation, and anger.
 The Rorschach Inkblot is a projective test
in which participants respond to ink
blots.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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Sexual abuse is psychologically damaging to
children.
 Victims of childhood sexual abuse often have
behavior problems, lower achievement ability,
depression, achieving below expectations,
having difficulty with peer relationships, and
aggressive behavior.
 Developmental difficulties that have been
identified in sexually abused individuals include
low self-esteem, inability to trust, inability to
distinguish between thought and action, and
muted sensory perceptive responses.
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ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 The
clinical symptoms of adult females
are anxiety, thought disturbances,
somatic complaints, depression, anxiety,
social avoidances, posttraumatic stress,
high-risk sexual behavior, and passiveaggressive personalities.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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 Projective
tests have been used successfully to
diagnose childhood sexual abuse.
 The social implications of psychological tests
that can identify and indicate that sexual abuse
has occurred would be enormous.
 Since the average age which women who were
sexually abused as children seek counseling is
between the ages of 32-38, being able to
identify that childhood sexual abuse has
occurred also would mean that treatment could
begin at a much earlier age.
ICAADA Central Indiana Regional Chapter (CIRC)
2010 Workshop, November 19, 2010
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