1. November 19, 2010 Charles W. Sanders, Ph.D. LMFT, LMHC, LCSW, School Psychologist, Sanders and Associates, LLC, Indianapolis, IN

2.  Identifying Childhood Sexual Abuse  Using Projective Drawings with Sexually Abused Children  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 2

3.  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  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 3 ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 Symptoms that you may see when children have been sexually abused:

4.  Decline in school performance  Difficulty concentrating  Sleep disturbance  Adolescents will have pseudo- maturity; they will act more like a 30 or 40 year old  Poor peer relations  Poor social skills  Depression  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. 4 ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 Clues that you may see when adolescents have been sexually abused as children:

5.  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  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 5 Clues to identifying childhood sexual abuse in adults: ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010

6.  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 6

7.  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 7

8.  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 8

9.  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 9

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20.  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 20

21.  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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 21

22.  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 22

23.  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 23

24.  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 24

25.  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 25

26.  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 26

27.  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 27

28.  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 28

29.  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 29

30.  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 30

31.  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 31

32.  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 self- esteem, 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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 32

33.  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 self- esteem, 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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 33

34.  Women who seek treatment for childhood sexual abuse tend to fall into one of three groups: 1. 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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 34

35.  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 35

36.  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 36

37.  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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 37

38.  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 38

39.  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 self- esteem, and suicide ideation. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 39

40.  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. 40 ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010

41.  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 41

42.  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 42

43.  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 43

44.  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 44

45.  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 45

46.  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 46

47.  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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 47

48.  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 48

49.  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 49

50.  Many perpetrators intimidate children to continue victimization.  Perpetrators seek out vulnerable children; these children may be socially isolated, have low self- esteem, 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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 50

51.  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 51

52.  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 52

53.  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 53

54.  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 54

55.  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. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 55

56.  The clinical symptoms of adult females are anxiety, thought disturbances, somatic complaints, depression, anxiety, social avoidances, posttraumatic stress, high-risk sexual behavior, and passive- aggressive personalities. ICAADA Central Indiana Regional Chapter (CIRC) 2010 Workshop, November 19, 2010 56

57.  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 57