Daniel

 Introduction

While child sexual abuse (CSA) involves the child in a physical

act, its deleterious consequences are primarily psychological. It is

a significant risk factor for the development of psychopathology

in childhood, adolescence and adulthood.

CSA may be the explicit reason for referral to CAMHS (child

and adolescent mental health services), but may also be discovered

incidentally during assessment or treatment, especially

when common sequelae are encountered. At times, an unsolicited

disclosure is made by a child during therapeutic work.

Child psychologists, psychiatrists, and psychotherapists may

contribute to investigations of CSA, particularly in assessment

interviews of young or very traumatized children, or in children

with communication difficulties. Consultation to social

services in case management and to caregivers of children who

have been sexually abused is often requested. Risk assessments

of adolescent abusers may also be required. It is therefore of

importance to CAMHS.

The hallmarks of CSA are its secret nature and the very frequent

denial of alleged abuse by the abuser. Sexual abuse extends

beyond incest, occurring both within and outside the family but

the abuser is frequently already known to the child. Indeed this

acquaintance may follow a deliberate befriending or “grooming”

of the child by the abuser.

CSA is not a new phenomenon. General Booth, founder

of the Salvation Army, wrote in 1890: “I understand that the

Society for the Protection of Children prosecuted last year a

fabulous number of fathers for unnatural sins with their children”

(Booth, 1890). However, CSA only began to be noted as a

significant form of child maltreatment in the 1970s. Increasing

recognition came with the development of the women’s movement,

reports by women survivors of their childhood abuse

and a greater openness regarding sexuality. There have been

Rutter’s Child and Adolescent Psychiatry, Sixth Edition.

Edited by AnitaThapar and Daniel S. Pine, James F. Leckman, Stephen Scott, Margaret J. Snowling, Eric Taylor.

© 2015 JohnWiley & Sons, Ltd. Published 2015 by JohnWiley & Sons, Ltd.

successive reports frommany countries in the scientific press, in

particular in Child Abuse and Neglect, the International Journal.

In the United Kingdom and many other jurisdictions, disapproval

of CSA is expressed by the legal prohibition of incest and

sexual contact between an adult and a child. However, some of

the harmful effects of child sexual abuse are largely consequent

on societal disapproval. Despite the high frequency of CSA

reports (see later), most suspicions of sexual abuse continue

to be met with caution, and disclosures are often regarded

with suspicion. This is probably explained by the social taboo

surrounding adult sexual contact with children, the absence of

noninvolved witnesses to this (secret) activity and the potentially

serious consequences for the alleged abuser if found guilty.

Thus the rates of criminal prosecution and conviction are low

(Hagborg et al., 2012) and lower in comparison with other

crimes (Cross et al., 2003).

Controversy has surrounded disputed memories of childhood

sexual abuse recovered in adulthood, (Davies & Dalgleish,

2001). Some memories have returned spontaneously whereas

others have been triggered by reminders or recalled in response

to enquiry that include leading questions and other forms of

suggestion (Loftus et al., 1994; see also Chapter 20). A few have

been induced by over-zealous therapists.While this debate has

(inappropriately) rekindled doubts about the general truth of

allegations made by children, there has now been recognition

of considerable magnitude of CSA outside the family by clergy

and media persons who have gained access to children.

Definitions

A myriad of definitions for legal, research and other purposes

continue to be used. A recent definition guiding child protection

work in England states: “Sexual abuse involves forcing or enticing

a child or young person to take part in sexual activities, not

necessarily involving a high level of violence, whether or not thev child is aware of what is happening. The activities may involve

physical contact, including assault by penetration (for example,

rape or oral sex) or non-penetrative acts such as masturbation,

kissing, rubbing and touching outside of clothing. They may

also include noncontact activities, such as involving children

in looking at, or in the production of, sexual images, watching

sexual activities, encouraging children to behave in sexually

inappropriate ways, or grooming a child in preparation for

abuse (including via the internet). Sexual abuse is not solely

perpetrated by adult males. Women can also commit acts of

sexual abuse, as can other children” (Department for Education,

2013).TheUnitedNations Committee on the Rights of the Child

(UNCRC, 2011) in its General Comment 13 (a detailed guidance

on Article 19 which deals with violence against children)

has the following definition: “Sexual abuse and exploitation

includes: (a) The inducement or coercion of a child to engage in

any unlawful or psychologically harmful sexual activity. Sexual

abuse comprises any sexual activities imposed by an adult

on a child against which the child is entitled to protection by

criminal law. Sexual activities are also considered as abuse when

committed against a child by another child, if the child offender

is significantly older than the child victim or uses power, threat

or other means of pressure. Sexual activities between children

are not considered as sexual abuse if the children are older than

the age limit defined by the State party for consensual sexual

activities; (b)The use of children in commercial sexual exploitation;

and (c) The use of children in audio or visual images of

CSA; (d) Child prostitution, sexual slavery, sexual exploitation

intravel and tourism, trafficking (within andbetween countries)

and sale of children for sexual purposes and forced marriage.

Many children experience sexual victimization which is not

accompanied by physical force or restraint butwhich is nonetheless

psychologically intrusive, exploitive and traumatic.” It is

important to note that the abuser’s intentions or motivations are

not considered necessary to be included in definitions.

The term pedophilia applies to a sexual attraction to, and

arousal by prepubertal children, of either gender. It is clear that

many sexual abusers are therefore not pedophiles.

Cultural aspects

Culturally sanctioned and normative practices may be harmful

(McKee, 1984) and “cultural practice … should not justify hurting

a child or young person” (National Institute for Health and

Care Excellence (NICE), 2009). A particular example of harmful

cultural practice is female genital mutilation (Powell et al.,

2004), which is regarded as a clear form of child abuse in many

jurisdictions.

Legal considerations

The differences between the civil – family and child protection

law and criminal law are pertinent to CSA. The threshold for

a criminal prosecution, which is solely concerned with the

innocence or guilt of the alleged abuser, is higher than that

required for the civil legal protection of the child.

In some jurisdictions, such as in England and the United

Stated of America, civil and criminal proceedings can continue

in parallel and independently of each other. Thus, a child may

be protected from an abuser by being moved from his care

under civil law, when there has been no criminal trial, or a failed

prosecution. In other jurisdictions, child protective procedures

will only follow a criminal conviction of the abuser; the CRC

definition (see earlier) refers to the criminal law. This confers

considerably less protection for children, especially as the

rate of convictions worldwide is low relative to the number of

allegations.

Demographics

The victims

Age of victims

Children may be abused from infancy onwards but frequency

and severity increase with age (Finkelhor et al., 2009; Radford

et al., 2011).

Gender of victims

Girls are more commonly victims of sexual abuse than boys.

There is a tendency for sexual abuse of boys tobe under-reported

(Holmes & Slap, 1998), in part because of shame and the fear

of homosexuality. Extrafamilial abuse more commonly involves

boys although there is no agreement about whether boys are

more commonly abused by strangers (Watkins & Bentovim,

1992).

Disability

The rate of sexual abuse of children with disabilities is 2 or 3

times greater than in “normal” children (Sullivan & Knutson,

2000), the reasons for this including: the children’s difficulties in

communicating about abuse (Morris, 1999); their dependency

on intimate physical care; social isolation in institutional care

(Utting et al., 1997); and care by staff rather than parents (Westcott

& Jones, 1999).

Abusers

Adults

Sexual abusers constitute a heterogeneous group in terms of

personal, social, and demographic factors. The majority of

abusers (85–95%) are male. Men in old age may well continue

to abuse children. Pedophiles, who abuse prepubertal children,

may target both boys and girls (Strassberg et al., 2012). A small

proportion of CSA is carried out by female abusers (Saradjian,

1996), often in conjunction with a man. Women abusers on

their own are more likely to abuse boys (Faller, 1989). There is

no unitary psychological profile of abusers. Moreover, whereas

many will have experienced disruption and physical abuse in

their formative years, sexual abuse in childhood is only one predisposing factor (summarized inWatkins & Bentovim, 1992)

and is not a prerequisite to sexual abuse.

Children and adolescents

Sexual abuse by both children and adolescents, mostly boys,

has become widely recognized and is no longer considered an

acceptable variant of childhood or adolescent sexual development.

A significant proportion of adolescent abusers are of low

intellectual ability and show heterogeneous maladaptive mental

schemata regarding social interaction and abuse (Richardson,

2005). Most children and adolescents who sexually abuse other

children have experienced psychosocial adversity.They include

material neglect, lack of supervision, sexual abuse by a female

person and witnessing intrafamilial violence (Salter et al., 2003),

discontinuity of care, and experience of physical violence and

emotional abuse (Skuse et al., 1998). Sixty six per cent of contact

sexual abuse reported by children and young people in the

United Kingdom was perpetrated by other children and young

people under the age of 18 (Radford et al., 2011).

Many adult abusers report the onset of their abusive activities

in adolescence and abuse by an adolescent cannot necessarily

be considered safely to “burn out” in adulthood (Vizard et al.,

1995). However, there is evidence of good response to treatment

of adolescent abusers (see later).

Abuser–child relationship

The majority of children know their abuser and abuse by

strangers is rare. However, the abuser may befriend the child as

part of the grooming process, or the abuser and child may be

part of the same family, or social network. In community studies,

the commonest relationship is step-father – step-daughter

(Finkelhor, 1984). The same abuser may abuse children both

within and outside the family and include biological as well

as step-children. Intrafamilial abuse continues for longer than

sexual abuse outside the family, and some forms, such as

parent-child abuse, have more serious and lasting consequences

(Finkelhor, 1994.)

The nature and circumstances of the abuse

Frequency and duration of abuse for an

individual child

Whereas some population studies include a majority with a single

episode of abuse, for many children and in clinical samples

there has been repeated abuse by the same abuser, often continuing

for several years.

Contact abuse

Broadly, any physical contact between the breasts and genitalia

of a child or adult and a part of the other’s body, with the

exception of isolated accidental touch or for developmentallyand

age-appropriate cleaning or for applying medication or

ointment, is considered to be sexual abuse. It includes fondling,

masturbation, oral-genital contact or penetration, attempted

or actual digital and penal penetration of, and the insertion of

objects into, the vagina or anus. There is, typically, a gradual

progression from touching to more penetrative abuse (Berliner

& Conte, 1990), so as to avoid causing initial pain or injury

which would be more likely to lead the child to complain about

or report the abuse. Anal abuse is understandably commoner in

boys, although younger girls are not infrequently anally abused

(Hobbs & Wynne, 1989). In a small proportion of cases, actual

physical violence is used, either as a way of intimidating or

coercing the child, or as an integral aspect of the abuse.

Noncontact abuse

This includes deliberate exposure of children to adult genitalia

or sexual activity, either live or depicted in photographs or

film. It also includes intrusive looking at the young person’s

body, inducing children to interact sexually with each other and

taking photographs for pornographic purposes. Although the

most serious effects of sexual abuse are associated with contact,

and especially penetrative, abuse, many young persons report

the experience of being intrusively observed as humiliating and

intimidating, with greater coercion increasing the harm.

The use of the internet andmobile phone technology

Theinternet andmobile phone technology have become sources

of sexual abuse of children by a number of different ways (Taylor

& Quayle, 2003). Childrenmay view pornographic images inadvertently

or by deliberately searching for them. This exposure

is increasing (Wolak et al., 2006) and is reported by children

as very disturbing (Finkelhor et al., 2000). The internet is also

increasingly used by adults in a variety of ways (CEOP, 2013)

including requests for children’s pictures of themselves or for

grooming with the intention of luring children into sexual activity

(O’Connell, 2003). In addition, children are being made the

subjects of abuse images (Palmer, 2005). Lastly, child pornography

may act as a motivator or reinforcer of sexually abusive

activity by adolescents (Quayle & Taylor, 2006). Children are

also distributing images of themselves and of other children captured

on mobile phones. As with other forms of sexual abuse,

children and adolescents are often reluctant to talk about this

activity,whichmay be discovered in the course of criminal investigations

regarding material found on computers, rather than

disclosed by the child.

Organized abuse

Most abusers abuse in isolation. However, there are also

organized forms of abuse involving more than one abuser and

multiple children, some of whom are recruited in sex rings

(Wild & Wynne, 1986). Some adolescents are being targeted

on the basis of their vulnerability, for example, living in care

and institutions. Organized abuse also includes the use of

children and young persons for the production of child pornography.

Questions remain about the reliability, verifiability, and credibility (Young et al., 1991) of the reports of formalized

rituals (Frude, 1996).

Commercial sexual exploitation of children

Commercial sexual exploitation or “transactional sex” (Williams

et al., 2012), involving both boys and girls, takes the inter-related

forms of prostitution and trafficking – usually across borders

(Chase & Statham 2005). While an accurate scale of the problem

is difficult to determine (Dottridge, 2008), it is likely to be

global and increasing with economic hardship (ECPAT International,

2009). Sexual exploitation can provide a source of money

to support drug dependency and introduces the young person

to addictive drugs as a means of gaining control over them for

subsequent sexual exploitation.

Abuse by clergy, media personnel, and in

institutions

Sexual abuse by clergy and media personnel has come to

light in a number of countries including the United Kingdom,

Ireland, the United States of America and Australia.

It includes abuse of both single and multiple victims, across

the age-range and of both genders (Haywood et al., 1996),

although boys were over-represented (Parkinson et al., 2012).

Finkelhor (2003) mentions negative as well as some positive

consequences including increased public belief in the existence

of CSA; enabling more children and adolescents to talk of their

own abuse; lessening the stigma of sexual abuse for boys; and

recognition of corporate or organizational responsibility for

employees’ behavior.

Children in residential settings are particularly vulnerable,

being dependent on staff and often isolated from confiding

contact with adults outside the residential setting (Utting et al.,

1997).

Epidemiology

Published figures for incidence and prevalence of CSA vary considerably

according to the definition used, the source of data, and

the population studied. Whereas broad definitions point to the

extent of the problem, they are less helpful in indicating severity

and the kind of therapeutic services required.

Prevalence

The most accurate prevalence figures are from population studies

(Finkelhor et al., 1990). Even here, responses to interviews

or questionnaires may be underestimates, due to reluctance to

report, or a lack of recall of previous abuse, even when this had

been documented at the time (Williams, 1994).

In population, as opposed to victim samples, nonpenetrative

contact abuse is more commonly described than in clinical samples.

A meta-analysis of self-report studies across a number of

countries (Andrews et al., 2004) found the following prevalence

rates (see Table 30.1).

Table 30.1 Prevalence rates of sexual abuse.

Girls (%) Boys (%)

Any sexual abuse 25.3 8.7

Contact abuse 13.2 3.7

Penetrative abuse 5.3 1.9

In a retrospective study using a questionnaire with a random

probability sample of 18–24 years olds in the United Kingdom

(May-Chahal & Cawson, 2005) 10% reported experiencing contact

sexual abuse while under 16 years of age (15% girls and

6% boys). A retrospective study from the United States, using

a mailed questionnaire to a national geographically stratified,

random sample of 1442 subjects with mean age 46 years (range

of 18–90) yielded a response by 64.8% and 32.3% female and

14.2% male respondents reported childhood sexual abuse. Rates

of abuse within the immediate or extended family (46.8%) and

penetrative abuse (52.8%) did not differ according to gender of

subject (Briere&Elliott, 2003). Prevalence rates of maltreatment

including CSA were reported in a recent large random probability

sample from the United Kingdom, in which there were

interviews with parents of children under the age of 11 years,

children aged 11–17 and their caregivers, and young adults aged

18–24, respectively (Radford et al., 2011). Percentage of contact

and overall, including noncontact, sexual abuse in the samples

was reported as follows (see Tables 30.2 and 30.3).

Considerable co-occurrence of different forms of maltreatment

is reported in many of these studies.

Fluctuations in rates of reported cases

Rates of reporting increased over the 20 years after 1970, both

in the United Kingdom (Markowe, 1988) and in the United

States of America (Finkelhor, 1991) probably due to increased

awareness with little evidence that the actual incidence had

been changing significantly (Feldman et al., 1991). However,

the number of substantiated cases of CSA in the United States of America has decreased by an estimated 49% between 1990

and 2004 with fewer disclosures, confessions by abusers and a

reduction in emotional and behavioral problems associated with

CSA (Finkelhor & Jones, 2006). A similar finding, of declining

rates of sexual abuse of males over some decades and of females

more recently, has been reported from Australia (Dunne et al.,

2003) and a possible decline in substantiated cases in Canada

(Collin-Vézina et al., 2010) and the United Kingdom (see

Radford et al., 2011 above). There could be several reasons for

these findings: (a) an actual decline (Finkelhor & Jones, 2004)

possibly signaling a positive effect of interventions for reported

CSA; growing awareness of children’s rights or greater vigilance

and child-focused parenting; (b) a decline in reporting due, for

instance, to fear of legal repercussions or (c) changes in agency

responses to reported abuse, such as increased cautiousness and

a raised threshold for an active professional response. It is likely

that this decline in substantiated cases of sexual abuse reflects

some actual reduction in incidence.

Country, ethnicity, culture, socioeconomic,

and family status

CSA is now reported frommost, including developing countries

(e.g., Luo et al., 2008) with some 5% of children in sub-Saharan

Africa reportedly experienced penetrative sexual abuse in childhood

(Lalor, 2004).

Within theUnited Kingdomand theUnited States of America,

population-based studies have shown no ethnic differences in

the rates of CSA (Fontes, 1995).However, data onCSA incidence

in minority and different ethnic communities are lacking, partly

due to decisions on data collection criteria, which do not classify

racial/ethnic background sufficiently finely, and partly because

shame and denial about sexual abuse within some minority cultures

conspire against reporting. Incidence within a particular

ethnic group may reflect effects of that group’s recent traumatic

and migration experiences, rather than aspects of the particular

culture. Lastly, some societies continue to find difficulty in

facilitating open acknowledgment of the existence of child maltreatment

in general and sexual abuse in particular.

Socioeconomic status is unrelated to the incidence of CSA

in population studies (Berliner & Elliott, 1996) but there is an

overrepresentation of lower socioeconomic groups in clinic

samples (Bentovim et al., 1987). This may be because these

groups are more likely to come to the attention of child protective

agencies than middle class families who may find ways

of hiding the abuse or avoiding its reporting (Gomes-Schwartz

et al., 1990). Different forms of child abuse and neglect are

not infrequently found in the same family and the same child

(Mullen et al., 1994), especially among the socially disadvantaged.

CSA is associated with troubled family life including

family disruption (Russel, 1986), reconstituted families, intrafamilial

violence (Bifulco et al., 1991), and parents who are

perceived as emotionally distant and uncaring (Alexander &

Lupfer, 1987).

Risk and maintaining factors

for child sexual abuse

There is no unitary theory of causation to explain CSA.

Although, by definition, it is an interaction between the

abuser/perpetrator and child/victim, intention and responsibility

rest with the abuser.The abuser’s wish for sexual gratification

and for power are the two main motivators. Pedophilia is based

on sexual arousal to prepubertal children. An explanatory

theory needs to include biological, psychological, cultural, and

situational factors (Ward & Siegert, 2002).

Finkelhor’s (1984) systemic model of four preconditions continues

to provide a basis for understanding CSA.They are:

1 Motivation to sexually abuse children

Motivations include pedophilia, fear/avoidance of peer intimate

and sexual relationships, sadism; interpersonal motivators

such as a need to overpower or gain mastery over more

vulnerable persons, often as a result of one’s own past abuse

and low self-esteem. Sexual interest in children and a consequent

predisposition to sexual abuse is far commoner than the

action, requiring other factors to exist before abuse will actually

occur. Mothers who sexually abuse have been described

as simultaneously attacking andemotionally engulfingor possessing

their children (Welldon, 1988).

2 Absence of internal inhibitors

Absence of internal inhibitors includes the effects of alcohol

and emotional dysregulation. Abusers also use cognitive

distortions or rationalizations including minimization of the

harm to the child; conceptualizing the abuse as “love” or “education”;

and placing responsibility on the child or adolescent

who is described as inviting or requesting the abuse.

3 Absence of external inhibitors

External inhibitors of sexual abuse include cultural, social,

and family protective structures and relationships surrounding

the child, in particular a secure attachment to primary

caregiver(s), good monitoring of the child’s whereabouts and

the existence of confiding relationships for the child. Their

absence renders the child or adolescent vulnerable to sexual

abuse.

4 Child’s vulnerability

The particular child’s vulnerability by virtue of age, disability,

neglect, being orphaned and homeless, social isolation,

and previous sexual abuse all increase the likelihood of sexual

abuse, all of which abusers recognize.

This explanatory schema does not remove the abuser’s responsibility

for the abuse, whatever the nature of contributory risk

factors.

Maintaining factors

Despite a growing recognition of CSA worldwide, the censure

surrounding it leads to secrecy, denial, and disbelief of children

about its occurrence. About 1 in 3 young people show no outward

indicators (Kendall-Tackett et al., 1993), allowing abuse to

be undetected over prolonged periods.This is particularly likely with children as compared with adolescents (McLeer et al.,

1998). By the time sexual abuse is discovered in childhood, it

has often occurred repeatedly. In the Radford et al. (2011) study,

in 34% of cases of sexual assault by an adult and 82.7% of cases

of sexual assault by a peer nobody else knew about it at the time

of the interview. Children’s own coping through a psychological

accommodation process may help to maintain the secret.

Effects of child sexual abuse

Charting the “natural history” of sexual abuse-related symptomatology

is difficult for a number of reasons. Most studies

have been retrospective and have variously included clinical,

convenience, and population samples. While there is no post

CSA syndrome (Kendall-Tackett et al., 1993; Paolucci et al.,

2001), CSA is a significant risk factor for mental health disorders

both in childhood and adulthood (Cutajar et al., 2010) as

well as having effects on physical health. There has been little

systematic study of the effects of CSA on people with learning

disability. Findings suggest that the effects are similar to those

in the general population (Sequeira & Hollins, 2003).

Effects in childhood and adolescence

Not all children who have been sexually abused will develop

difficulties and some will develop them only later (Saywitz et al.,

2000). However, a wide range of difficulties, which may not

appear immediately, has been found with considerable effect

sizes: depression, anxiety, PTSD, self-harm, low self-esteem,

conduct disorder, drug misuse, age-inappropriate sexual activity

(Friedrich, 1993) and promiscuity, sexual victimization of other

children, and academic underachievement (Kendall-Tackett

et al., 1993; Paolucci et al., 2001; Cutajar et al., 2010). Some

symptoms – post-traumatic phenomena and sexualized behavior,

attenuate only slowly (Beitchman et al., 1991) even with

treatment (Lanktree & Briere, 1995). Bulimia has also been

found following CSA (Carter et al., 2006). Sexual abuse may

lead to unwanted pregnancy or sexually transmitted disease

including HIV. Rarely, it may cause genital injuries. However,

the search for conclusive evidence of CSA on the basis of

physical signs is now deemed of limited value (Adams, 2010).

Useful instruments to assess effects include Children’s Impact

of Traumatic Events Scale – Revised (CITES-R) (Wolfe et al.,

1991) and the Trauma Symptom Checklist for Children (Briere

et al., 2001).

Factors and postulated explanations for variability

Paolucci et al. (2001) found that gender, socioeconomic status,

type of abuse, age when abused, relationship to perpetrator,

and number of incidents of abuse did not moderate the effects

of CSA on depression, PTSD, self-harm, inappropriate sexual

activity, and academic achievement. Cutajar et al. (2010) found

that affective, anxiety, conduct, and other childhood Axis I

disorders and drug abuse, but not PTSD, were significantly

associated with sexual abuse at a younger age. Penetrative abuse

and abuse by more than one perpetrator were associated with

mental health disorders.

The variability of post-sexual abuse difficulties, and the search

for possible protective or ameliorating factors, has led to much

research on moderating factors, with conflicting results, summarized

in Yancey et al. 2013. They have grouped potential

factors into (i) child’s personal factors (age at abuse, gender,

and attributions about the abuse); (ii) family factors (parental

own sexual abuse and mental health and family stress); and

(iii) abuse-specific factors (victim-perpetrator relationship and

abuse duration and severity). Using a cluster analysis, they

established four distinct subtypes of clinical presentation following

CSA: (a) a highly distressed group with clinical levels of

child-reported depression, anxiety and PTSD symptoms, and

parent-reported internalizing, externalizing, and sexualized

behaviors; (b) a problem behavior group with parent-reported

difficulties as in (a); (c) a self-reported distress group of children

reporting difficulties as in (a); (d) a subclinical group with

low level child and parent reports, respectively. They found

that (i) a child’s negative attributions about the abuse such as

self-blame and shame correlated significantly with being in the

highly distressed and problem behaviors groups; (ii) children

in the highly distressed group had parents with depression;

(iii) children whose sexual abuse included penetration were

more often in the highly distressed group.

Other influences on outcomes have been found.Maternal coping

through avoidance strategies correlates with deterioration

in behavior (Oates et al., 1994). Onset of sexual abuse before

the age of 7, appears to be a risk factor for later inappropriate

sexualized behavior (McClellan et al., 1996; Mian et al., 1996).

Boys experience anxiety about their own latent homosexuality

or having been rendered homosexual by the abuse (Watkins &

Bentovim, 1992). Distress following CSA is greater in girls with

higher cognitive functioning (Shapiro et al., 1992). Interestingly,

the child’s coping strategies and cognitive evaluation of the abusive

experiences have been shown to contribute less to the child’s

later functioning than severity of the abuse and the support of

the non-abusing caregiver (Spaccarelli & Kim, 1995). Bal et al.

(2003) suggest that for adolescents, avoidant coping strategies

following sexual abuse are associated with more distress.

Protective factors

Thenon-abusing parent(s)’ belief, support, and active protection

of the child are significant determinants of a better outcome for

the child regardless of the nature of the sexual abuse (e.g., Everson

et al., 1989). Conversely, the closer the relationship between

the abuser and the non-abusing caregiver(s), the less the child

will be supported by her caregiver(s) (Berliner & Elliott, 1996).

Effects in adulthood

Mental health

CSA is followed by significant adult mental health problems

(Fergusson et al., 1996) and has been estimated to contribute independently to 13.1% of adult psychopathology (Fergusson

et al., 2008). Findings from many retrospective studies have

been confirmed by a large, controlled prospective study from

Australia (Cutajar et al., 2010), which found that 23.3% (22.5%

female, 26.5% male) of adult survivors of substantiated CSA

required lifetime (childhood or adulthood) mental health services,

in comparison with 7.7% of a comparison population

sample. Effects are summarized in the Table 30.4.

Stigma and self-blame, but not betrayal and powerlessness,

have been found to mediate the effects of sexual abuse on

adult psychological functioning (Coffey et al., 1996). Contrary

to common belief, a systematic review of the impact of

CSA on health (Maniglio, 2009) did not find that a number

of variables concerning aspects of the abuse experience, such

as age when abused, incestuous abuse, level of contact, use of

force, frequency, and duration of abuse, influence the outcomes

of CSA.

Only a minority of homosexual men have been sexually

abused in childhood, and they have no greater sexual interest in

children than heterosexual men.

Physical health

CSA, among other forms of maltreatment and other adverse

childhood experiences, is significantly associated with adult

physical illnesses and earlier death (Felitti et al., 1998).

Suspicion, recognition, investigation,

validation, and protection

Principles

Whenever sexual abuse is suspected or presented explicitly to

a professional, including child mental health practitioners, a

multi-agency professional involvement will follow. Its broad

aims are to ascertain what, if anything, has happened to the child

and to gain an understanding of the child’s current functioning,

family context, and needs. If the child has been abused, the

child’s needs will include:

(a) immediate and long-term protection

(b) amelioration of the effects of the abuse including

(i) reduction of distress and the resolution of internal conflicts

and mental health disorders

(ii) resolution of interpersonal conflicts surrounding the

child

(iii) treating physical consequences of the abuse

(c) ensuring optimal development for the child following cessation

of abuse.

The achievement of these aims is, in practice, fraught with

difficulties. Suspicions need to be verified and a child’s account

tested, because protection comes at a cost and therapy can only

follow protection. As there are rarely witnesses to the abuse,

establishing whether it has occurred will rest heavily on the

child’s verbal description, which may be retracted even if it

was true. Discovery of abuse is often accompanied by denial

by the alleged abuser, and some doubt or disbelief, and usually

constitutes a crisis for the family and a challenge to the

professional system. The child’s ultimate well-being will, to a

significant extent, be determined by the support given by the

family. The nature of the early intervention by professionals,

and their consideration of the position and needs of the mother

or non-abusing caregivers, will have long-lasting effects on the

child’s and the family’s subsequent expectations and attitudes

toward professionals with whom they may need to continue

to work.

In most countries, the responsibility for protecting the child

rests with social services or the courts to whom suspicions of,

or actual abuse are reported. The subsequent multidisciplinary

and multi-agency process involves, in addition, the police,

health, education, and the courts. A number of well established,

coordinated steps in the process have been identified, each step

depending on the outcome of the previous one, and involving a

number of agencies:

1 Suspicion or recognition leading to referral to (child protection)

social services

2 Establishing whether there is a need for immediate protection

3 Planning the investigation including

° interagency discussion

° interviewing the child

° medical examination of the child

° initial assessment of the family

4 Validation and initial child protection meeting (conference)

leading to a protection plan and a more comprehensive

assessment

5 Implementation of plans and review

6 Possible criminal prosecution

7 Therapy.

Suspicion, recognition, and disclosure

CSA either comes to light when a child talks about it to a friend,

relative, or a teacher or is suspected on the basis of one or

more indicators which are more or less specific. Spontaneous

and intentional disclosures are likely to be credible. Specific

indicators include: age-inappropriate sexualized behavior, and

rarer genital physical signs, sexually transmitted diseases, and

pregnancy in a young girl or when the identity of the father is

unclear (NICE, 2009). Nonspecific indicators include sudden

onset of unexplained difficulties in a previously untroubled

child such as distractibility, educational deterioration, social

isolation, aggressiveness, low self-esteem, marked unhappiness,

disturbed sleep and nightmares, fearfulness, and separation drug and alcohol misuse may arise later.

CSA of other children in the family and known contact with a

sexual abuser should also raise the possibility of abuse of a particular

child.

Source and explanations for indicators of CSA need to be

explored in a non-leading way. This is important as children

(especially younger ones) will not usually describe sexual abuse

during a formal interview, unless they have previously spoken

about it (Keary & Fitzpatrick, 1994). (The converse is not,

however, true). As a result of such enquiries, sexual abuse may

come to light.

Disclosure of sexual abuse needs to be reported to social

services or police who will inform each other; confidentiality

will need to be overridden. A child may not wish for their

disclosure to be passed on. As this cannot be honored, the

child’s misgivings need to be explored, and the child requires

an explanation for the need to report the abuse. Referral is

usually made with the knowledge of the family, unless there are

indicators that this will place the child at increased risk which

includes placing pressure on the child to retract an allegation.

The investigation, protection, and formal

interview

The need for immediate protection is a decision of social services

or the court in consultation with other professionals and agencies.

There are helpful guidelines in most developed countries,

including those by the American Academy of Child and Adolescent

Psychiatry on evaluation and treatment of trauma abuse

(AACAP, 1997).

Children will be interviewed formally if there are clear

suspicions of abuse or if the child has already disclosed the

abuse informally. The formal interview should be carried out

by trained professionals, usually police and social workers,

and video-recorded evidence can be used both for criminal

prosecution and/or civil legal child protection proceedings. It is

therefore carried out according to strictly specified guidelines

(Lamb et al., 2007). Rarely, when children are too distressed or

traumatized or have significant difficulties in communication, a

child mental health professional may be required to interview

the child. Facilitated Communication with autistic children

who are suspected of having been abused is not recommended

(Howlin & Jones, 1996). Anatomically-correct dolls should not

be used as a screening tool or cue despite little evidence that

young, non-abused children proceed beyond exploration of the

dolls’ genitalia (Glaser & Collins, 1989).

Validation

Validation of CSA requires assessment of the evolution of suspicions

and the circumstances as well as the crucially important

content of the child’s first description or disclosure of abuse;

the outcome of a formal interview; findings in a medical examination;

family circumstances; the child’s relationship with the

alleged abuser; and the responses to the allegation by themother

or the non-abusing caregivers and by the alleged abuser. In a retrospective

review of 551 case notes of reported concerns about

possible CSA, 43% were substantiated, 21% were inconclusive,

and 34% were not considered to be abuse cases. Only 2.5% were

erroneous concerns emanating from children, and included

only 8 (1.5%) of false allegations originating from the child,

and 3 made in collusion with a parent (Oates et al., 2000). In

other studies, false allegations are found to be most commonly

made by a parent in the context of contact or residence disputes

between warring parents, or rarely under the influence of a

parent in the context of inter-parental disputes (Faller, 2005).

The nature of protection

A child can only be protected from further harm when all contact

with the alleged abuser is either fully supervised or stopped

and when the child is believed and not blamed for the abuse or

the disclosure. Children abused by persons outside the family

tend to be excluded from child protective services on the, sometimes

erroneous (Tebbutt et al., 1997), assumption that they will

be protected by their families. If protection is achieved, and if nolegal proceedings ensue, there may never be a formal record of

the validated fact of the abuse.

Therapeutic work

Therapeutic work follows closely on protection. A systemic

treatment approach to the effects of CSA attends to the child’s

needs both individually and in the context of the family.

Relationships between the three participants in the “abuse triangle”

– the abuser, the child, and the non-abusive caregiver(s)

(Glaser, 1991) are important. Some of the child’s acute difficulties

may be related more to their family’s response to the abuse

or to moves and separation from the family than to the sexual

abuse. Work with the child needs to be linked with work with

the parent(s) or caregivers and family, separately and together.

Fulfilment of children’s therapeutic needs

Not all children who have been sexually abused require therapy.

However, a minimum requirement is for the child to have an

appropriate narrative about their abuse and to have access to an

identified person who believes the child and is able to listen to

the child supportively and uncritically. Coping by avoidance,

which includes not being able to talk about the abuse when

appropriate, is a predisposing factor for the development of

PTSD (Kaplow et al., 2005). Children who have been sexually

abused also require age-appropriate education about sexuality

and the nature and risks of sexual abuse.

Although some symptoms such as sexualized behavior are

readily apparent, others such as PTSD or depression may need

to be actively sought within a full assessment of the child’s

functioning. It is important to include children who have been

abused by strangers or by someone outside the family (Grosz

et al., 2000), as their therapeutic needsmay be overlooked when

protection from re-abuse is not required.

There are several ways in which treatment approaches for children

can be categorized. Childrenmay be treated individually or

in groups; treatmentmay be offered to a sexually abused child or

directed at specific symptoms; there is a range of different treatments

including psycho-education about sexual abuse, sexuality

and self-protection, comprehensive brief trauma-focused work

with the child and parents, and intensive and more prolonged

therapeutic work. Finkelhor & Berliner (1995) found that overall,

therapy facilitated recovery independently of time elapsed

from the abuse and other external factors and particularly when

directed at specific difficulties. Others have found no effects of

treatment (Oates et al., 1994; Tebbutt et al., 1997) or some deterioration

during therapy for aminority of children (Jones & Ramchandani,

1999). It is not clear what contribution intercurrent

developments in the child’s life or therapy made to the reported

deterioration.Despite this, treatment should be offered to symptomatic

children.

Several meta-analyses have found large to moderate effect

sizes for psychotherapy, group treatment, and CBT combined

with supportive, psychodynamic, or play therapy. King et al.

(2000) found that, compared with wait-list controls, children

with PTSD who received CBT either individually or as a family

intervention improved equally in both treatment conditions.

Group therapy

Overall good outcomes have been reported for group therapy

in terms of general psychological distress, internalizing and

externalizing symptoms, sexual behaviors, self-esteem, and

knowledge of sexual abuse/prevention (Reeker et al., 1997).

Several reviews have shown individual and group treatments to

be equally effective (Trask et al., 2011).

Parallel groups for caregivers support the process (Rushton &

Miles, 2000).

Individual therapy

Several meta-analyses (Hetzel-Riggin et al., 2007; Sánchez-

Meca et al., 2011; Trask et al., 2011) have found an overall

improvement in the many difficulties studied. Longer duration

of treatmentwas associated with larger effect sizes and treatment

effects tended to be maintained. There were conflicting results

regarding the inclusion of the caregiver. Boys did well.

Specifically, several studies of trauma-focused cognitive

behavioral therapy (TF-CBT) (Cohen et al., 2006) were included

in the meta-analyses.This programmatic, trauma-focused work

involves the child and parent. It includes psycho-education,

parenting skills, and relaxation for the child; recognition of

feelings and learning to master and modulate affect are followed

by cognitive coping. A narrative account is followed

by beginning of reprocessing of the traumatic experience, correcting inaccurate recollections and unhelpful cognitions

and mastering traumatic reminders. Despite some uncertainty

regarding the outcomes (Macdonald et al., 2012), it is likely that

TF-CBT is helpful for PTSD, anxiety, and depressive symptoms

but may be less effective in treating externalizing behaviors.

Nondirective supportive therapy does not appear to be of much

benefit. Adolescent depression following sexual abuse appears

to respond less well to CBT (Barbe et al., 2004).

Therapeutic work with caregivers and family

Non-abusing caregivers

The outcome for the abused child is, in part, determined by the

mental health of the non-abusing caregivers, who are often faced

with a conflict of loyalties between the abuser and the child, as

well as guilt for not protecting the child and possibly memories

of their own past abuse. Lack of belief in and support of the child

may lead to removal of the child. Individual or group work is

therefore important.

Siblings and the family

Siblings are sometimes the silent witnesses of abuse and may be

overlooked. Whole family meetings are important in enabling

the family to talk openly about the fact of the abuse but would

not include an abuser unless he has taken responsibility for the

abuse and is receiving treatment. Other dysfunctional aspects

of family interactions that are associated with CSA include,

in particular, inappropriate intergenerational boundaries, and

parental neglect and unavailability which also need to be

addressed (Elton, 1988).

Work with abusers

Child and adolescent abusers

The treatment of child and adolescent abusers requires coordinated

support by child protective and youth justice systems as

well as support by the young person’s parents or primary caregivers.

Cognitive behavioral therapy (Kolko et al., 2004) which

may be offered individually or in groups, includes:

• challenging denial and minimization of the abuse and responsibility

for it

• sex education

• development of social skills

• victim awareness

• recognition of cognitive distortions concerning the abuse

• mapping the abuse cycle (Hawkes, 1999) and learning to halt

its progression.

Structured group work for children and young adolescents

who had sexually abused has been shown to be effective with

a long follow-up showing little recurrence (Carpentier et al.,

2006).

A small number of children and adolescents may show features

of lack of empathy and cruelty, which will indicate a more

serious problem and call for careful monitoring of the child

and very skilled therapy, sometimes requiring residential care

(Vizard et al., 1995).

Adult abusers

Treatment for adult abuser is important for those children who

wish to resume a meaningful relationship with him and for

society in general. Therapy addresses denial of the extent of the

abuse, responsibility for the abuse, and the harm caused to the

child. CBT has shown significant reduction in recidivism in sex

offenders (Hanson et al., 2002).