Parent Handbook for PTSD in Children by hanlie_wentzel

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The Spirit of the Lord GOD is upon me; because the LORD hath anointed me to preach good tidings unto the meek; he hath sent me to bind up the

brokenhearted, to proclaim liberty to the captives, and the opening of the prison to them that are bound. -Is. 61:1 ●

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2018

CHILD ABUSE and TRAUMA/PTSD Parent Handbook

Hanlie Wentzel 079 877 8678 Baobab Consulting hanlie.baobab@gmail.com www.baobabtherapy.com

Content: Psycho-Education & Skills Building Page 1. Background information on Child Abuse Did you know? Child Abuse Facts Worldwide statistics

2. Myths of Child Abuse

3. Definition of Child Abuse

4. Categories of Abuse 4.1 Physical Abuse 4.2. Emotional/ Psychological abuse 4.3. Neglect 4.4 Sexual Abuse Family Incest

5. Sexual Predators 5.1 Profile Of A Child Molester 5.2 Signs of Child Molestation 5.3 How To Report Suspected Child Predators

6. Causes of Child Abuse and Neglect 6.1 The Parents that Abuse 6.2 The Family

7. Appropriate/ Inappropriate Childrenâ&#x20AC;&#x2122;s Behaviours Related to Sex, Sexuality and Gender

8. Bullying

9. Child Abuse Effects

10. Keep your child safe: Prevention and Protection

11. Intervention 11.1 Disclosure of Abuse 11.2 Stages of Recovery and Healing 11.3 Post-traumatic Stress Disorder, Stress and Trauma

12. Treatment

13. Adult Survivors of Childhood Abuse

1. Background information on Child Abuse DID YOU KNOW? 1 in every 3 girls will be sexually molested before the age of 18 1 in every 6 boys will be sexually molested before the age of 18 Every 10 SECONDS a child is raped or killed in the U.S. Today up to 5 children will die from abuse or neglect In 13 seconds, another child will be abused in the U.S There were 2.9 million child abuse reports made in 1992 ONLY 28% of the children identified as harmed by abuse are investigated 85% of the 1.2 - 1.5 million runaways are fleeing abuse at home Today 6 children will commit suicide Suicide is the 3rd leading cause of death (ages 15-24) Untreated child abuse increases the likelihood of arrest for a violent crime by 38 npercent 60 MILLION survivors are former victims of child sexual abuse in America today 38% of women & 20% of men have been sexually abused during adolescence It is estimated that 3%-6% of the clergy population has abused a child The typical child sex offender molests an average of 117 the offense

children - most of whom do not report

Imagine the outcry if these statistics represented a disease, which was wiping out 5 children per day, victimizing millions, and who's by-products where disabilities and expanding violence. Youth rights are really about human rights, and simple empathy is a giant first step to the benefits of increased awareness. The high jump in child abuse statistics shows the importance of youth rights by showing cases of frightening lack of knowledge!

CHILD ABUSE FACTS The safest family for a child is a home in which the biological parents are married. Co-habitation, an increasing phenomenon, is a major factor in child abuse. The incidence of child abuse decreases significantly as family income increases. Child abuse frequently is inter generational. Child abuse is prevalent in "communities of abuse" with family breakdown. Child abuse is directly associated with serious violent crime. The lowest risk for physical abuse is one in which the biological parents aremarried and family has always been intact. Abuse is 6x's higher in the second-safest environment: the blended family in which the divorced mother has remarried. Abuse is 14x's higher if the child is living with a biological mother who lives alone. Abuse is 20x's higher if the child is living with a biological father who lives alone. Abuse is 20x's higher if the child is with biological parents who are not married but are cohabiting. Abuse is 33x's higher if the child is living with a mother who is living with a man. 1,500 children die from abuse each year. There are 140,000 injuries to children from abuse each year. There are 1.7 million reports of child abuse each year. 1 in 4 women in North America were molested in childhood. 2 million+ cases of child abuse and neglect are reported each year in the U.S. An estimated 150,000 to 200,000 new cases of sexual abuse occur each year. There were an estimated 903,000 victims of maltreatment nationwide. An estimated 1,100 children died of abuse and neglect, a rate of approximately 1.6 1 in 7 males will have been sexually molested before the age of 18. 10 deaths per 100,000 children per year in the general populations. Each day in the U.S. more than 3 children die as a result of child abuse in the home. Child abuse is reported on average every 10 seconds.

Approximately 3 MILLION child abuse reports are made each year. Only two-thirds of the reported cases were investigated. An estimated 903,000 victims were substantiated by child protective services agencies in 1998. Convicted rape and sexual assault offenders report that 2/3 of their victims were under the age of 18. Rape victims less than 12 years of age, 90% of the children knew the offender, according to police reports. Frequently, the person who sexually molests a child is also a child themselves.

WORLDWIDE STATISTICS: Worldwide, approximately 40 million children are subjected to child abuse each year (WHO, 20014). Suicide is the third leading cause of death in adolescents around the world (WHO, 20025). One study revealed that about 30% of all severely disabled children relegated to special homes in the Ukraine died before they reached 18 years of age (Human Rights Watch, 20016). UNICEF estimates that two million children died as a result of armed conflict during a recent 10-year period, and that another six million were injured or disabled (Human Right Watch, 20017). In Canada, U.S. and Mexico, over 6.5 million children annually are exposed to sexual materials on the Internet; 1.7 million of these report distress overexposure to these materials (Estes & Weiner, 20018). Each year, approximately one million more children around the world are introduced into commercial sexual exploitation (Casa Alianza, 20019). Sexual abuse statistics vary between countries and reports, but are consistently alarming: One country's research indicates that up to 36% of girls and 29% of boys have suffered child sexual abuse; another study reveals up to 46% of girls and 20% of boys have experienced sexual coercion (The 57th session of the UN Commission on Human Rights10).

2. Myths about Child Abuse There are many myths about child abuse, for example: children are usually molested by strangers; there is a universal taboo in all cultures about incest; men who abuse are psychotic or retarded; incest only happens to girls; the child always feels negative towards the offender; mothers know of incest and condone it; it does not happen in my family or community; and there is no love and affection in families in which abuse occurs.

3. Definition of Child Abuse “Any interaction or lack of interaction by a parent or caretaker which results in the nonaccidental harm to the child’s physical and/or developmental state.” The term child abuse therefore includes not only the physical non-accidental injury of children, but also emotional abuse, sexual abuse and neglect. Therefore abuse can range from habitually humiliating a child to not giving the necessary care.

4. Categories of Abuse 4.1

Physical abuse

Physical abuse is regarded as the non-accidental injury or other physical harm inflicted upon a child. Injuries range from cuts and bruises to burns and fractures and the consequences may include death, and permanent disability of the body and/or psyche of the child. Physical abuse can also include the administration of drugs or alcohol e.g. inappropriate medication or sedation of a child. 4.1.1 What Constitutes Physical Abuse? � Beating � Scolding � Hitting with an object � Strangulation � Tying up � Locking in a small space � Burning � Kicking � Sticking with pins � Suffocation � Murder � Burning with cigarettes or hot objects 4.1.2. Physical Abuse Indicators � Unexplained bruises/ welts � Unexplained burns � Bald spots and scalp bruises �Unexplained abdominal injuries � Unexplained lacerations, abrasions, fractures � Bite marks 4.1.3. Behavioral Signs for Physical Abuse � Weary of adult contacts � Behavioural extremes � Apprehensive when other children cry � Frightened of parents and afraid to go home � Absence from school, particularly on Mondays � Reports injury by parents � Lags in emotional and intellectual development � Unbelievable explanations for injuries

Signs of physical abuse #1: BRUISING Bruising is the most common of abuse injuries. There are four factors to take into account when determining whether or not the bruising is suspicious: location, size, color and frequency.

Location Normal bruising can be found on the knees, shins, elbows, and the forehead. Toddlers are especially vulnerable to forehead bruising, as they frequently bump into furniture, counters, anything that is at their head level. But the size of the bruise(s), the color, and the frequency in which bruising occurs can turn even normal bruising into suspicious bruising. Suspicious bruising can be found on the face, head, chest, back, arms, genitalia, thighs, back of the legs, and buttocks.

Size The size of the bruise(s) can tell us what object or body part the child was struck and/or harmed with. See under Beatings and Choking for more details on size of bruising.

Color: The color of the bruise(s) can tell us how fresh the bruise is and the force with which the child was struck. With Caucasian people, a bruise takes on a red, purple, black or blue appearance when it first appears, depending on the force of the blow. As the bruise heals it will turn green, and then become jaundice yellow before fading away completely. Though it seems obvious, I'll say it anyway: these changes in color will be difficult to see in dark-skinned children. Just remember that bruising is only one sign; keep reading for other signs.

Frequency: The more frequent the bruising incidents occur, the more likelihood of physical child abuse. The child may have a legitimate reason for the bruising, but if there are too many incidences, then the red flags of suspicion should go up.

Signs of physical abuse #2: BEATINGS The pattern of bruising and/or abrasions will resemble the shape of the object or body part used. The most common are belts, sticks, bats, bottles, and fists), but children are frequently attacked with firearms and knives.

If a belt is used, there will be red welts that are the width of the belt. There may also be bruising, and/or bleeding. The length of the welt depends on how much of the belt came in contact with the skin. Typically, caregivers who use a belt will strike the buttocks, the back, and the backs of the legs. If a child is beaten with a fist, the shape of the bruise(s) can be that of a whole fist, or the bruising can show up as a cluster of lines (the imprint of the fingers of the fist). If the knuckles were used, bruising will be a line of roundish discolorations that are somewhere between the size of a dime and a quarter, depending on the size of the fist. Caregivers who use their fists generally give blows to the face, head, chest, stomach, and arms. Injuries are often to the face and head: black eyes, bloody and/ or broken nose, fat and split lips, swelling of the eyes, cheeks or jaw, bruising and abrasions to the side of the head. Broken ribs and internal injuries can also result with severe blows to the chest and stomach.

Signs of physical abuse #3: BURNING Burning is the third most frequent cause of death in children from 1 - 14 years of age, and the fourth most frequent in children under one year of age. 70 - 90% of childhood burns occur in the home during the winter months, early morning and late afternoons being the most vulnerable times. There are several kinds of burns: chemical, cigarette, electrical, heat, and water burns. Each presents their own unique signs of physical abuse. With chemical burns on the skin's surface, depending on the chemical used, there can be a rash, blistering, and/or open sores that are pushing and/or bleeding. When caustic substances such as lye or acid are thrown, they are typically aimed at the child's face. If a child is forced to ingest chemicals, there will likely be nausea, vomiting, cramping, chest and abdominal pain, distention, and possibly unconsciousness. Cigarette burns will be the size and shape of the cigarette tip. Typically, caregivers who burn children/youth with cigarettes do so on the backs of the arms, the buttocks, and the backs of the legs. Electrical burns appear as black marks at the site of the burn, and can extend beyond, depending on the electrical appliance used, and the volts of electricity the child is exposed to. Size and shape are also determined by these latter two factors. Heat burns such as that from a flame and/or flammable liquid can encompass any part of the body. If clothing is ignited, the whole body can be burned. Victims of this type of burning are often older children. It is important to note here that not all water burns constitute signs of physical abuse. Accidental water burns generally appear as a splatter of splash burns. With non-accidental water burns, excessive splash marks will appear above the site of the primary impact, on body parts where accidental burning is unlikely. A child who is held under flowing hot water or immersed in scalding water will learn that the pain is lessened if they keep perfectly still. What results is what the medical profession calls the red sock or red glove. There will be a clear margin of bright red skin starting where the water line was and continue to all parts of the body that were immersed. Typically, the buttocks, legs, feet, and hands. Eventually, there will be peeling of skin layers.

Signs of physical abuse #4: CHOKING AND HANGING With these signs of physical abuse, a child who is choked will have bruising around the front and back of the neck that will resemble the fingers and thumb of the caregiver doing the choking. The bruising can also take the shape of a red band, depending on the pressure used, the length of time the pressure was exerted, and how much of the hand came in contact with the skin. If the caregiver is facing the child, the bruises at the front of the neck will be two thumb imprints, while the bruising at the back of the neck will be a tier of finger marks. This will be reversed (finger marks at the front, thumb marks at the back of the neck) if the caregiver is behind the child when doing the choking. Bruising and possibly 'rope burns' around the neck will be evident when a child is hanged. The bruising will take on the imprint of the rope or material used to hang the child. With these two signs of physical abuse, the child may be hoarse and/or have a cough, especially immediately and shortly after the choking or hanging incident. Damage to the larynx can occur in more severe cases. In extreme incidences', the neck may be broken.

Signs of physical abuse #5: SMOTHERING AND DROWNING During smothering, a child's breathing may be compromised, but other than this immediate effect, there may not be any noticeable physical abuse evidence. There can be bruising around the face, especially the nose and eyes, and upper chest area, depending on the item used to do the smothering, and the force exerted to asphyxiate the child. With drowning, there may be hand or finger bruising at the back or side of the neck, or at the shoulders where the child was held under water with force. The child's breathing may be jeopardized on a more long-term basis when these two signs of physical abuse are done regularly. If the child's breathing is raspy or the child has difficulty catching his/her breath, this may be a sign of smothering or drowning.

Signs of physical abuse #6: POISONING Poisoning may be difficult to detect because quantity is what determines the ill effects. Children can be poisoned with drugs, dish liquid, gas (i.e., combination of ammonia and bleach), and other noxious substances. A child who has been poisoned may suffer from nausea, vomiting, abdominal cramping, diarrhea, lethargy, sleepiness, light-headiness, dizziness, and, in more severe cases, unconsciousness. When noxious substances are force-fed to a child, depending on the substance, signs of physical abuse are: redness, chemical burns or bleeding in and around the mouth. If a child is forced to ingest dish liquid, the child will not be able to control his/her bowels, and a rash may be present around the mouth and lips.

Signs of physical abuse #7: HAIR-PULLING Thinning hair and bald patches on the scalp may be present with severe hairpulling. The child may experience headaches, and may also exhibit neck pain if the hair-pulling incidents are accompanied with jerking or snapping of the child's head.

Signs of physical abuse #8: Pushed from Heights Bruising and broken bones are the most common abuse injuries when a child is pushed from heights. If a child is pushed down a flight of stairs, bruising may be present anywhere and everywhere on the child's body.

SHAKEN BABY SYNDROME: SBS/AHT (shaken baby syndrome/abusive head trauma) is a term used to describe the constellation of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child. In any abusive head trauma case, the duration and force of the shaking, the number of episodes, and whether impact is involved all affect the severity of the infant's injuries. In the most violent cases, children may arrive at the emergency room unconscious, suffering seizures, or in shock. But in many cases, infants may never be brought to medical attention if they don't exhibit such severe symptoms. AHT (Abusive Head Trauma) can be caused by direct blows to the head, dropping or throwing a child, or shaking a child. Head trauma is the leading cause of death in child abuse cases in the United States. Approximately 60% of identified victims of shaking injury are male, and children of families who live at or below the poverty level are at an increased risk for these injuries as well as any type of child abuse. It is estimated that the perpetrators in 65% to 90% of cases are males â&#x20AC;&#x201D; usually either the baby's father or the mother's boyfriend, often someone in his early twenties. When someone forcefully shakes a baby, the child's head rotates about the neck uncontrollably because infants' neck muscles aren't well developed and provide little support for their heads. This violent movement pitches the infant's brain back and forth within the skull, sometimes rupturing blood vessels and nerves throughout the brain and tearing the brain tissue. The brain may strike the inside of the skull, causing bruising and bleeding to the brain. The damage can be even greater when a shaking episode ends with an impact (hitting a wall or a crib mattress, for example), because the forces of acceleration and deceleration associated with an impact are so strong. After the shaking, swelling in the brain can cause enormous pressure within the skull, compressing blood vessels and increasing overall injury to its delicate structure.

In less severe cases, a child who has been shaken may experience:  lethargy  lack of smiling or vocalizing  irritability  rigidity  vomiting  seizures  poor sucking or swallowing  difficulty breathing  decreased appetite  altered consciousness  unequal pupil size

4.2.

 

an inability to lift the head an inability to focus the eyes or track movement

Emotional/ Psychological abuse

Physical abuse is without a doubt emotionally damaging but it is possible for a child to be abused without being physically harmed. This is emotional abuse and it takes the form of:   

withholding necessary warmth and affection (necessary for normal physical and psychological development); verbal abuse including denigration, frightening and threatening the child; and parental indifference resulting in poor discipline and control.

4.2.1. What Constitutes Emotional Abuse � Humiliating a child � Parental indifference � Inconsistencies especially discipline � Lying to a child � Manipulation � Threats 4.2.2. Emotional Abuse Indicators � Withdrawal � Neurotic traits � Failure to thrive � Extremely poor self-concept � Habit disorders � Speech disorder � Development lags � Inability to relate to others 4.2.3. Behavioral Signs of Emotional Abuse � Withdrawal � Neurotic traits � Low self-esteem � Inability to relate to others � Anxiety � Overly adaptive behaviour � Depression � Attention-seeking behaviour � Neglect of appearance

BOYS (Emotional Abuse Signs)           

Aggression Temper tantrums Fights with peers and siblings Bullying tactics Frustrates easily Disobedience Lying and cheating Destructive behaviors Impulsive behaviors Argumentative Loud

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Tease excessively Worry excessively Withdrawn Speech disorders Delayed physical or emotional development Ulcers, asthma, severe allergies Habit disorders, sucking, rocking Unduly passive and undemanding

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Infinite patience Clinging to adults Overly dependent stubborn Tease excessively

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Very low self esteem Extremely demanding, aggressive and angry Antisocial, destructive Depressed and/or suicidal Attention seeking Delinquent behavior, especially in adolescents

GIRLS (Emotional Abuse Signs)     

Withdrawn Passive Approval-seeking Compliant Frustrates easily

    

Worry excessively Psychosomatic complaints

4.3. Neglect It is very important that children receive care and attention by being provided with adequate nutrition, shelter, and a safe environment. Neglect in these aspects can result in retarded growth and development, both physically, intellectually and emotionally. The definitions of neglect include physical neglect, child abandonment and expulsion, medical neglect, inadequate supervision, emotional neglect and educational neglect by parents, parent substitutes, and other adult caretakers of children. 4.3.1. What Constitutes Neglect � Lack of adequate supervision � Lack of proper hygiene � Lack of adequate protection � Deprivation of sleep � Lack of adequate clothing � Driving with children while under the influence of alcohol/drugs � Lack of adequate medical/ dental care � Failure to nurture and provide emotional support � Lack of education opportunities 4.3.2. Neglect Indicators � Constant hunger or poor hygiene � Falling asleep in class � Fatigue and listlessness � Early arrival/ leaving late � Unattended physical problems � Delinquent acts � Saying that there is no-one to care for him/her. � Neglected personal cleanliness 4.3.3. Behavioral Signs of Neglect � Withdrawal � Conduct disorders � Failure to thrive � Begging/stealing food � Anxiety � Attention seeking behaviour � Depression

Refusal of Health Care:       

Failure to provide or allow needed care in accord with recommendations Failure or delay to seek timely and appropriate medical care for a serious health problem Abandonment or Desertion of a child without arranging for reasonable care and supervision Expulsion or blatant refusals of custody, such as permanent or indefinite expulsion of a child from the home or refusal to accept custody of a returned runaway. Other Custody Issues: Custody-related forms of inattention to the child's needs other than those covered by abandonment or expulsion. (For example, repeated shuttling of a child from one household to another due to apparent unwillingness to maintain custody, or chronically and repeatedly leaving a child with others for days/weeks at a time.)

Other Neglect:   

4.4

Conspicuous inattention to avoidable hazards in the home Inadequate nutrition, clothing, or hygiene Any other forms of reckless disregard of the child's safety and welfare (Such as driving with the child while intoxicated or leaving a child unattended in a vehicle.

Sexual abuse

Most professionals are fairly certain they know what child sexual abuse is, and there is a fair amount of agreement about this. For example, today very few people would question the inclusion of sexual acts that do not involve penetration. Despite this level of consensus, it is important to define what sexual abuse is because there are variations in definitions across professional disciplines. Child sexual abuse can be defined from legal and clinical perspectives. Both are important for appropriate and effective intervention. There is considerable overlap between these two types of definitions.

Statutory Definitions: There are two types of statutes in which definitions of sexual abuse can be found – child protection (civil) and criminal. The purposes of these laws differ. Child protection statutes are concerned with sexual abuse as a condition from which children need to be protected. Thus, these laws include child sexual abuse as one of the forms of maltreatment that must be reported by designated professionals and investigated by child protection agencies. Courts may remove children from their homes in order to protect them from sexual abuse. Generally, child protection statutes apply only to situations in which offenders are the children's caretakers. Criminal statutes prohibit certain sexual acts and specify the penalties. Generally, these laws include child sexual abuse as one of several sex crimes. Criminal statutes prohibit sex with a child, regardless of the adult's relationship to the child, although incest may be dealt with in a separate statute. Definitions in child protection statutes are quite brief and often refer to State criminal laws for more elaborate definitions. In contrast, criminal statutes are frequently quite lengthy. Sexual abuse is the most difficult form of abuse to deal with as it is so invasive. While small children, or even infants, can be victims of sexual abuse, the most common age of abuse seems to be preadolescence. When a child discloses sexual abuse, it is very important that it be taken seriously and handled with sensitivity. Expressions of horror, disbelief or blame can be just as damaging to a child as the act itself. Contrary to popular belief, 80% of sexual abuse appears to be committed by parents, relatives and family friends and only 20% by strangers.] 4.4.1. What Constitutes Sexual Abuse  An adult showing a child his/her genitals  An adult touching the child’s genitals  An adult having a child touch his/her genitals  Oral genital contact  An adult having a child show his/her genitals  Insertion of an object into the child’s genitals 4.4.2. Sexual Abuse Indicators  Torn, stained, bloody clothing  Pain when passing urine  Sexual transmitted diseases  Pregnancy  Psychosomatic problems  Physical trauma such as redness, rashes, and/or bleeding to oral, genital and/or anal areas  Bruises on breasts, buttocks, lower abdomen, thighs, genital and/or rectal areas  Complaints of pain or itching in genital or anal areas  Difficulty walking or sitting  Unusual or offensive body odors  Difficulty in bladder or bowel control  Constipation

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         

Forced masturbation � Digital penetration � Intercourse The use of a child in the production of pornographic material an forcing a child to watch pornographic material Sexual talk to children Exposing a child to the sexual behaviour of others Voyeurism

Pain or discomfort on urination Blood in urine Abnormal dilation of vaginal or rectal openings Foreign bodies in vaginal, rectal or urethral openings Sexually transmitted diseases found vaginally, rectally or orally Yeast or bacterial infections Frequent sore throats; difficulty swallowing; choking Ear infections/problems Sudden weight gain or extreme weight loss Severe psychosomatic complaints such as stomach-aches and headaches

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Engages in sexual activity that is not appropriate for the child's age Suffers sleep disturbances or nightmares Has pain, itching, bruising or bleeding in the genitalia Had venereal disease

4.4.3. Behavioral Signs of Sexual Abuse  Unwilling to change for PE class  Shy, reserved, fearful, abrupt change in personality or behaviour  Withdrawal, fantasy, infantal behaviour � Mutilating behaviour  Inappropriate sexual knowledge and seductive behaviour  Layers of clothing, double dressing

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      

Has frequent urinary tract or yeast infections Has a detailed and sophisticated understanding of sexual behaviors Goes back to behaviors such as bedwetting, speech loss Poor peer relations � Excessive masturbatory behaviour Learning difficulties/ deterioration in school Drastic change in appetite Delinquency, runaway, truancy Regression & Compulsive behaviours Attempted suicide Over compliance

Sexually abused older children may:   

Exhibit delinquent or aggressive behavior Show signs of depression Display injuries behaviors such as substance abuse, self-mutilation, attempts at suicide, prostitution and running away

FAMILY INCEST: Incest refers to sexual acts between relatives. The type of incest that people are most worried about is parentchild incest. Sexual contact between an adult and a child is never all right for any reason. Even if the incest occurs when the child is legally an adult, it is very harmful. Incest between other adult family members and children or teens is also very hurtful. Any abuse of this kind, even if only suspected, should be reported. Incest between those who are similar in age may be less damaging, but still harmful. Brother-sister incest, for example, often leaves children or teens feeling guilty once they realize it is not normal in society. In addition, the dual roles are confusing. A girl may feel that she can break up with a boyfriend, but how can she break up with a brother?

Signs of incest may include:     



having vaginal or rectal bleeding, pain, itching, swelling or discharge having trouble walking or sitting being depressed or withdrawing from friends or family being very secretive either avoiding or being unusually interested in things of a sexual nature, acting sexual, or drawing sexual themes having sleep problems or nightmares



    

having stomach pain, bed-wetting, urinary tract infection, or a sexually transmitted disease. refusing to go to school saying that their bodies are dirty or damaged, or being afraid that there is something wrong with them in the genital area trying to run away trying to commit suicide.

Sexual Predators:

As a parent, there is probably no limit to the extent you're willing to go to protect your child. The worrying began about 9 months before their birth and won't end until your death. One of the biggest areas of

concern is safety from sexual predators. How do you know who the known predators are, how to identify a molester, or worse, if your child is being molested, and how to report suspected abuse? Registered Sex Offenders: Now it's possible to go one place in the USA to get a list of registered offenders in your area. You no longer need to try to sort through private databases or pay some online child security service to do this for you, but the list is only as current as the Governments have, it's not complete. What you need to understand is, it is only a list of people known to have offended in the past. Any sexual predators who have not been caught are not on the list. Plus, those on the list may not be active any more, for a number of reasons. Knowing who is in your area may help you guard against those people but there is still much work to do to protect your child from molestation. One way is to learn to spot suspicious people where your child goes....Educate yourself--Learn the signs.

5.1

Profile Of A Child Molester

Profile is a much abused word, but still the best one to describe someone who would possibly molest a child. Contrary to popular belief, this has more to do with behavior than looks. A pedophile will frequent places children gather...at church, school, playground and the internet. Sometimes you'll spot suspicious behavior, like stalking, treats or the "Help me find my dog" routine, but usually, they won't be doing that where adults can see. This is key! You want to protect your child from pedophiles? Make sure your child is always where adults can see. When it isn't you, make sure the adult who is watching is dedicated and trustworthy. Pay attention for strangers and people without children at schools and playgrounds. If you see a stranger, watch the behavior. If it seems suspicious, get a friend and confront the stranger (politely). Most likely, it's nothing, so don't worry. If it's something, both you and your friend should be able to sense that and take appropriate action. A quick note about churches, clubs, etc. Make sure they interview and fingerprint screen every volunteer who works with kids...even the ministers. It's a shame we have to be suspicious of people volunteering to work with kids, but pedophiles love to volunteer. Even with all these cautions, someone could get through, making it important to know early, if something is going on.

5.2

Signs Of Child Molestation

Talk about something no parent wants to see! There's no way to be sure, even if they can tell you something's happening. One friend of mine found out at church that her husband was molesting her daughter. ..a very unpleasant, but fortunate coincidence. Fortunate, because it forced the truth to come out and the molestation to be stopped. The most useful methods I've found to determine the likelihood of molestation are the Signs Of Child Molestation provided by the National Center for Missing & Exploited Children. Unfortunately, unless your child confirms your suspicions, you'll still be left doubting. If there are physical signs and the child is too young to accurately describe the cause, a trip to the doctor may help. In any event, if you still strongly suspect molestation, it's better to report your suspicions than to assume nothing's happening.

5.3

How To Report Suspected Child Predators:

The bottom line is, if you have strong suspicions your child is being molested you need to report it to your local police or child services. If you see someone engaging in suspicious behavior around the children in your neighborhood, local park, etc. report it and let the authorities figure it out. I'm sure they don't mind a few false alarms for every kid they can save. The police might even give you some free training as a result. So, your child's safety isn't assured through the sexual predators database, but it can help as part of a complete strategy. That strategy should also include knowing the profile of a child molester, the signs of molestation and how to report suspected molestation and suspicious people. Doesn't assure your child will be safe. The only assurance we have that, our children will be safe is from God.

6. Causes of Child Abuse and Neglect Although their actions shock and anger people, child abusers have serious problems and they require help. These reasons do not preclude adults and older children who abuse children from taking responsibility for their behaviour. The reasons for abuse vary and can include:       

6.1.

Premature/ difficult birth; Poor ante-natal care; Sickly child; An unwanted child; Poor bonding; Handicapped child; and Difficult pregnancy/labour;

   

Difficult child-behaviourally, medically, educationally. Poor impulse control on the part of the parent Alcohol and drug abuse Inappropriate sexual development and attachments

The Parents who Abuse

Abusing parents may be aggressive, non-trusting, defensive, suspicious or frightened. There are many reasons why parents abuse their children, some of which follow:     

6.2

Parents were abused as children Abuse alcohol/drugs Unemployed Have inadequate income Socially isolated

    

Live far away from extended family Working parents Insufficient leisure time Immature personality characteristics Neurotic/psychiatric disorders

The Family

As with parents, the family unit (i.e. both parents) may be the abusers of children. Following are some reasons for this:   

Very young/immature parents Inadequate spacing between children Handicapped or seriously ill child in family

  

Family is socially isolated Parents have no support structure Parents have no parenting role-models

7. Appropriate/ Inappropriate Children’s Behaviours Related to Sex, Sexuality and Gender Age

Behaviour

Requires parental or caretaker intervention

Requires external advice for management*

Inappropriate response

Infancy

Child experiences spontaneous erections accompanied by expressions of pleasure. Child experiences erections when suckling at the breast or on the bottle.

A negative response to the behaviour.

Child plays with own genital area when sufficient coordination has developed.

No, best ignored.

A negative response to the behaviour.

Child pats or searches for mothers or caretakers’ breasts.

A negative response to the behaviour.

Telling the child or giving the child the message that they are bad.

Child touches and self stimulates genital area, often in the presence of others.

No, if uncomfortable or embarrassing for the mother or caretaker gently distract the child and give the child something to hold. This is a normal behaviour and child should not be punished. A firm no and putting overalls on child should limit this behaviour. Parent begins to explain rules for self touching – not in public.

Child puts crayons, other objects into body orifices.

Firm parental “no”, distract the child.

Child rubs genitals against objects and receives pleasure from this activity. Persistent and continuous self stimulation either through self touching and rubbing against objects.

Distract the child.

Punishment & making the child feel guilty, telling the child that the penis will fall off if touched. Panic and punishment, an assumption that the child has been abused. Panic and punishment.

Distract the child, explain the rules about self stimulation in public.

Yes – it may be helpful to look at a range of needs which the child might be attempting to

Child reaches into nappy or pants and removes and plays with and smears/”paints” with feces.

Toddlers

Panic and punishment, telling the child s/he is bad, assuming that the child has been abused.

fulfil through self stimulation of the genitals such as insecurity. Child attempts to explore the bodies of other children, touches genitals, sucks genitals of others.

Looking at and touching the genitals of animals. Looking at, asking questions about and touching the genitals and private parts of adults. Interested in watching/ peeking at people doing bathroom functions, genitals, and sex. Refuses to wear clothes, keeps undressing and running around naked.

All of the above behaviours The Preschool may occur. Child

Hiding â&#x20AC;&#x201C;eg. under bedclothes, bushes in order to explore, touch and play â&#x20AC;&#x153;sexâ&#x20AC;? games with friends.

Clear explanation of rules in respect of touching the bodies of others and the consequences of not adhering to these. Acknowledgement that sometimes this touching can feel good but that does not make it OK. As above.

If behaviour persists seek professional help and advice.

However consider this possibility as one of a range of possible contributing factors. Over-reaction, panic and severe punishment. Failure to apply appropriate sanctions when the behaviour does reoccur. Avoid labeling the child negatively.

As above.

As above, but also make sure that children learn to respect the privacy of others. Explain clearly the rules about when clothes must be worn. Institute a simple system of rewards when the child gets and remains dressed appropriately such as praise, or a hug. Explanations and repeated confirmations of the rules, and firm but gentle application of consequences once the behaviour has been clearly labeled as inappropriate.

As above.

Avoid threatening with drastic consequences.

As above.

As above, and discuss with parents of caretakers without labeling the children but ensuring consistent and clear management.

If persists despite intervention then seek advice on behaviour management.

As above.

Uses dirty words for bathroom functions, genitals and sex, tells “toilet jokes”.

Asking questions about reproduction, sex, how do babies come out of tummies etc.

Tells “toilet” jokes and/or stories about body functions.

Wants privacy when bathing, changing and/or using the toilet. Pretends to be pregnant or giving birth.

The Latency years – 6 –11 years

Pretends to be of the opposite gender – wants to dress like the opposite gender. Any of the above.

A complete lack of apparent interest in sexual issues, physical development and other related issues.

Clear rules for the use of appropriate language, ensure the child knows the correct words for body parts, and ignore the dirty jokes. However appropriate humour in children is tension relieving, fun and to be encouraged. Give simple clear explanation, answering the question asked without too much elaboration. Best ignored, but humour is a positive attribute to be encouraged!

As above.

Not needed.

Respect this request, and teach the child to ask for this appropriately. This gives an opportunity for information giving to the child. Otherwise ignore. Best ignored. Use this as an opportunity to reaffirm the value of both genders. As above, but with very clear sanctions for unacceptable behaviour, firmly applied.

Not needed.

Punishment – interest in body functions very normal at this stage. Refuse the request.

As above.

As information about adolescence and puberty should be given to prepare child for physical and emotional changes, both their own and their peers, ensure that child does have information about these processes.

None required.

Assuming that the child does not need this information because they do not ask questions.

Not needed.

Belittling the child or making fun of the child’s imaginative game. Do not ridicule the child ortease.

Shows interest in “dirty” pictures and may even bring them home and hide them.

Plays games that involve looking at and even touching other children’s and one’s own body such as “Doctor and Nurse” and “Mummy and Daddy” games. Is rude and negative about the opposite gender and makes negative remarks about gender and body parts associated with the opposite gender.

11/12 years and older

Many of the above.

Secretly self touches and explores body.

Child begins to explore sexual touching and behaviour with peers.

Clearly explain the rules about pornography and unacceptable pictures and written material and why these rules are important for you and the family. Continue to clarify the rules and apply consequences to breaking the rule that are reasonable.

None required.

Destroying the pictures with no explanation, shock and horror, not dealing with the issue gently and firmly.

None.

Over-reacting and negative labeling.

Talk to the child about differences, equality and the value of each person. Ensure that the child is exposed to positive role models of both genders. All of the above, adjusted to the increasing age and maturity of the child.

None.

Ignore. However if your culture and religion has firm rules about masturbation explain these and why these rules are important to you and your family. Give accurate information about sexuality, contraception, sexually transmitted disease, and what you regard as responsible sexual behaviour. Encourage your child to make responsible choices.

None.

Getting into debates over the relative superiority of either gender, as well as sweeping negative statements about “all men/boys” or “all women/girls”. Refuse to communicate or debate issues, values etc with the adolescent. Telling the child that masturbation will stunt your growth, make you blind, deaf, sterile, etc.

Don’t hesitate to call Childline for advice if you are concerned.

Sometimes information from someone outside the immediate family circle is more acceptable to adolescents than information from a parent.

React with shock and horror.

* If any of the behaviours described above are persistent and excessive then parents and caretakers are advised to seek advice. Sometimes it is difficult to know what is “persistent” and “excessive” as children will repeat behaviours and activities that they find pleasurable.

Bullying

CHILD BULLYING: IN SCHOOL The child abuse continuum shows that children who have been abused can go on to exhibit bullying behaviours, though it's important to understand that not all abused children become bullies, and that not all bullies come from abusive homes. Other factors to consider include: the child's temperament lack of supervision the social climate at school School is one of the few places that children are brought together in large numbers. Children and youth spend an average of about 6 hours a day in school; therefore, school is a society within a society. Children and youth try to fit in, often by joining in peer group circles and cliques. 1

STAT: Most bullying happens in or close to the school building (British Columbia Ministry of Education, 2000 ). Bullying and harassment have traditionally been considered rites of passage, something all children and youth must go through. This is a myth. It has only been in the past 20 years or so that bullying and harassment have received international attention. This attention has in large part been due to children and youth who commit suicide as a result of being a victim of relentless bullying and their inability to cope. There have been enough incidents' of children committing suicide for this reason that a new phrase has been coined: bullycide. In Canada, 1 in 5 children is bullied; 1 in 12 youth are regularly harassed in school by other students (Gladue, 2 1999 ).

Children at Risk:           

being submissive shy, reserved, quiet, sensitive the youngest or smallest unwilling to fight exhibits annoying behaviours expresses emotions quickly new kid on the block previously traumatized rich or poor a different ethnicity gender/sexual orientation is seen as inferior or deserving of contempt 3

STAT: 1 in 6 gay teens is beaten so badly during adolescence that he requires medical attention (Egan, 2000 ).    

religious beliefs are considered inferior or deserving of contempt bright, talented or gifted does not conform to what is considered the norm unusally fat, thin, short or tall

STAT: Young girls were more afraid of becoming fat than they were of nuclear war, cancer or losing their 4 parents.(Rigby, 1996 ).

  

wears braces or glasses acne or any other visible skin condition physical, developmental/mental disability

The above list reflects that ANYONE can be a target. Boys and girls are equally likely to be victims. As a violence and abuse prevention educator, I often hear from people that their school does not have a bullying problem. This is simply not true. Perhaps liability issues enter into the mix, or perhaps they really do believe the claim. The following statistics dispel that claim: STAT: 56% of boys and 40% of girls in grades 6 and 8 had bullied someone that year (International study done 5 for Health Canada, 1999 ). STAT: 43% of boys and 35% of girls said they had been bullied in that year (International study done for Health 6 Canada, 1999 ). STAT: 71% of teachers said they usually intervene in bullying episodes; 25% of students said teachers intervene 7 (Pepler & Craig, 2000 ). This last statistic shows a huge discrepancy, and tells us that teachers are unaware of how prevalent the problem is in schools. If teachers are unaware of the problem, they are not in a position to intervene. Without intervention, bullies do not stop the behaviour. Left unchecked, the behaviour eventually escalates to harassment. If your child is being bullied, Free From Bullies is a book that could help you help your child.

Bullying vs Harassment (B & H): The difference between B & H is in the age of the people involved, and the legal ramifications of each. Bullying describes behaviours between children under the age of 12 that is offensive, cruel, intimidating, or humiliating. It is not normal aggression between very young children. Harassment is the adult term for bullying. Bullying is a relationship issue; harassment is a human rights issue. Harassment is considered a form of discrimination that can be based on:           

race national or ethnic origin colour religion age sexual orientation sex/gender marital status family status disability pardoned conviction

In Canada, harassment is dealt with under human rights legislation and victims can charge the offender. Bullying is not dealt with under human rights legislation. Both B & H have the potential to fall under the Criminal Code of Canada, if the law has been broken. The significant factor in harassment is IMPACT not INTENT. Once the harasser becomes aware that his or her behaviour is offensive and unappreciated, either by being told or the body language of the other person or

persons makes it clear that the comment or gesture is unwelcome, if the offensive behaviour continues, it becomes harassment.

Power: It is not possible to talk about any kind of violence without talking about power. There are several kinds of power:          

physical power - physical strength or ability personality power - gender, ethnic identity, age, physical appearance and personal presence positional power - position of authority relational power - status within the social system; with adolescents it comes in the form of popularity, money and/or talent connection power - connections with influential people organizational power - specific authority, rights, and privileges as determined by job description network power - membership in formal/informal networks expert power - perception of expertise, skills/knowledge information power - information possessed or ability to access information resource power - ability to access human, educational, financial and technical resources

When a power imbalance exists between two people, that imbalance may result in B & H behaviour. Abuse of power is at the core of B & H. All of society needs to be concerned about B & H. Consider these criminality statistics: STAT: Bullies who have been identified by age 8 are six times more likely than others to be convicted of a crime by the time they reach the age of 24. They are five times more likely to end up with serious criminal records by 8 age 30 (National Resource Centre for Safe Schools, 1999 ). STAT: 60% of boys who were nominated as bullies in grades 6 to 9 had at least one court conviction by age 24; 35% to 40% had three or more convictions compared to 10% for the control group of non-bullying boys (Voices 9 for Children, 2002 ). Unchecked bullying turns into harassment when the child becomes an adolescent. When the adolescent starts dating, relationship violence often begins. When the youth becomes an adult and enters the workforce, workplace harassment begins. When the adult marries, spousal abuse begins. When they have children, child abuse begins. And as they and their parents age, elder abuse begins. If society chooses not to intervene, if society operates under the myth that bullying is a fact of life and of growing up, we will all pay the price as the bullies get older and their crimes escalate.

Bullies today become criminals tomorrow.

We believe that bullying does not mysteriously disappear as children leave elementary school, but rather that its forms change with age: playground bullying changes into sexual harassment, gang attacks, dating violence, assault, marital violence, child abuse, workplace harassment, and elder abuse. The common element in all these forms of abuse is the combination of power and aggression, a behavioural style that is learned early and 10 persists if not corrected (Pepler & Craig, 1999 ).

"Cyberbullying involves the use of information and communication technologies to support deliberate, repeated, and hostile behaviour by an individual or group, that is intended to harm others." -Bill Belsey

Child Abuse Effects

The effects of child abuse are largely related to the extent of the abuse. If you're reading this, it's likely you're concerned about the more extensive abuses. Even the milder-seeming types of neglect and emotional abuse can have serious effects on you. The abuse seems like normal family life which you will try to duplicate when you start a family. Obviously, all forms of abuse have serious effects on your idea of who you are, how you perform in school, on the job, how you make and keep friends, who you choose for friends, and how you treat your own spouse and children. Though it probably isn't even a majority, many abused children grow up to abuse their children. Abused children tend do more poorly in school, have a much higher delinquency and drop out rate, tend towards torturing animals...even other children, tend to be reclusive and anti-social. Severe abuse leaves severe, invisible, emotional scars that, unless dealt with, can cripple important areas of your life. This is why, if you have been abused, or if you are helping an abused child, you must get professional help to begin to heal and recover a normal, happy life.

Physical child abuse effects vary from child to child, depending on six factors: 1. 2. 3.

severity of the physical abuse frequency of the physical abuse age of the child when physical abuse began

4. 5. 6.

child's relationship to the abuser availability of support persons child's ability to cope

   

intimacy control over his/her body normal loving and nurturing safety and security

Molested children suffer many losses, including:    

self-esteem and self-worth trust childhood, including the opportunity to play and learn the opportunity for normal growth and development

Child Sexual Abuse has been demonstrated to lead to increased rates in adults of:      

Depressive and anxiety disorders Suicidal risks Anti‐social behaviors and delinquent behavior Substance abuse and dependence Poor educational achievement Physical health problems

   

Sexual risk taking and promiscuous behaviors Unstable and poorly functioning relationships Marital and family problems including intimate partner violence Personality disorders

10.Keep your child safe: Prevention and Protection Teach your children the difference between acceptable and unacceptable touching, and to trust their instincts about people. Educate yourself about the signs of abuse so you'll be able to detect it. 1. 2. 3. 4.

Understand that "child abuse" means any kind of harm done to a child and does not just mean sexual abuse. Teach your children that there is a difference between "good" and "bad" touches. Explain what these are. Explain that no one has the right to hurt your child or touch him or her in private areas or touch in anyway that makes him or her feel uncomfortable. Tell your children that the words they need to remember are No, Go, Yell, Tell. If anyone touches them in a way they don't like or tries to get them to go with a stranger, or person they don't feel comfortable with, they should always say "No!" and ...

5. 6.

Go away from the person or situation as quickly as possible. Use their danger voice to yell. A danger voice is a very loud, low-pitched yell, that gets attention immediately. It is not a high-pitched screech. It should never be used in any other situation. 7. Tell a parent, teacher or caregiver immediately about what happened. 8. Help your children understand that they need to be wary not just of thetraditional idea of "strangers", but of anyone who makes them feel uncomfortable, even if it is someone they know. 9. Talk to your children about situations they must avoid, like taking any food or medicine from a person who is not a parent, teacher, caregiver or close friend. Help them understand how to identify a police officer. Take them to the local police station and let them see what a uniform looks like and what a badge looks like. 10. Show your children how to make a collect call to home and how to call 10111. 11. Learn what the signs of abuse are so that you will notice if something is going on with your child. Look for bruises, burns, bloody or missing underwear, difficulty with bowel movements or urination, problems with walking or sitting, behavior problems, inappropriate sexual behavior, sore genitals or anything that just makes you feel there is something amiss. 12. Get help from the police, social services department or through a child abuse hotline if you suspect there is a problem. Resources on child abuse prevention, protecting children from risk of abuse, and strengthening families. Includes information on supporting families, protective factors, public awareness, community activities, positive parenting, prevention programs, and more. Understanding child abuse prevention and what to do when children are at risk. Includes frequently asked questions and links to related Federal and national organizations and State contacts that work to prevent child abuse.    



Strengthening families: Enhance protective factors in families---Educate yourself....Learn the signs of child abuse & neglect. Public awareness & creating supportive communities: Assist your community with child abuse awareness techniques and build community support. Prevention programs: Research prevention programs and resources for specific types of programs. Developing & sustaining prevention programs: Consider managing a prevention program, including community needs assessments, collaborating with community partners, family engagement and retention, cultural competence, training, and funding. Evaluating prevention programs: Evaluating program effectiveness and performing cost analyses for yourcommunity.

PROTECTION: Don't just worry about your children. Arm them with information... There are steps that every parent can take to keep her child safe:  Listen to your child. Child abusers often use a legitimate activity to trick the child into performing a sex act.  Be aware that sex abusers carefully choose their victims. They often look for a needy child or a troublemaker who is easily discredited if he or she says anything.  At the doctor's office, insist that another adult (you or a nurse) remain with your child in the exam room at all times.  Encourage your child to inform you of any person or any situation that makes her feel uncomfortable.  Explain to your child to never be alone with anyone they do not know, are not comfortable with or who hurts them.  Tell them it's OKAY TO TELL---instruct them to tell an adult they trust and tell them what is happening.  Check the National Child Abuse Sex Offender Registries (Family WatchDog is also a wonderful tool for any parent to use)  Know who your child is with at all times and where your child is.  Be familiar with who your child is hanging out with--friends, coaches, teachers, music/band/sport intructors, church members, etc.  Monitor your child's internet use.

  

Educate your child--Make sure they are familiar with Stranger Danger & Sexual Predators. Monitor the actions of adults around all children---Always trust your gut instinct. If you suspect sexual or physical abuse, chances are you are right. Always report any suspected abuse of a child---It could just save a child's life!

11.

Intervention

Child abuse intervention (a report of abuse and neglect to the proper authorities) may be done by telephone, by letter, by e-mail or in person. A report can be made anonymously, but divulging who you are and the relationship you have with the child will aid in the investigation.

11.1

DISCLOSURE OF ABUSE

Child abuse intervention refers to handling disclosures of abuse. Disclosures can be purposeful (verbal) or accidental (non-verbal). Purposeful disclosures occur when the child or youth consciously decides to discuss his or her abuse. See table below for top reasons why youth disclose:

Why A Child DOES Discloses Abuse: 76% 56% 56% 53% 50% 48% 41% 41% 40% 35% 31% 28% 22%

I told because I couldn't hold it in any longer. I told because I wanted it to stop so my life could go on. I told because I wanted him/her to be punished. I finally felt comfortable enough to tell. I was afraid someone else would get hurt if I didn't talk. I was afraid I'd get hurt if I didn't tell. I told because I couldn't sleep/ eat/ think anymore. I got tired of the unwanted sexual experiences. Someone else convinced me to tell. Someone else told me about their unwanted experiences. I was pregnant or afraid I might be. Due to a school program about unwanted sex experiences. I told because I didn't want to go home.

Why A Youth DOESN'T Disclose Abuse: 74% 60% 55% 47% 46% 29% 29%

I was scared. I was embarrassed. I didn't want to get into trouble. I didn't want anyone else to get into trouble. No one would believe me. I still like/love the other person. I was my fault as much as the other person's.

When a report of abuse and neglect is made, child abuse intervention dictates that the person or organization making the report must act in a way that: protects the child or youth protects other children/youth who may be involved respects the rights of alleged abuser; keeps information confidential cooperates with Child Protection Agencies and possibly police

You may report suspected child abuse to: 1. Child Protection Agencies, like your local welfare office: ACVV, Badisa, Child and Family Welfare, other. 2. Local Law Enforcement/Police Station 3. National Child Abuse Hotlines, Childline, Rape Crisis

Child abuse intervention is everyone's responsibility, ethically, morally, and legally.... Stop further child abuse by reporting it!

11.2

8 STAGES OF RECOVERY & HEALING 1. Denial:

It is not unusual for people to be trapped in this stage for many years after the physical nature of the abuse has ended. Many survivors develop addictive or compulsive behaviors while attempting to mask the feelings and emotions connected to child sexual abuse. Those who remain in denial about the definition of sexual child abuse, the truth about the most frequent sexual child abuse offender are part of the reason sex offenders have the opportunity to abuse children. We are responsible...â&#x20AC;&#x153;Those who ignore the past are condemned to repeat it.â&#x20AC;?

2. Confused awareness: At this stage, people begin to recognize the connection between their past trauma and present concerns. This new awareness may introduce feelings of anxiety, panic and fear. This can lead to a diagnosis of Post-traumatic stress disorder, also known as PTSD, is an anxiety disorder that can develop after exposure to one or more terrifying events that threatened or caused grave physical harm.

3. Reaching out: Survivors can be in a situation in which the perils of silence become more painful than the risk involved in speaking out. The healing process begins when we realize that we need help. This is the most important step in healing. Receiving individual counseling and/or joining support groups may play a role in the healing process.

4. Anger: After they reach out and become more aware of the impacts of the abuse, survivors often deal with intensified anger. This anger is an expected, natural part of the healing process. Thoughts of disclosure and confrontations may dominate this stage. Anger may be channeled towards anyone who excused or protected the abuser, anyone who did not believe their disclosure of the abuse, and anyone they feel should have been concerned but never took steps to help.

5. Depression: At this stage, adult survivors may recall the negative messages or criticisms that they received from their abuser as a child. If these seem valid to the adult survivor, they may cause him or her to become depressed when faced with and unable to make positive changes. If symptoms and triggers of their depression are identified and an appropriate support team is found, the chances of their being overwhelmed with feelings of despair may be minimized.

6. Clarity of feelings and emotions: For adult survivors of child sexual abuse, a key component to healing is to express and share their feelings. This can be achieved by survivors' learning to acknowledge and identify a wide variety of feelings and emotions, as well as finding ways to release them without hurting themselves or others. A good support team can be extremely valuable at this time.

7. Regrouping: This phase involves many positive changes in survivors' attitudes and feelings. In this stage, they develop a new sense of trust in others but, most importantly, they start to trust themselves. This phase includes learning from the past, examining the present, and planning for the future. Many survivors have suggested that this stage represents a transition from merely existing to actively living.

8. Moving on: This stage includes a shift in focus from the negative experiences of the past to positive plans for the future. Painful feelings and emotions do not dominate memories from the past. Positive coping skills developed in earlier stages are enhanced and assist survivors in moving on with their lives. Several coping skills that can help survivors to move on include learning to love and accept themselves, recognizing and celebrating personal growth, creating a healthy support team, grieving current losses as they occur, learning to deal with stress effectively, and recognizing when it is time to let go of painful feelings connected to the past.

11.3

POST-TRAUMATIC STRESS DISORDER:

Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that's triggered by a traumatic event. You can develop post-traumatic stress disorder when you experience or witness an event that causes intense fear, helplessness or horror. Signs and symptoms of post-traumatic stress disorder typically begin within three months of a traumatic event such as warcombat- military, terror attacks, natural disasters, serious car accidents, rape, child abuse, or physical, sexual or mental abuse. Post traumatic stress is a natural human reaction to extreme stress. A traumatic event is a shock to the whole body/mind system which can overwhelm the mind's processing system, leaving the symptoms unresolved and as if they are fixed in time. It can be very incapacitating and distressing. Developing symptoms of PTSD can happen to anyone, but fortunately there are very effective treatments available now which enable the mind's natural healing processing of the event to take place and then eliminate the symptoms, usually completely. PTSD makes you feel stressed and afraid. It affects your life and the people around you. Post-traumatic stress disorder symptoms have three categories: intrusive memories, avoidance and numbing, and increased anxiety or emotional arousal.



SYMPTOMS MAY INCLUDE:

     

 

Flashbacks Trouble sleeping or nightmares Feeling alone Angry outbursts Feeling worried, guilty or sad Upsetting dreams about the traumatic event Avoiding thinking or talking about the event Feeling emotionally numb Avoiding activities you once enjoyed



Other PTSD symptoms may include:

     

Drinking or drug problems Feelings of hopelessness, shame, or despair Employment problems Relationships problems including divorce and violence Physical symptoms Suicidal Tendencies.



        

Hopelessness about the future Memory problems Trouble concentrating Difficulty maintaining close relationships Irritability or anger Overwhelming guilt or shame Self-destructive behavior Being easily startled or frightened Hearing or seeing things that aren't there

Defining Trauma and Child Traumatic Stress Children and adolescents experience trauma under two different sets of circumstances. Some types of traumatic events involve (1) experiencing a serious injury to yourself or witnessing a serious injury to or the death of someone else, (2) facing imminent threats of serious injury or death to yourself or others, or (3) experiencing a violation of personal physical integrity. These experiences usually call forth overwhelming feelings of terror, horror, or helplessness. Because these events occur at a particular time and place and are usually short-lived, we refer to them as acute traumatic events. These kinds of traumatic events include the following:

   

School shootings Gang-related violence in the community Terrorist attacks Natural disasters (for example, earthquakes, floods, or hurricanes)

  

Serious accidents (for example, car or motorcycle crashes) Sudden or violent loss of a loved one Physical or sexual assault (for example, being beaten, shot, or raped)

In other cases, exposure to trauma can occur repeatedly over long periods of time. These experiences call forth a range of responses, including intense feelings of fear, loss of trust in others, decreased sense of personal safety, guilt, and shame. We call these kinds of trauma chronic traumatic situations. These kinds of traumatic situations include the following:    

Some forms of physical abuse Long-standing sexual abuse Domestic violence Wars and other forms of political violence

Child Traumatic Stress Child traumatic stress occurs when children and adolescents are exposed to traumatic events or traumatic situations, and when this exposure overwhelms their ability to cope with what they have experienced. Depending on their age, children respond to traumatic stress in different ways. Many children show signs of intense distress—disturbed sleep, difficulty paying attention and concentrating, anger and irritability, withdrawal, repeated and intrusive thoughts, and extreme distress—when confronted by anything that reminds them of their traumatic experiences. Some children develop psychiatric conditions such as posttraumatic stress disorder, depression, anxiety, and a variety of behavioral disorders. While some children "bounce back" after adversity, traumatic experiences can result in a significant disruption of child or adolescent development and have profound long-term consequences. Repeated exposure to traumatic events can affect the child's brain and nervous system and increase the risk of low academic performance, engagement in high-risk behaviors, and difficulties in peer and family relationships. Traumatic stress can cause increased use of health and mental health services and increased involvement with the child welfare and juvenile justice systems. Adult survivors of traumatic events may have difficulty in establishing fulfilling relationships, holding steady jobs, and becoming productive members of our society. Fortunately, there are effective treatments for child traumatic stress.

APA Diagnostic Criteria Pertaining to Part B of the DSM PTSD criteria, “The traumatic event is persistently re-experienced in one (or more) of the following ways,” these elements may also exist in children: (1) In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. (2) In children, there may be frightening dreams without recognizable content. (3) In young children, trauma-specific reenactment may occur.

Age Specific Indicators Age 5 years and younger: (1) Fear of being separated from the parent – crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions and excessive clinging. (2) Parents may also notice children returning to behaviors exhibited at earlier ages such as thumbsucking, bedwetting, and fear of darkness (3) Worries about re-occurrence of the violence or traumatic event. (4) Children in this age bracket tend to be strongly affected by the parent(s) reactions to the traumatic event.

Children 6 to 11 years of age: (1) May show extreme withdrawal, disruptive behavior, and/or inability to pay attention. (2) Nightmares, sleep problems, irrational fears, irritability, refusal to attend school, changes in eating habits, outbursts of anger, fighting, and/or repetitive thoughts of death and dying. (3) Complaints of stomachaches or other bodily symptoms that have not medical basis. (4) School work often declines. (5) Symptoms of depression and/or anxiety, as well as feelings of guilt, flat affect, and emotional numbing resulting in lack of interest in once enjoyed activities. (6) Increased sensitivity to sounds, such as sirens, planes, thunder, backfires, and other loud noises.

Adolescents 12-17 years of age: (1) May exhibit responses similar to those of adults, including flashbacks, nightmares, emotional numbing, and avoidance of any reminder of the traumatic event. (2) Symptoms of depress and/or substance abuse. (3) Problems with peers and anti-social behaviors; hate and anger statements. (4) Withdrawal and isolation, physical complaints, suicidal thoughts, school avoidance, academic decline, sleep disturbances, and confusion. (5) May feel extreme guilt over his/her failure to prevent injury or loss of life. (6) May harbor revenge fantasies that interfere with recovery from the trauma. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders text revised: DSM-1V-TR (4th ed.). Washington D.C.: Author American Psychiatric Association (n.d.). Reactions and guidelines for children following trauma/disaster. Retrieved on April 23, 2004 from the APA HelpCenter Website: http://helping.apa.org National Institute of Mental Health (2001). Helping children and adolescents cope with violence and disasters. Retrieved on April 23, 2004 from the NIMH Website: http://nimh.nih.gove/publicat

POST-TRAUMATIC STRESS DISORDER SELF-TEST If you suspect that you may suffer from Post-Traumatic Stress Disorder (PTSD), complete the self-test form below. Simply circle either 'YES' or 'NO' in answer to the questions. When you have completed the test, print the page and show the results to your Doctor, who will be able to help you. 1.

Have you experienced or witnessed a life-threatening event that caused intense fear, helplessness or horror? This includes sexual abuse. YES/NO

Do you re-experience the event in at least one of the following ways? 2.1. Repeated, distressing memories and/or dreams? YES/NO 2.2. Acting or feeling as if the event was happening again? (flashbacks or re-living it). YES/NO 2.3. Intense physical and/or emotional distress when you are exposed to things that remind you of the event? YES/NO

Do you avoid reminders of the event and feel numb, compared to the way you felt before? YES/NO

Do you avoid thoughts, feelings and conversations about the event? YES/NO

Do you avoid activities, places or people who remind you of it? YES/NO

Have you blanked on parts of the detail? YES/NO

Are you losing interest in significant activities in your life? YES/NO

Are you feeling detached from other people? YES/NO

Do you feel as if your range of emotions is restricted? YES/NO

10.

Do you feel as if your future is diminished in terms of marriage, children or a normal life span? YES/NO

11.

Are you troubled by two or more of the following: 11.1. Problems sleeping? YES/NO 11.2. Irritability or outbursts of anger? YES/NO 11.3. Problems concentrating? YES/NO 11.4. Feeling 'on-guard'? YES/NO 11.5. An exaggerated startle response? YES/NO

12.

Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Illness that sometimes complicate an anxiety disorder include depression and substance abuse. With this in mind, please take a moment to answer the following:

13.

Have you experienced changes in sleeping or eating habits? YES/NO

14.

More days than not, do you feel: 14.1. Sad or Depressed? YES/NO 14.2. Disinterested in life? YES/NO 14.3. Worthless or guilty? YES/NO

15.

During the last year, has the use of alcohol or drugs: 15.1. Resulted in your failure to fulfill responsibilities with work, school or family? YES/NO 15.2. laced you in a dangerous situation, such as driving a car under the influence? YES/NO 15.3. Been responsible for you being arrested? YES/NO 15.4. Continued despite causing problems for you and your loved ones? YES/NO

Reference: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC, American Psychiatric Association.

Stress and Trauma Key Concepts • • • • • •

• •

Children and adolescents are exposed to various types of stress and traumatic events during their developmental years. How you define a situation determines your emotional response. Primary or acute stressors are relatively circumscribed in time and space. Secondary or chronic stressors derive from longterm and continuing exposure. A traumatic event occurs when an individual experiences, witnesses or is confronted with a situation in which there is a perceived or real threat of bodily injury or a threat to life itself. The acute traumatic moment for the child is frequently ushered in by the discovery that parents are not able to protect them and there is a sudden awareness of vulnerability in the presence of imminent physical injury or death. The individual response to stress is shaped by the reality of the impact of the fateful event and by one’s subjective appraisal. Traumatic reminders refer to those events in the aftermath of traumatic exposure which result in the child or adolescent reliving and re-experiencing the trauma as if it was occurring one more time.

Introduction Throughout the course of the life cycle, all of us are confronted with threats to well-being or even to life itself. Although children are generally exposed to the same spectrum of hazards as adults, they are still maturing physically, emotionally, cognitively and socially. Therefore, the impact of perceived threat, psychological trauma, or overt physical harm may become woven into the tapestry of their emergent personalities and their repertoire of adapting and coping capacities. In this chapter we will define terms essential to understanding the psychological effects of trauma exposure: stress, acute and chronic stressors, primary and secondary stressors, traumatic event, acute traumatic moment, and traumatic reminders.

• Stress is the subjective experience that occurs when we perceive that the demands of the situation exceed our resources to successfully cope with those demands • Stress may be in the eye of the beholder

Stress Stress is a non-specific response of the body to any demand placed upon the organism. Stress can be defined as a real or imagined threat to the psychological or physical integrity of the self, a threat to one’s equilibrium or homeostasis. Stress represents an incongruity between the individual’s adaptive capacities and the demands placed on the organism (Taylor & Fraser, 1981). The child’s level of emotional and cognitive development greatly influences the psychological response to events in which demands exceed capacities. It is important to understand the role of subjective appraisal in responding to stress. From a cognitive perspective, stress, like beauty, is often in the eye of the beholder. How one defines a situation determines one’s emotional response to it. Indeed, a situation that one person might perceive as stressful may be experienced by another person as an interesting challenge. As John Milton observed, “The mind is a place in and of itself, it can make a heaven of hell or a hell of heaven.” If you define something as real, it is real in its consequences.

The Spectrum of Stressors Stressors are events and situations that prompt and provoke the stress response. Stressors will be presented from three vantage points: stressors in the human experience, primary versus secondary stressors, and acute versus chronic stressors.

Stressors in the human experience. From the perspective of the human experience, stressors are intrinsic to important milestones in the life cycle. Life developmental stressors include such events as childbirth, birth of a sibling, early parent death, separation from loved ones, family discord, divorce, aging, hospitalization, surgery, and physical illnesses. Children who are exposed to such stressors may exhibit clearly discernable behavior changes. For example, a school-age boy who experiences the sudden unexpected death of his father may resume bedwetting, became afraid to sleep alone and cling to his mother, insisting that he does not want to go to school. Natural disasters include weather-related events (hurricanes, tornadoes, and floods), seismic events (earthquakes, tsunamis, and volcanoes), droughts and pandemics. Human-generated disasters may be subdivided into non-intentional versus intentional events (Shultz et al., 2007). Non-intentional, humangenerated incidents include transportation crashes, hazardous materials spills, and structural collapses, reflecting accidental failures of human technologies. In other instances, harm is clearly intended during acts of aggression toward individuals (child maltreatment, assault, rape, torture) and acts of mass violence (war, civil strife, ethnic conflict, and terrorism).

Primary stressors are associated with acute threats to well-being, physical harm or life-threat to self or loved ones. Primary stressors are associated with direct exposure to the forces of harm during an episode of interpersonal violence or during the period of disaster impact. Secondary stressors occur subsequent to a primary stressor as a cluster of consequences or adversities encountered in the aftermath of a traumatic event. For example, a child who is accidentally burned by scalding water (primary stressor) may experience a multiplicity of secondary stressors including hospitalization, severe pain, surgical procedures, debridement, scarring and disfigurement, separation from parents, interruption of school attendance, and disruption of daily routines including play activities and socialization. At the community level, the coastal landfall of a strong hurricane will subject the population in the impact zone to such primary stressors as ravaging winds, storm surge, and torrential rainfall. While the impact phase of the hurricane is brief (hours to days), the stormâ&#x20AC;&#x2122;s aftermath may produce a succession of secondary stressors including disruption of power and utilities, shortages of basic necessities, damage to home, displacement, repair delays, loss of valued possessions, school closures, and disruption of health care services, unemployment, and economic crisis. Acute and chronic

stressors. An acute stressor refers to an event which is circumscribed in time and space. The ground-shaking of an earthquake, the touchdown of a tornado, a terrorist event involving conventional explosives, or the violence of a physical assault provide examples of acute stressors. Each has a well-defined onset and endpoint. A chronic stressor is characterized by ongoing exposure to continuous and unrelenting adversities, such as child maltreatment, war-related trauma, and kidnapping; or episodic, repetitive exposures as occur with periodic terrorist attacks. Children exposed to chronic stressors may experience a gradual loss of resiliency and adaptive coping skills. Cumulative stress is associated with both immediate and long-term neurobiological changes (Cooper et al., 2007). A distant stressor refers to a traumatic stimulus experienced from a remote and physically safe distance away from the impact zone. A distant stressor may be encountered repetitively through the media or interpersonal interactions.

Chronic Stress: Long-Term Consequences • Sleep and appetite disturbances • Bodily symptoms such as gastrointestinal problems, chronic pain • Interpersonal, social and performance problems at school or work • Trauma-specific mental disorders (acute stress disorder--ASD, post-traumatic stress disorder- PTSD) • Anxiety and mood disorders

• Autoimmune diseases or flare-ups of these conditions (asthma, endocrine disorders) • Cardiovascular illness

The Stress Response Acute Stress Response. Direct exposure to a stressor activates the acute stress response, a state of physiological “hyperarousal” frequently described as the “fight-flight-or- freeze” response. Encountering a stressor disturbs the body’s biological and psychological equilibrium. The stressor is interpreted as a potentiallythreatening change in the environment instantaneously activating the hypothalamicpituitary-adrenal (HPA) axis at the base of

the brain. The activated HPA axis signals the release of adrenocorticotropic hormone (ACTH) that stimulates the endocrine system and the adrenal cortex which produces cortisol. Cortisol has essential and beneficial effects in the short term (restoring depleted energy by increasing glucose availability) but detrimental effects in the long term (Perry et al., 1995; McEwen, 2004; Yehuda, 2002). This alarm reaction simultaneously stimulates the sympathetic nervous system which results in the release of epinephrine (adrenaline) from the inner part of the adrenal glands, the medulla, which prepares the individual for a “fightorflight” response. Epinephrine increases heart rate, blood pressure and respiration and is accompanied by a sharp spike in glucose which is released into the blood stream as an energy source, priming the body for rapid action. Simultaneously, quantities of endorphins, the body’s natural painkillers, are secreted. This adaptive response acts to restore the individual to a more optimal level of function. Regardless of whether the stressor is a minor daily hassle, a bout of the “common cold,” a “fender-bender” motor vehicle accident or an overt threat to life itself, human neurobiology responds in an attempt to restore order and homeostasis. It is assumed that there is a natural impetus to recover and that with sufficient infusion of resources and the passage of time, recovery is the expected outcome to an acute stressor (Watson and Shalev, 2005).

Chronic Stress Response. In some instances, the traumatic situation is prolonged. Continuing exposure to chronic stressors creates long-term effects on the organism’s psychological and physiological well-being. When the stress response system remains in “overdrive”, high levels of epinephrine and cortisol are continuously released. Maintaining the stress response on “high alert” leads to wear and tear on organ systems and increases the risk for a number of psychobiological symptoms. These include anxiety, depressed mood, sleep and appetite disturbances, interpersonal and social problems, and diminished The Traumatic Event performance either at school or work. Bodily symptoms such as gastric ulcers, headaches, or irritable bowel A traumatic event is stated to have syndrome may ensue. When stress and physiological occurred when the person “hyperarousal” continue unabated, cortisol remains experiences, witnesses, or is elevated with possible detrimental effects on immune confronted with an event that involves function and increased risk for chronic conditions such actual or threatened death or serious as cardiovascular disease, obesity, depression, injury, or a threat to the physical hyperthyroidism, diabetes, and even anatomical integrity of the self or others often changes in the brain (Perry et al., 1995; McEwen, 2004). associated with fear, helplessness, or In some instances, the individual’s stress response is terror. insufficient to meet the crisis. In situations of inadequate neuroendocrine response, insufficient production of adrenal Children rarely will describe such emotions and may respond with disorganized or agitated behavior.

stress response hormones and low levels of cortisol may elevate risks for fibromyalgia, hypothyroidism or chronic fatigue syndrome (McEwen, 2004).

Psychobiological Responses to Chronic Stress in Children Exposure to ongoing and repetitive traumatic experiences results in profound and reverberating effects on personality structure, psychological symptoms and developing neurobiological structures. When children remain suspended in a constant state of fearful expectation, their capacities to use cognitive, social and emotional experiences to develop solutions to problems are impaired. Moreover, continuing exposure to stress negatively impacts attachment behaviors, behavioral controls, cognition, psychobiology, self-regulation and interpersonal relationships in children. It is estimated that up to 80 percent of children who experience chronic stress (such as child victims of aggression and maltreatment by caretakers) will exhibit one or more stressrelated disturbances (Kendall-Tacket et al., 1991; Hadi & Llabre, 1998; Bayer et al., 2007). Disturbance in

behavioral controls may appear as impulsivity, aggression, sleep and appetite disturbances, eating disorders, oppositional behavior, substance abuse and suicidal behaviors. Disturbances in relationships may present as attachment disorders, social estrangement, overestimation of danger and adversity, problems with boundaries, distrust of others, a belief that intimate relations are dangerous, and avoidance of intimacy.

Negative self-attributions may occur in which the individual internalizes negative self-judgments regarding self-efficacy, competency and self-worth and a readiness for selfâ&#x20AC;&#x201C;blame, shame, guilt, feelings of helplessness and self-loathing. Affect dysregulation may be manifested by depression, anxiety, mood swings, emotional instability (rage, anger, and despair), suicidal thoughts or actions, impulsivity, hyperarousal, hyperactivity and substance abuse. Children may experience difficulties in identifying and describing emotions or even knowing what they feel. Emotional/behavioral problems may include posttraumatic stress symptoms, mood and other anxiety symptoms, dissociative disorders, severe personality disturbances, and behavioral problems. Disturbances in cognition may be appear as inattention, learning difficulties, problems with information processing, distorted social judgment and inability to interpret the intentions of others. There may be disturbances in thinking as evidenced by memory deficits, denial, repression, suppression, minimization, amnesia, and academic difficulties. The biological effects of chronic stress exposure are directly related to the intensity, duration and degree of impact of stressors on bodily integrity, the stress response system and physiological systems critical for sustaining life. Abuse and neglect affect brain development. The more prolonged the maltreatment, the greater the residual effects. Exposure to intense acute and chronic stressors during the developmental years has enduring neurobiological effects on the stress response, neurotransmitter systems and anatomical structures. Children who have been physically and sexually abused have decreased brain volumes (decreased size of the cerebrum and the corpus callosum) and poor regulation of the stress response (DeBellis et al., 1999a,b).

The Traumatic Event A traumatic event occurs when an individual experiences, witnesses, or is confronted with an event that involves death, serious injury, or threats to the physical integrity of the self or others (APA, 1994). Exposure to trauma may occur from direct physical impact, visual exposure, media presentation, or through interpersonal relationships with disaster survivors. Experiencing multiple types of trauma exposure increases the risk of psychological consequences. The essence of the traumatic situation is embodied in feelings of helplessness and fears of imminent death (Shaw, 1987). Trauma may lead to a perceived sense that life has lost its intrinsic meaning and predictability and may never be the same again. The individual grapples with the need to accept and assimilate what has happened and to ultimately find new meaning and purpose (Doctors Without Borders,

2005). The adolescent may be left with a sense of a “foreshortened future” and take flight into pleasureseeking or risk-taking activities. Trauma invariably impacts not only the individual, but also the family and social system within which the individual lives. The impact of trauma in children is modulated by the fact that the child has limited life experience. The child is still developing cognitively and emotionally and may be struggling with such issues as separation, individuation, and identity formation. Children typically exhibit immature adaptive and coping strategies. When exposed to trauma, children rarely describe such emotions as fear and helplessness; rather, they may respond with disorganized or agitated behavior.

The Acute Traumatic Moment The acute traumatic moment is defined as the sudden, conscious awareness of vulnerability in the presence of imminent physical injury or death. For children it is often the sudden awareness that parents are unable to protect and provide for them in their hour of need that ushers in and exacerbates the traumatic moment. The illusion of safety is shattered. The traumatic moment may be associated with feelings of helplessness and anxiety (Shaw, 1987). A distinguishing feature of the traumatic moment is the central role of anxiety and its management. Most commonly, the brief traumatic moment, with its experience of anxiety and helplessness, is followed by rapid remobilization and reintegration of developmentally-appropriate coping and adaptive strategies. The child who is able to successfully adapt will restore normal developmental progression with age-appropriate self-direction, academic performance, and peer and family relations. In some instances, distress persists and there is a failure of reparative defenses leading to a sustained traumatic experience. This may precipitate various degrees of regression with loss of developmental achievements and psychosocial gains as well as various symptoms of somatic ills, anxiety, mood and behavioral disturbances (Shaw, 2000).

Traumatic Reminders In the aftermath of an acute trauma, the survivor may experience “flashbacks”, in which they vividly relive the traumatic moment over and over again. “Flashbacks” are frequently triggered by “ traumatic reminders”, external or internal cues that suddenly make the individual feel as if the traumatic event was happening again. For example, sudden exposure to strong winds, torrential rains, thunder and lightning may bring back all the emotions, fears, and cognitions associated with living through a hurricane. A child who was once painfully injured in a bicycle accident may re-experience all the emotions, ideations and physical sensations of that event when exposed to the cue of seeing another child’s mangled bicycle.

Summary Children and adolescents are exposed to various types of stress and traumatic events during their developmental years. The individual response to stress is shaped both by the reality of the impact of the fateful event and by one’s subjective appraisal.

How you define a situation determines your emotional response. Stressors may be acute or chronic. A traumatic event occurs when an individual experiences a situation in which there is a perceived or real threat of bodily injury or death. The acute traumatic moment for the child involves a sudden awareness of vulnerability in the presence of probable physical harm or death. Traumatic reminders refer to those events in the aftermath of traumatic exposure that result in the child or adolescent reliving and re-experiencing the trauma as if it was truly recurring at that moment.

12.

Treatment

Child Family Traumatic Stess Intervention Treatment (CFTSI) Trauma from child abuse can produce devastating effects on children, making them afraid, anxious, depressed, and unable to stop thinking about the abuse. It can also harm their ability to perform well in school and to relate well with others. Trauma can also lead to problems as children get older, unable to fully function as adults, or developing substance and alcoholic abuse issues to numb their pain. These reasons are why the Yale University School of Medicineâ&#x20AC;&#x2122;s Child Study Center developed the Child Family Traumatic Stress Intervention treatment, known as CFTSI. Through CFTSI, children are brought together with their parents or caregivers so the whole family can learn how to recognize and deal with trauma symptoms. What makes CFTSI treatment special is its emphasis on engaging the entire family to help children heal from abuse. CFTSI counselors works with parents of children ages seven to 18, to identify their childâ&#x20AC;&#x2122;s trauma symptoms, learn how to discern them, and learn practical skills to help deal with trauma symptoms. CFTSI treatment takes place over the course of just four to six sessions. This shorter treatment period helps families who may not feel ready to commit to longer-term treatments, who have multiple issues to deal with in the aftermath of abuse, or who may not need longer-term treatment. The results from the treatment have been remarkable. When Yale initially studied the results of treatment for children and families in their pilot program on the Yale campus, they found 73% of those children were less likely than children and families undergoing other counseling methods to show some or all symptoms of trauma.

Most of the research literature agrees that social and family supports are some of the most salient protective factors in preventing negative outcomes for individuals after exposure to PTE.

13.

Adult Survivors of Childhood Abuse

Compiled by Alister Lamont National Child Protection Clearinghouse Published by the Australian Institute of Family Studies ISSN 1448-9112 (Online) ISBN 978-1-921414-29-9 Exposure to child abuse and neglect can lead to a wide range of adverse consequences that can last a lifetime. The purpose of this Resource Sheet is to indicate the potential long-term effects of child abuse and neglect that may extend into adulthood.

Types of abuse and neglect Child abuse and neglect consists of any act of commission or omission that results in harm, potential for harm, or the threat of harm to a child (0-18 years of age) even if harm was unintentional (Gilbert et al., 2009). In the case of all but sexual abuse it is generally perpetrated by a parent or caregiver. The five main types of child maltreatment are: physical abuse; sexual abuse; emotional maltreatment; neglect and witnessing domestic violence. Evidence suggests that different types of abuse and neglect rarely occur in isolation and children who experience repeated maltreatment often experience multiple forms of abuse (Higgins, 2004).

Factors affecting the consequences of abuse and neglect The consequences of child abuse and neglect that extend into adulthood will vary considerably. For some adults, the effects of child abuse and neglect are chronic and debilitating, others have more positive outcomes as adults, despite their abuse and neglect histories (Miller-Perrin & Perrin, 2007). Factors that may impact on the way child abuse and neglect affects adults include:        

their age were when maltreatment occurred; the severity of maltreatment; the frequency and duration of maltreatment; the relationship they had with the perpetrator; the type/s of abuse/neglect; whether the abuse or neglect was detected and action taken to assure the safety of the child (e.g., child protection intervention); positive or protective factors that may have mitigated the effects of maltreatment (e.g., a strong relationship with grandparents); and whether victims/ survivors received therapeutic services to assist them in recovery.

Sometimes, the effects of child abuse and neglect remain largely hidden only to emerge at key times in later life (McQueen, Itzin, Kennedy, Sinason, & Maxted, 2009). Abusive experiences in adulthood can reopen old wounds of past child abuse or neglect that may lead to further adverse outcomes for adult survivors. For some adults, the effects of child abuse and neglect are chronic and debilitating, others have more positive outcomes as adults, despite their abuse and/or neglect histories (Miller-Perrin & Perrin, 2007).

Childhood trauma/trauma theory The impact of childhood trauma is often used to explain the strong associations between past histories of child abuse and neglect and adverse consequences in both children and adults. Experiences of childhood trauma caused by abuse or neglect can lead to a variety of overwhelming emotions, such as anger, sadness, guilt, and shame. In order to avoid such feelings, children can take refuge in dissociation, denial, amnesia, or emotional numbing (Everett & Gallop, 2001). These coping mechanisms can become over-generalised with time and without protective factors (i.e., positive events or characteristics) to intervene, these negative outcomes may continue throughout life. Adult survivors of childhood trauma may also find it difficult to control emotions and or actions. For adults with a history of childhood trauma, recollections of past trauma can almost be as strongly felt as if it was happening again, which may lead to unexpected reactions, such as lashing out in anger or bursting into uncontrolled weeping in response to what most people would view as relatively minor events (Everett & Gallop, 2001).

Multiple types of abuse Any maltreatment of a child may lead to damaging adverse consequences, however, research indicates that chronicity and experiencing multiple types of abuse and neglect may lead to more severe adverse outcomes in both childhood and adulthood (Arata, Langhinrichsen-Rohling, Bowers, & Oâ&#x20AC;&#x2122;Farrill-Swails, 2005; Ethier, Lemelin, & Lacharite, 2004; Higgins & McCabe, 2001). Chronic abuse and neglect can be defined as "recurrent incidents of maltreatment over a prolonged period of time" (Bromfield, Gillingham, & Higgins, 2007). Chronic experiences of child abuse and neglect occurring over a long period of time increases the probability of more severe adverse outcomes in adult survivors (Gilbert et al., 2009; Sachs-Ericsson, Cromer, Hernandez, & KendallTackett, 2009). Research indicates that chronicity and experiencing multiple types of abuse and neglect may lead to more severe adverse outcomes for children and adults.

Long-term consequences of child abuse and neglect Experiences of child abuse and neglect may lead to negative physical, cognitive, psychological, behavioural or social consequences in adulthood. Adverse outcomes of abuse and neglect that emerge in children and adolescents may continue in adults with histories of abuse and neglect (Miller-Perrin & Perrin, 2007). For a more detailed discussion of the impact of child abuse and neglect on children see, The Effects of Child Abuse and Neglect for Children and Adolescents (Lamont, 2010). The following section discusses the long-term effects of child abuse and neglect that may extend into adulthood. The research reviewed included high quality literature reviews/meta-analyses and primary research in English speaking countries. The negative consequences associated with past histories of abuse and neglect are often interrelated, as one adverse outcome may lead to another (e.g., substance abuse problems or engaging in risky sexual behaviour may lead to physical health problems). Adverse consequences are broadly linked to all abuse types, however, where appropriate, associations are made between specific types of abuse and neglect and specific negative outcomes. Experiencing child abuse and neglect may lead to adverse physical, cognitive, psychological, behavioural or social consequences in adulthood.

Physical health problems Adults with a history of child abuse and neglect are more likely to have physical health problems and chronic pain symptoms. Research indicates that adult survivors of childhood abuse and neglect have more health problems than the general population, including diabetes, gastrointestinal problems, arthritis, headaches, gynecological problems, stroke, hepatitis and heart disease (Felitti et al., 1998; Sachs-Ericsson et al., 2009; Springer, Sheridan, Kuo, & Carnes, 2007). In a review of recent literature, Sachs-Ericsson et al. (2009) found that a majority of studies showed that adult survivors of childhood abuse had more medical problems than non-abused counterparts. Using survey data from over 2,000 middle-aged adults in a longitudinal study in the United States, Springer et al. (2007) found that child physical abuse predicted severe ill health and several medical diagnoses, including heart and liver troubles and high blood pressure. Some researchers suggest that poor health outcomes in adult survivors of child abuse and neglect could be due to the impact early life stress has on the immune system or to the greater propensity for adult survivors to engage in high-risk behaviours (e.g., smoking, alcohol abuse and risky sexual behaviour) (Sachs-Ericsson et al., 2009; Watts-English, Fortson, Gilber, Hooper, & De Bellis, 2006). Exposure to abuse and neglect in childhood may also contribute to the development of chronic pain disorders in adulthood (Davis, Luecken, & Zautra, 2005; Sachs-Ericsson et al., 2009). In a meta-analysis by Davis et al. (2005), studies assessing the abuse and neglect history of chronic pain patients indicated that patients were more likely to report having been abused or neglected in childhood than healthy controls.

Mental health problems Persisting mental health problems are a common consequence of child abuse and neglect in adults. Mental health problems associated with past histories of child abuse and neglect include personality disorders, posttraumatic stress disorder, dissociative disorders, depression, anxiety disorders and psychosis (Afifi, Boman, Fleisher, & Sareen, 2009; Chapman et al., 2004; McQueen et al., 2009; Springer et al., 2007). Depression is one of the most commonly occurring consequences of past abuse or neglect (Kendall-Tackett, 2002). In an American representative study based on the National Co-morbidity Survey, adults who had experienced child abuse were two and a half times more likely to have major depression and six times more likely to have posttraumatic stress disorder compared to adults who had not experienced abuse (Afifi et al., 2009). The likelihood of such consequences increased substantially if adults had experienced child abuse along with parental divorce (Afifi et al., 2009). In a prospective longitudinal study in the United States, Wisdom, DuMont, and Czaja (2007) found that children who were physically abused or experienced multiple types of abuse were at increased risk of lifetime major depressive disorder in early adulthood.

Suicidal behaviour Consistent evidence shows associations between child abuse and neglect and risks of attempted suicide in young people and adults. In the Adverse Childhood Experiences (ACE) study in the United states, Felitti et al. (1998) indicated that adults exposed to four or more adverse experiences in childhood were 12 times more likely to have attempted suicide than those who had no adverse experiences in childhood. In a meta-analysis by Gilbert et al. (2009), retrospective studies, which record participants recollections of past traumatic events showed a strong association between child abuse and neglect and attempted suicide in adults. Prospective studies, which trace participantâ&#x20AC;&#x2122;s experiences of traumatic events over several years indicated a more moderate relationship. The higher rates of suicidal behaviour in adult survivors of child abuse and neglect has been attributed to the greater likelihood of adult survivors suffering from mental health problems.

Eating disorders and obesity Eating disorders and obesity are common among adult survivors of child abuse and neglect (Johnson, Cohen, Kasen, & Brook, 2002; Kendall-Tackett, 2002; Rodriguez-Srednicki & Twaite, 2006; Rohde et al., 2008; Thomas, Hypponen, & Power, 2008). Prospective research studies have consistently shown links between child abuse and neglect and obesity in adulthood (Gilbert et al., 2009). Using a large population-based survey, Rohde and colleagues (2008) found that both child sexual abuse and physical abuse were associated with a doubling of the

odds of obesity in middle-aged women. In a prospective longitudinal study in the United Kingdom, results indicated that severe forms of childhood adversity, such as physical abuse, witnessing domestic violence and neglect were associated with increased risk of obesity in middle adulthood by 20 to 40% (Thomas et al., 2008). In a community based study, Johnson and colleagues found (2002) that adolescents and young adults with a history of child sexual abuse or neglect were five times more likely to have an eating disorder compared to individuals who did not have a history of abuse. Stress and mental health problems such as depression may increase the likelihood of adults with a history of abuse and neglect becoming obese or having an eating disorder (Rodriguez-Srednicki & Twaite, 2006).

Re-victimisation Research suggests that adults, particularly women, who were victimised as children are at risk of revictimisation in later life (Mouzos & Makkai, 2004; Whiting, Simmons, Havens, Smith, & Oka, 2009; Widom, Czaja, & Dutton, 2008). Findings from the Australian component of the International Violence Against Women Survey (IVAWS) indicated that 72% of women who experienced either physical or sexual abuse as a child also experienced violence in adulthood, compared to 43% of women who did not experience childhood abuse (Mouzos & Makkai, 2004). In a prospective study by Widom and colleagues (2008), all types of childhood victimisation (physical abuse, sexual abuse and neglect) were associated with increased risk of lifetime revictimisation. Findings indicated that childhood victimisation increased the risk for physical and sexual assault/abuse, kidnapping/stalking, and having a family friend murdered or commit suicide (Widom et al., 2008). Women who experience childhood violence or who have witnessed parental violence could be at risk of being victimised as adults as they are more likely to have low self-esteem and they may have learnt that violent behaviour is a normal response to dealing with conflict (Mouzos & Makkai, 2004).

Alcohol and substance abuse Associations have often been made between childhood abuse and neglect and later substance abuse in adulthood (Simpson & Miller, 2002; Widom, White, Czaja, & Marmorstein, 2007). In a systematic review by Simpson and Miller (2002) of 224 studies, a strong relationship was found between child physical and sexual abuse and substance abuse problems in women. Less of an association was found among men, although men with child sexual abuse histories were found to be at greater risk of substance abuse problems. The authors suggested that it is possible that men are less likely to disclose childhood abuse due to social values and expectations (Simpson & Miller, 2002). In the Adverse Childhood Experiences Study in the United States, adults with four or more adverse experiences in childhood were seven times more likely to consider themselves an alcoholic, five times more likely to have used illicit drugs and ten times more likely to have injected drugs compared to adults with no adverse experiences (Felitti et al., 1998). The higher rates of substance abuse problems among adult survivors of child abuse and neglect may, in part, be due to victims using substances to self-medicate from trauma symptoms such as anxiety, depression and intrusive memories caused by an abusive history (Whiting et al., 2009).

Aggression, violence and criminal behaviour Violence and criminal behaviour is another frequently identified long-term consequence of child abuse and neglect for adult survivors, particularly for those who have experienced physical abuse or witnessed domestic violence (Gilbert et al., 2009; Kwong, Bartholomew, Henderson, & Trinke, 2003; Miller-Perrin & Perrin, 2007). Widom (1989) compared a sample of adults with a history of substantiated cases of child abuse and neglect in the United States with a sample of matched comparisons and found that adults with a history of abuse and neglect had a higher likelihood of arrests, adult criminality, and violent criminal behaviour. In a study of 36 men with a history of perpetrating domestic violence, Bevan and Higgins (2002) found that child maltreatment (particularly child neglect) and low family cohesion were associated with the frequency of physical spouse abuse. Witnessing domestic violence (but not physical abuse) as a child had a unique association with psychological spouse abuse and trauma symptomalogy. Adults with a history of child physical abuse or witnessing domestic violence may be more likely to be violent and involved in criminal activity as they have learned that such behaviour is an appropriate method for responding to stress or conflict resolution (Chapple,

2003). Substance abuse problems are also associated with higher rates of criminal behaviour (e.g., theft, prositution) to support addiction (Dawe, Harnett, & Frye 2008).

Intergenerational transmission of abuse and neglect Evidence suggests that adults who are abused or neglected as children are also more likely to abuse or neglect their own children (Kwong et al., 2003; Mouzos & Makkai, 2004; Pears & Capaldi, 2001). In a study by Pears and Capaldi (2001), parents who had experienced physical abuse in childhood were significantly more likely to engage in abusive behaviours toward their own children or children in their care. Oliver (1993) in a review of the research literature concluded that an estimated one-third of children who are subjected to child abuse and neglect go on to repeat patterns of abusive parenting towards their own children. This is a significant number, however, it is also important to note that Oliverâ&#x20AC;&#x2122;s estimations indicate that a majority of maltreated children do not go on to maltreat their own children. Kwong and colleagues (2003) determined that growing up in an abusive family environment can teach a child that the use of violence and aggression is a viable means for dealing with interpersonal conflict, which can increase the likelihood that the cycle of violence will continue when the child reaches adulthood. Although links have been made between adult survivors of child physical abuse perpetrating the same type of abuse on their own children (Kwong et al., 2003; Pears & Capaldi, 2001), there is little evidence to suggest that maltreating parents who experienced other forms of abuse or neglect, such as child sexual abuse will perpetrate the same type of abuse on their own children.

High-risk sexual behaviour Adults who have experienced childhood abuse and neglect, particularly child sexual abuse are more likely to engage in high-risk sexual behaviour. This can lead to a wide range of sexually transmitted diseases or early pregnancy (Cohen et al., 2000; Hillis, Anda, Felitti, Nordenberg, & Marchbanks, 2000; Steel & Herlitz, 2005). Using a random population sample in Sweden, Steel and Herlitz (2005) found that a history of child sexual abuse was associated with a greater frequency of unintended pregnancy, younger age at first diagnosis of a sexually transmitted disease, greater likelihood of participation in group sex and a greater likelihood of engaging in prostitution. In a large retrospective study in the United States, the prevalence of sexually transmitted diseases was three and a half times higher for men and women who were exposed to three to five adverse childhood experiences compared to adults who had no adverse childhood experiences (Hillis et al., 2000). Steel and Herlitz (2005) determined that factors that may increase the likelihood of engaging in risky sexual behaviours include: the inability to be assertive and prevent unwanted sexual advances, feeling unworthy and having competing needs for affection and acceptance. These are all feelings that may occur as a consequence of child abuse and neglect.

Homelessness Strong associations have been made between histories of child abuse and neglect and experiences of homelessness in adulthood. A study by Herman, Susser, Struening, and Link (1997) found that the combination of lack of care and either physical or sexual abuse during childhood was highly associated with an elevated risk of adult homelessness. Adults who experienced a combination of a lack of care and either child physical or sexual abuse were 26 times more likely to have been homeless than those with no experiences of abuse. In a study examining whether adverse childhood events were related to negative adult behaviours among homeless adults in the United States, 72% of the sample had experienced one or more adverse childhood events (Tam, Zlotnick, & Robertson, 2003). Higher rates of homelessness among adult survivors of abuse and neglect could be due to difficulties securing employment or experiences of domestic violence. Although evidence associating past histories of child abuse and neglect and unemployment is limited, a small body of research suggests that children and adolescents affected by abuse and neglect risk poor academic achievement at school, which may lead to difficulties finding employment in adulthood (Gilbert et al., 2009). The relationship between homelessness and adult survivors of abuse and neglect may also be connected to other adverse outcomes linked to child abuse and neglect such as substance abuse problems, mental health problems and aggressive and violent behaviour. These consequences may make it difficult to achieve stable housing.

Research limitations Research investigating the effects of child abuse and neglect in adulthood is extensive, however in most research studies it is difficult to make casual links between abuse and neglect and adverse consequences due to several limitations. Many research studies are unable to control for other environmental and social factors. This makes it difficult to rule out influences such as socio-economic disadvantage, disability and social isolation when associating abuse and neglect with negative consequences. Most research studies on adult survivors are based on retrospective studies and are therefore reliant on participants’ recollection of events over long periods. This can limit the data in that participants’ recollections may have changed over time. Prospective studies have the advantage of tracing participants with reported experiences of child abuse or neglect over several years. However prospective studies alone are not completely representative of the population, as a high proportion of child abuse and neglect goes undetected and those experiencing abuse and neglect are less likely to participate or remain in a longitudinal study (Kendall-Tackett & Becker-Blease, 2004). Kendall-Tackett and Becker-Blease (2004) argued that there should be a mix of prospective and retrospective studies as both types of research can provide insight into the long-term consequences of child abuse and neglect. Other limitations in the research included: 

studies focusing solely on one type of abuse (particularly sexual abuse).

Focusing research on only one type of abuse or neglect overlooks the effects of children experiencing chronic and multiple types of abuse and neglect. Without assessing chronicity and the effects of other forms of child abuse and neglect, bias and misleading conclusions are often made on the specific impact of that form of maltreatment (Bromfield et al., 2007; Higgins & McCabe, 2001). 

a reliance on recruiting participants already involved in clinical services.

Only including participants involved in clinical services excludes adult survivors who have not sought clinical services. This can make negative outcomes appear worse than in reality as participants are only those who have presented with a problem. 

far more studies focusing on the effects of child abuse and neglect in women compared to men.

Having more research on the effects of child abuse and neglect in women makes it difficult to compare differences between men and women as less is known on the effects of child abuse and neglect on men (Springer et al., 2007; Widom, DuMont et al., 2007). In spite of the various limitations, research consistently indicates that adults with a history of child abuse and neglect are more likely to experience adverse outcomes.

Conclusion The effects of child abuse and neglect can lead to a wide range of adverse outcomes in adulthood. Adverse outcomes associated with past histories of child abuse and neglect are often inter-related. Experiencing chronic and multiple forms of maltreatment can increase the risk of more severe and damaging adverse consequences in adulthood.

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