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Mental health professionals assume that every sexually abused child deserves and needs treatment. And in fact, children who are victims of sexual abuse are more likely to receive treatment (from 44 to 73% of them receiving treatment, according to Finkelhor and Berliner) than are victims of other types of child maltreatment.

Child Sexual Abuse

Table V Criteria Included in Guidelines for Decision Making about Sexual Abuse

1. Child interview information

A. Sexual abuse description from the child

1. Detail about the sexual abuse

2. Child's perspective evident in the description of abuse

3. Advanced sexual knowledge for the child's developmental stage

B. Offender behavior description, as described by the child

1. Use of inducements to participate in the sexual activity

2. Admonitions not to tell about the sexual abuse

3. Progression of abuse from less to more intrusive sexual acts

C. Information about the context of the sexual abuse

1. Idiosyncratic event

2. Where the abuse occurred

3. When the abuse occurred

D. Emotional reaction to the abuse by the child

1. Affect consistent with the abuse description

2. Affect related to the offender

3. Recall of affect during abuse

4. Reluctance to disclosure

E. Child functioning

1. Competency a. Cognitive test results b. Recall of past events c. Ability to differentiate the truth from a lie d. Ability to differentiate fact from fantasy e. Child is not suggestible

2. Child is motivated to tell the truth

3. Consistency of the child's accounts

4. Feasibility of the events the child describes

F. Structural qualities of the child's account

2. Information from other sources

A. Child's behavior in other contexts

1. Statements to others about the abuse

2. Nonsexual behavioral and emotional symptoms

3. Sexualized behavior

4. Evidence of advanced sexual knowledge

B. Offender characteristics

1. Overall functioning

2. Results of polygraph

3. Results of Plethysmograph

4. Psychological test results

5. Evidence of other victims

6. Confession/admission

C. Family

1. Information related to nonoffending parent

Table V Continued

2. Marital functioning and family functioning

3. Family history of abuse D. Other

1. Medical findings

2. Police evidence

3. Witnesses

Treatment of child sexual abuse may only involve the child, the child and his/her family, or the offender and sometimes the offender's family. The relationship of the victim to the offender will usually have an impact on the structure of treatment. However, in intra-familial sexual abuse, the offender's prognosis also affects whether his treatment will prepare him/her for some level of future contact with the child. Because of space limitations, the focus in this article will be on child victim treatment.

A variety of theoretical frameworks related to treatment and rehabilitation are being used in victim treatment, including psychodynamic, play therapy, cognitive behavioral, and eclectic, drawing upon psy-chodynamic, behavioral, and family systems frameworks. However, one thing they have in common is that they dictate a direct focus on the abuse in the course of treatment. For example, it is not recommended that the therapist merely focus on the child's self-esteem or avoidance of men without addressing the underlying cause of these problems, the experience of sexual abuse. [See Behavior Therapy; Cognitive Therapy; Psychoanalysis.]

A variety of treatment modalities are employed, the most common being individual, group, and family therapies. These may be employed concurrently or in progression, depending upon the structure of the treatment program, the functioning of the child, and the treatment issues being addressed. [See Family Therapy.]

Common treatment issues for victims are fears and phobias associated with the sexual abuse, the inability to trust adults, altered body image, guilt and responsibility associated with the abuse and its aftermath, anger because of the abuse, sexualized behavior, a need to understand aspects of the sexual abuse experience, and personal boundary and prevention issues.

Child Sexual Abuse

A number of treatment manuals and descriptive writings have been developed that propose the structure of the treatment and even provide specific exercises to address treatment issues. These are geared to children at different developmental stages, and some have been especially developed for boys.

Illustrative of treatment manuals is one developed by Mandell and Damon for group treatment of 7-to 12-year-old sexually abused children. It includes guidelines for group membership selection and a rationale for group treatment. It also contains 10 modules and provides topics and exercises for each module. Issues covered in the curriculum are shown in Table VI.

Outcome studies of treatment efficacy for victims of sexual abuse are just beginning to be conducted. In 1995, Berliner and Finkelhor provided a summary of 29 treatment outcome studies. All of these treatments lasted less than a year and most were treatment of a few weeks. These studies demonstrated that children who receive treatment for sexual abuse improve, but only 5 studies demonstrated that it was the therapy, itself, rather than, for example, the passage of time, that led to the children's improvement.

In providing appropriate treatment, the mental health professional must consider the nature of the abuse, the child's age and functioning, the offender -victim relationship, and the impact and symptomol-ogy. The treatment approach and modality should take into account the child within his/her context and should be of sufficient length to address the child's

Table VI Treatment Issues Developed by Mandell and Damon

1. Learning to trust others, beginning with other members of the grĀ°up.

2. Identifying feelings (e.g., proud, special, jealous, worried, embarrassed, ashamed).

3. Telling the secret (i.e., disclosing the sexual abuse).

4. Feelings related to sexual abuse (e.g., betrayal, shame, guilt, responsibility, secrecy, protectiveness, helplessness).

5. The effect of sexual abuse on the victim, caretakers, and the family unit.

6. Recovery from sexual abuse.

7. Rebuilding and enhancing self esteem.

8. Protecting oneself in the future from sexual abuse and other harms.

9. Preparation for puberty.

treatment issues and symptoms. A systematic way of measuring the child's functioning before and after treatment is advisable. The child may need to return to treatment as subsequent developmental stages raise new concerns about past abuse and when new crises and traumas reactivate issues related to the sexual abuse.

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