Child Sexual Abuse and its Impact on Adolescent Development
The present study explores the effects of CSA on adolescent development and possible interventions that can be used to promote resiliency in adolescent victims of CSA. Child sexual abuse (CSA) is not a new phenomenon, but has been present throughout history. The society remained silent on the problem until England enacted a law to protect girls and boys from rape and sodomy in the 16th century (Deb & Mukherjee, 2009, p. 15). Since then, the society begun recognizing and responding to CSA as a social problem. For example, a Connecticut court sentenced a father to death for sexually abusing his daughter. The 18th century scholars and educators urged parents to protect their children against sexual abuse. However, CSA remained poorly understood until the 1970s because of the paucity of research on the subject and lack of coordinated effort to respond to the problem. Studies on child maltreatment by Kempe and colleagues in the 1960s revived interest in the subject and ignited much of the existing scientific knowledge about CSA (Deb & Mukherjee, 2009, p. 16). Child sexual abuse is now recognized worldwide as a pressing social problem, thanks to the over four decades of research on the subject (Collin-Vezina et al., 2013, p. 22). At least 20,000 studies and numerous texts on CSA have been published and the literature continues to grow.
One of the issues that plague CSA research and practice is lack of consensus on the meaning of child sexual abuse. Earlier definitions of CSA emphasized sexual contact such as kissing, fondling, touching and penetration while neglecting non-contact acts such as exhibitionism and exposing children to pornography (Collin-Vezina et al., 2013, p. 22). However, the definition of CSA has expanded to include all contact or non-contact sexual activities targeting a minor through manipulation, force, threat or intimidation. As a result, the list of sexual activities included in CSA is broad but the most common acts are fondling, touching, incest, rape, penetration, sodomy, child prostitution, child pornography exhibitionism and online sex activities targeting children.
Many aspects of CSA such as the nature of the relationship between the victim and the perpetrator, the sexual acts involved, and their frequency and duration render each case of CSA unique. Although only adults were initially considered to be capable of perpetrating CSA, child perpetrated sexual abuse is now considered equally dangerous to the psychological wellbeing of the victim as adult-perpetrated abuse (Collin-Vezina et al., 2013, p. 23). However, child-perpetrated CSA is difficult to detect considering the blurred line between sex play and sexual abuse among children. The age difference necessary to consider sexual activities among children as abusive remains unclear considering the numerous cases of child-perpetrated CSA involving children whose age difference falls outside the initially suggested 2-5 years (Collin-Vezina et al., 2013, p. 23).
Cross-cultural issues regarding the definition and perception of CSA render it difficult to estimate the prevalence and seriousness of the problem across countries. Various cultures differ in their understanding of sexual maturity and sexual consent and these differences affect the extent to which sexual acts involving minors may be ruled as CSA. In some countries such as Spain, children as young as 12 can engage in consensual sex while Australia and the United states set the age of consent at 17 years (Deb & Mukherjee, 2009, p. 16). Most European countries consider children aged 16 years to be capable of consensual sexual relations. These variations in age of consent point to the large extent to which contextual issues affect government and community interpretation and response to CSA. Despite these definitional issues, the prevalence of CSA is alarmingly high, ranging between 10-30% for females and 4-20% for boys (Pereda et al., 2009, p. 337). Worldwide CSA prevalence estimates indicate that Asia has the lowest prevalence (11.3% for girls and 4.1% for boys, Africa has the highest prevalence of CSA among boys (19.3%) and Australia has the highest prevalence of CSA for girls (21.5%) (Stoltenborgh et al., 2011, p. 86).
The Multidimensional Nature of Adolescent Development
Adolescence stage is marked by rapid changes in all the developmental dimensions of human life including physical, cognitive, social, emotional, and moral aspects (Hutchison, 2011, p. 37). This stage begins at age 12 and continues until age 20 for most children. The changes occurring during adolescence can only be compared to gestation and infancy in terms of magnitude. The body grows bigger and many of the features absent in childhood appear, transforming the person from his/her childish look to a grown up man/woman. The brain advances in its ability to carry out concrete and logical processes. The affect matures and the person begins to relate with others in a more mature way. The child also reaches higher levels of moral development by internalizing moral laws and utilizing them in decision-making. These rapid changes in all aspects of life that occur during adolescence can only be understood by adopting a multidimensional view of development as described by Hutchison (2011). This section discusses the multidimensional aspects of adolescence development.
Hormonal changes responsible for adolescent biological development begin as early as age 9 and mainly include the increase in the production of androgens and estrogens in boys and girls respectively. These hormonal changes account for most of the changes in the physical appearance of the child’s body including increase in physical size, appearance of pubic and ancillary hair, and structural and functional changes in reproductive organs (Bjorklund & Blasi, 2011, p. 153). At age 10-12, girls experience rapid enlargement of breasts followed by menstruation. By age 14, most girls will have experience their first menstruation. The age of onset of menstruation varies within and among cultures. For some cultures such as America, girls are increasingly entering puberty at a younger age (12 years) than they used to in the past (15 years) (Bjorklund & Blasi, 2011, p. 154). Girls of African descent tend to enter puberty earlier than Caucasian girls. The period of rapid physical change in boys usually occurs between ages 12 and 14 years. The main unique changes include the enlargement of the scrotum, testicles penis, emergence of the prostate gland, and the deepening of the voice due to growth of the larynx. They gain height and weight rapidly and their shoulders become broad. Other changes include appearance of hair on various parts of the body including the pubic area, legs, arms, chest and the beard.
Developmental theorists believe that children reach the final stage of cognitive development during adolescence. One of these theorists, Jean Piaget believed that children go through four phases of intellectual development: sensorimotor (0-2 years), preoperational (2-7 years), concrete operation (7-11 years) and formal operations (12 years) (Austrian, 2008, p. 143). The age of onset of formal operations development ranges between 12 and 15 years depending on culture. Piaget believed that adolescents develop formal operations differently depending interests, aptitudes and occupation. In addition, many other internal and external factors such as physical development, neurological functioning, genetics, and environment affect cognitive development. According to Piaget, a child who has reached formal operations stage of intellectual development is able to form hypotheses to guide reasoning. The development of formal operations occurs in two phases. The first phase is the preparatory stage characterized by the emergence of operational thinking in which children engage in hypothetical thinking but are unable to make rigorous and systemic assumptions (Austrian, 2008, p. 144). It occurs at ages 12-15. When children enter the second phase of formal operations, they gain confidence in their hypothetical thinking and consistently demonstrate their ability to relate their reasoning and decisions to verbally stated hypotheses. They can also reflect on the experience and ideas of others and compare them with their own when making decisions. The development of formal operations enables adolescents to predict outcomes of actions and events, and participate more in the society by engaging in matters of importance to community development.
Erik Erikson believed that children undergo a series of interconnected stages of identity formation characterized by ego crises, cognitive and behavioral disequilibrium (Hutchison & Chalseworth, 2010, p. 58). Successful completion of each phase requires that the child engage in the stage-specific crises and resolve them to acquire new psychological strength needed to pursue the next stage. According to Erikson, adolescence is the period when children enter the final stage of ego development and begins at age 13 (Austrian, 2008, p. 141). The main task that children should accomplish at this age is to develop a sense of identity. Failure to achieve this goal would result in role confusion. Erickson saw adolescence as a period of experimenting with roles and identities, which explains the increased adventurous behavior of adolescents. Adolescents not only acquire new knowledge required to develop a sense of identity but also integrate new information with their experiences from the earlier stages of development. Peers become particularly important at this stage because they provide social feedback and role models. Teenagers engage in romantic relationships mainly to achieve identity rather than solely for sexual gratification. Erikson explained that children at this stage must resolve identity crisis and assume appropriate roles or risk role confusion.
Kohlberg postulated in his theory of moral development that children adopt moral principles in a predictable systematic process (Bjorklund & Blasi, 2011, p. 602). Kohlberg acknowledged that children achieve moral development milestones at different rates within each stage due to personal and external influences. According to Kohlberg, adolescent children operate at the Conventional level of moral reasoning. This level involves reasoning based on social rules and customs. Adolescents anticipate the consequences of different decisions and actions by predicting other peoples’ reactions to such actions based on their understanding of social norms (Bjorklund & Blasi, 2011, p. 604). Adolescents are most likely to settle for decisions that win the favor of their group members or influential others such as parents and peers. Adolescents undergoing conventional stage of moral development can either base their decisions on the anticipated response of significant others or the impact of such decisions on social order. In other words, the child in early stages of conventional reasoning would ask, “what will my mother say?” while the child in later stages of conventional moral development would ask, “will I go to jail?”
Impact of Child Sexual Abuse on Adolescent Development
Child sexual abuse affects many aspects of adolescents’ lives including physical, psychological, behavioral and social health. Violent CSA can present in various observable forms including swelling, bruises, bleeding, injury to the genitals, and sexually transmitted diseases (Rus & Galbeaza, 2013, p. 504). Immediate serious physical health effects are quite uncommon because most CSA cases are non-violent. Most studies focus on the effects of CSA on mental health of adolescents. One model adopted recently for explaining CSA effects on mental health is the Four-Factor Traumagenics Model (FFTM) (Collin-Vezina et al., 2013, p. 26). The basic idea of the FFTM model is the belief that CSA interferes with cognitive and emotional functioning of children by distorting their view of self and others. The FFTM model emphasizes that CSA makes adolescents to lose trust in others and thus makes it difficult for them to form intimate relationships. The four main factors responsible for mental health outcomes in child victims of sexual abuse include sexualized tendencies, helplessness, betrayal and stigmatization (Collin-Vezina et al., 2013, p. 26). Sexual abuse distorts the child’s understanding and expression of sexuality. While the child may be aware of the potential harm of sexual abuse, he or she feels helpless and powerless because the perpetrator is usually a more powerful figure. Since most CSA incidences involve close family members, the child feels betrayed since the abusive nature of the relationship denies the child protection. Sexually abused adolescents are highly prone to blame and stigmatization by the society. The perpetrator and the society reinforce unfavorable attitudes towards the victims such as making the victim feel own responsibility for the abuse.
Sexually abused adolescents are highly likely to suffer from a wide range of mental disorders especially posttraumatic stress disorder (PTSD) and depression. At least one third of sexually abused adolescents are present with dissociation and PTSD symptoms (Collin-Vezina et al., 2013, p. 26). Without treatment, these symptoms persist over long periods (more than one year) since the abuse started for both boys and girls. Besides PTSD, sexually abused children are more vulnerable to major depression than their non-abused counterparts are. This vulnerability persists into adulthood. The symptoms of major depression vary between sexually abused and non-abused adolescents with abused children showing more of reversed neurological symptoms such as weight gain, elevated levels of appetite and hyper-somnia than their counterparts without history of CSA. The increased rates of major depression might explain the high risk of suicide among adolescent victims of CSA (Lamont, 2010, p. 4)
CSA accounts for numerous problem behaviors among adolescents including sexualized behaviors, alcohol and substance abuse, and eating disorders. Sexualized behaviors include age inappropriate sexual talk or sexual relations, flirting, acting like a prostitute, and engaging in prostitution and sex crimes (Rus & Galbeaza, 2013, p. 504). While sexualized behaviors are not specific to sexually abused children, CSA significantly elevates the risk of such behaviors. Heightened sexualized tendencies in adolescents increase the risk of teen pregnancy and its associated health hazards such as birth complications, depression, low-birth weight and social stigmatization. Adolescent victims of CSA are more likely to engage in alcohol and substance abuse as compared to their non-CSA counterparts (Collin-Vezina et al., 2013, p. 27). Substance abuse serves as a means of escaping the adverse effects of CSA such as depression, PTSD and the psychological effects of stigmatization. Eating disorders such as binge eating/drinking and anorexia are associated with CSA. This could be the consequence of increased appetite, a common reversed symptom of major depression in CSA victims.
Risk and Resiliency Factors for CSA
Although CSA affects all adolescents, certain factors including gender, age, race and ethnicity, disability, and familial relationships influence the risk of CSA in different ways. To start with, girls are at least twice vulnerable to CSA than boys (Rickerby, 2013, p. 2). However, the exact contribution of gender to the risk for CSA is unknown since boys are more reluctant than girls to report sexual abuse. In addition, health professionals tend to focus more on girls when during CSA diagnosis. Age is also a significant risk factor. Adolescents and adults account for over one third of all victims of sexual abuse. The onset of CSA occurs earlier and lasts longer for girls as compared to boys. Furthermore, children with disabilities such as deafness, blindness and mental retardations are more vulnerable to CSA as compared to their typically developing peers because of their high level of dependency, confinement in residential care and social limitations (Collin-Vezina et al., 2013, p. 27). The effects of socioeconomic status, race and ethnicity on CSA are unclear. Ethnic variations in prevalence and symptom expression of CSA have been reported but are inconsistent (Collin-Vezina et al., 2013, p. 28). Family factors such as having a single parent significantly contributes to the risk for CSA. Being raised by a stepfather raises the risk for CSA for girls significantly. Presence of mental illness, substance abuse, and punitive disciplinary practices in parents also increases the risk of CSA.
Protective Factors for CSA
While risk factors increase a child’s likelihood to experience CSA, protective factors help the child to respond to CSA in healthy ways and recover quickly. Protective factors facilitate recovery through modifying or mitigating risk factors, or altering the child’s response to CSA (Afifi & MacMillan, 2011, p. 268). Protective factors fall into three main categories: personal, family and community factors. Personal factors include personality traits, self-efficacy, intellect, life-satisfaction, awareness and coping. According to Lamoureux et al. (2012, p. 606). Self-efficacy and self-esteem significantly promote resilience by reducing the negative effect of stressors. Self-esteem is particularly important for CSA victims because the abuse lowers their sense of self worth and appreciation of their sexuality. The feeling of powerlessness in the hands of the perpetrator erodes the child’s self-efficacy. Low self-efficacy is associated with poor interpersonal outcomes and increased risk for further abuse. The Family protective factors include stable care giving, family coherence, spousal support and supportive parenting. Community factors that facilitate resilience including supportive community members, friendships with peers, relationships with non-family members, support from faith groups and availability of social support systems. Longitudinal and cross-sectional studies on resiliency factors for CSA indicate that supportive relationships within the family and outside the family are consistently associated with resilience. Environmental mastery and strong family relations have been found to increase resilience by boosting confidence and sense of belonging in adolescents (McClure et al., 2008, p. 86).
Social Work Interventions Based On Resiliency Theory
Interventions for adolescent victims of CSA should be comprehensive enough to address the complex health outcomes of CSA. Since many developmental changes occur during adolescence, failure to treat CSA effectively would lead to negative outcomes in many dimensions of development including cognitive, affect, behavioral and social skills. Often, adolescents who have been sexually abused would experience difficulties developing normally in all areas. The best intervention for adolescents suffering from CSA is a multidimensional approach aimed at strengthening the individual’s resiliency and coping skills. The impact of sexual abuse should be interpreted as a form of complex trauma due to its many complex adverse psychological outcomes including PTSD, major depression and affect deregulation. Adolescent victims of sexual abuse show symptoms of complex trauma such as reluctance to interact with peers, aggression, poor coping strategies –drug abuse, alcohol intake, sexualized behavior, suicidal behavior, and risky sexual behavior (Lawson & Quinn, 2013, p. 504).
Many models can be used to promote resiliency in adolescents and help them overcome the psychological distress associated with CSA but trauma-focused-cognitive behavior therapy (TF-CBT) and structured psychotherapy for adolescents responding to chronic stress (SPARCS) are the most appropriate. TF-CBT is one of the most effective methods of improving resiliency in adolescents and helping them to process sexual abuse-related trauma. This model consists of eight components to address multidimensional nature of the effects of CSA—psychoeducation, relaxation training, affect regulation training, cognitive coping, trauma narrative, and mastery of trauma triggers, child-parent training sessions, and a safety component (Lawson & Quinn, 2013, p. 504). Psycho education increases the child and parent’s awareness of the nature and effects of CSA, and the need to confront the issue rather than keep it secret. Relaxation skills and affect regulation training enable the child to cope with mood disorders and aggression. Cognitive coping in conjunction with trauma narrative and trauma reminders enables the child to process sexual abuse-related trauma in a healthy manner. The rest of the components strengthen protective factors through improvement of parenting and safety factors. TF-CBT is quite effective in reducing PTSD and depressive symptoms in victims of CSA.
The SPARCS model mainly focuses on strengthening the ability of the child to cope with environmental stressors through increasing the child’s self-esteem and self-efficacy (Lawson & Quinn, 2013, p. 505). Cultivating the child’s awareness of self and others enables the child to cope with affect problems, challenges in interpersonal relations, dissociation symptoms and feelings of hopelessness. Since sexually abused adolescents struggle with low self-esteem and sense of self-worth, this model is highly appropriate for treating complex trauma in this group. The SPARCS model for adolescents consists of numerous components including psychoeducation, relationship building, problem solving, stress regulation, and communication skills training. SPARCS is implemented mainly in group therapy design because building relationships with others is a core treatment goal of the model.
Social workers and other health care professionals encounter numerous challenges as they engage in CSA prevention and treatment efforts. The main challenge is the lack of specialized training in responding to the needs of sexually abused children (Ortega & Coulborn, 2011, p. 27). Detecting victims of CSA is difficult considering many children prefer to keep the abuse secret for fear of intimidation and stigmatization. In addition, assessing the effects of CSA on the different dimensions of the child’s health can be quite difficult without adequate training and experience in identifying and responding to the needs of CSA victims. Furthermore, social workers require training in cultural competence to enable them to design and implement CSA interventions in a culturally sensitive manner (Ortega & Coulborn, 2011, p. 27). Cultural competence is necessary because the meaning of CSA and attitudes towards it vary across cultures.
Another challenge is lack of comprehensive national frameworks to combat CSA in many countries. While intervention efforts are increasing as the problem gains more recognition worldwide, it is difficult to achieve much progress without a national framework to provide training, funds and the coordination required to guide collective effort. Social workers and health professionals alone cannot eliminate CSA. Instead, government agencies should work together with health care professionals, communities, families and individuals to eliminate CSA and respond to the needs of CSA victims. With so many stakeholders to work with, the value of an effective national framework for responding to CSA cannot be overestimated.
The adverse effects of child sexual abuse on adolescent development are too severe to ignore. Since many developmental changes occur during this stage in life, the failure to respond appropriately to child sexual abuse could have disastrous consequences to not only the developing child but also in adult life. Although child sexual abuse has gained much recognition as a serious health problem, the high prevalence rates of the problem worldwide suggest that current response efforts are either inadequate or ineffective. Health professionals, social workers and other stakeholders involved CSA response efforts should combine various intervention models to boost resilience in adolescent victims of CSA and enable them to respond appropriately to environmental stressors. An integrated intervention consisting of the components of TF-CBT and the SPARCS models would be most effective for adolescent victims of CSA because it would boost both personal and external resilience factors if carefully designed.
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