Several specific signs of neglect and abuse are presented in the literature. Knowing these specific signs helps the professional working with children to identify cases of maltreatment. Child abuse includes physical abuse, emotional/psychological abuse, neglect and sexual abuse. Reporting a suspected case of child abuse is the responsibility of every adult who meets such a case and for professionals (teachers, nurses, psychologists, social workers, police, etc.) an obligation established by Law 272/2004.

A therapist may be involved at different stages of prevention, intervention and treatment of a child abuse case. All therapists should be familiar with the identification of families at risk of abuse as well as the interdisciplinary and community resources available to victims and families affected by child abuse.

Like other victims, abused children experience psychological dysfunction. Unlike adults, they are traumatised during the most critical period of their lives: when their views of themselves, others and the world are formed, when they establish relationships with their own states and when cooperative skills are first acquired. Such post-traumatic reactions can easily impact on later psychological and social maturation, leading to potentially atypical and dysfunctional development.

Regardless of the specific type of maltreatment, the consequences of abuse on child development appear to occur in at least three stages:

1. Initial victimization reactions, involving post-traumatic stress, changes in normal psychological development, grief affect and cognitive distortions;
2. Accommodation to continued abuse, involving cooperative behaviors to increase safety and/or decrease pain during victimization;
3. Long-term processing and secondary accommodation:
4. Consequences of initial reactions and abuse-related accommodations on the individual’s subsequent psychological development;
5. Survivor’s cooperative responses to abuse-related dysphoria.

Sexual abuse:

It is difficult to detect a sexually abused child through psychological testing.

On each child, the effects are particular, the symptoms depending on:

• Age of the child;
• Degree of relational closeness to the abuser;
• Strength of the abuser;
• Place of the event;
• Frequency of abusive situations.

The assessment of the seriousness of the acts committed in cases of sexual abuse against children is based on:

• Age of the child (the younger the child in chronological age, the more serious the acts are considered).
• The degree of force applied (the greater the force used, the more serious the offence).
• The relationship between the aggressor and the victim (the more serious the act, the closer the relationship between the aggressor and the victim).
• The type of sexual act used by the perpetrator (more serious if the child was penetrated).

Physical signs of sexual abuse:

• Reddening or injury to the anal or vaginal opening – “dilation reflex” (in the case of anal contact):
• Vulnerability to sexually transmitted diseases (including genital warts, gonorrhea, etc.);
• Digestive disorders, sleep disorders;
• Panic;
• Aggravation of certain diseases with a mental component (asthma);
• Eating disorders;
• Vague, non-specific symptoms may be added, such as headache and abdominal pain.

Psychological signs of sexual abuse:

Emotional distress:

• Guilt, strained responsibility to keep secret;
• Fear, punishment;
• Degradation of self-image;
• Feeling of bodily defilement;
• Fear of sexual and reproductive damage;
• Hostility, anger, depression;
• Suicidal tendencies.

Behavioural manifestations:

• Regression;
• Hostility or aggression towards others;
• Loss of social skills;
• Lethargy, lack of concern for self;
• Body posture expressing overwhelm, heaviness;
• Tendency to confess (in girls) or stubbornly hide painful secret;
• Protective attitude towards parents.

Feelings identified in sexually abused children:

 Fear

• of the abuser
• of causing trouble
• of losing adult affection
• of being excluded from the family
• of being ‘different

 Anger

• towards the abuser
• towards adults who did not protect them
• towards themselves (feeling guilty).

 Isolation

• because “something is wrong with me”
• because they feel alone in their experience
• because they cannot talk about the abuse.

Sadness

• about something taken away from them
• about losing a part of themselves
• because they grow up too fast
• because they were betrayed by someone they trusted.

Guilt

• because they can’t stop the abuse
• because they think they “consented to the abuse”
• because they confess the abuse – if they say they were abused
• because they kept it secret – if they say they were not abused

Shame

• in relation to their involvement in such an experience
• about their body responding to the abuse.

 Confusion (embarrassment)

• because they may still love the abuser
• because their feelings are always changing.

Children’s adjustment syndrome to sexual abuse

This syndrome has been described by Summit (1983) and thus delineates several stages of sexual abuse taking mainly the child into consideration. This model offers the possibility of understanding how the child adapts to sexual abuse.

• Stage 1 – Keeping secret – no child is ready to deal with sexual abuse. The child may be told directly “this is our only secret” or this may be implied. Blackmail, threats, bribery are used to keep the child afraid to disclose. The child feels helpless.
• Stage 2 – Feeling helpless – there is a power imbalance between an adult and a child, the child is helpless and trapped, the child have to obey the adult and cannot say NO.
• Stage 3 – Inability to respond and habituation – despite the sense of guilt the abuser feels encouraged by the fact that there is no prompt, aggressive response from the child, leading to a repetition of the abuse. Children use dissociation as a defence mechanism to cope with painful reality – the only person who can stop the abuse is the abuser, so the child will behave well if they want the abuse to stop, which means they have to accept the sexual demands. The child starts to feel guilty for causing the abuse in some way.
• Stage 4 – Disclosure of sexual abuse – can occur immediately after the abuse or over a longer period of time. Disclosure can take many forms:
  • Children may make broad, ambiguous statements that can be interpreted as behavioural symptoms, another behavioural symptom is when a young child tries to simulate a sexual act with another child;
  • Children may make statements to adults/friends that they have been sexually abused. The purpose of these is to test the listener’s reaction – if the listener is shocked or has a repulsed reaction, the child may say they lied – but such direct reactions show that something happened.
  • Significant changes in behaviour: behavioural outbursts, tantrums, insomnia, fear of staying home alone with parent, fear of going to bed. In teenagers, excessive drinking, running away from home or prostitution occurs.
  • The onset of illnesses: enuresis, venereal disease or even pregnancy.
• Stage 5 – involvement of certain specialist services, depending on the parents’ reaction.

Possible meanings of incest for children:

• I like it, but it’s not good;
• I like it and it is allowed;
• I don’t like it and it’s not good for me;
• I know I’m not okay with it, but it makes me special;
• I love my father, but I hate him for it;
• I’m proud to be treated like an adult;
• I like it, but my mother is very angry with me;
• I don’t like it, but Mom wants me to do it;
• I like making my brothers jealous;
• I don’t like it, but that’s how I protect my brothers/sisters;
• I’m bad, because of me my parents are wrong;
• Now I have something on my parents;
• My mom would leave if I didn’t do this with my dad;
• Why does my body feel good when I do bad things?
• My dad must love me a lot to risk so much;
• The only way to survive is to do this.

Consequences of sexual abuse on the child’s psycho-emotional development and social integration

• Emotionally: introversion, emotional disorders, depression, low self-esteem.
• Social: running away from home, school failure, prostitution, drug and alcohol abuse. As adults they may have inappropriate sexual behaviour, compulsive masturbation, difficulties in choosing a partner and in parenting (they distance themselves from their own children because they associate affection with physical contact).

Long-term consequences of child abuse

Although some of the initial reactions of abuse victims may subside over time, typical of these disorders, along with the coping behaviours specific to abuse, is that they become generalised and compound in the long term if left untreated. Seven major types of psychological disorders are specific, all of which are often found in adolescents and adults who were abused as children:

• Post-traumatic stress;
• Cognitive distortions/deformities;
• Emotional disorders;
• Dissociation;
• Poor self-reference;
• Distortion of self-image;

The implications of the post-abuse sequelae of ‘co-dependency’ and borderline personality disorder will also be considered. The literature highlights that adults abused or neglected in childhood have difficulties with intimacy, trust and social authority. Because such people are shunned, such problems can have long-lasting negative consequences on the lives of abused people.

Cognitive distortions/distortions

Studies of the cognitive consequences of sexual violence link childhood molestation to guilt, low self-confidence, and blaming, along with other dysfunctional attributions. Gold (1986), for example, pointed out that especially women with a history of childhood sexual abuse attribute negative events to internal, stable, and global factors, as well as to their own character and behavior. These mentally healthy women tended to attribute the causes of positive events to external factors. Such cognitive traces may contribute to or act as mediators of the negative symptomatology that is evident in adult survivors of childhood sexual abuse.

Although false self-perceptions are linked to all major forms of child abuse, it appears that the basis for such cognitive distortions is emotional abuse.    Negative thoughts related to abuse likely arise from two sources:

• Psychological reactions to specific abuse events;
• the victim’s attempt to understand the abuse.

Abuse anxiety typically seems to involve the following:

• hypervigilance to danger in the environment, whether objective or not;
• preoccupation with control, with the belief that even the slightest loss of judgment and self-protection can lead to danger or catastrophe;
• misinterpretation of objective neutral or positive interpersonal stimuli as evidence of threat or danger.

Dissociation is defined as a break in the normally occurring links between feelings, thoughts, behaviour and memories, consciously or unconsciously invoked to reduce psychological distress.

Although the etiology of dissociative symptomatology is complex, a number of writers and researchers link the onset of such behaviors to psychologically traumatic events, most of them major traumas that occurred in childhood. Recent studies in the USA link dissociative phenomena to childhood sexual abuse, directly or indirectly suggesting that molestation may motivate the development of dissociative stages as a defence against post-traumatic stress disorder.

Relationship difficulties. Disruption of privacy

The interpersonal consequences of abuse can be understood as stemming from two sources:

• Immediate and conditioned cognitive responses to long-term victimization (e.g. distrust of others, anger and/or fear of the stronger, worry about abandonment, awareness of injustice/unfair treatment, diminished self-esteem);
• Coping responses to continued brutalization (e.g. avoidance of others, passivity, sexualization, recalcitrance or depression caused by abuse).

These diverse reactions and responses, understandable through the narrow life experience of the abuse victim, nevertheless overlap with interpersonal functioning and thus have access to important social elements such as relationships, acceptance and support.

Most child abuse occurs in the context of close relationships and intimacies. It is therefore natural that those children who are abused may fear, shy away from or show ambivalence towards interpersonal closeness. Sexually abused individuals, for example, often have difficulty establishing and maintaining intimate relationships (Courtois, 1988, Elliot&Gabrielson – Cabush, 1990, Finkelhor et al; 1989) as do adults who have had childhood experiences of domestic violence (McCann & Pearlman, 1990).

Abused people’s intimacy issues seem to be mostly centered on ambivalence and fear about interpersonal attachment. Although sexual abuse is very often associated with subsequent dysfunction in intimate relationships, ambivalence in close human relationships can develop even before such treatments. Perhaps one of the most painful and disturbing aspects of child abuse is the impact on a person’s ability to trust. Requiring a suppression of defensive activity and a sense of safety in the relationship, trust is difficult to manifest, especially in people severely abused as children – at least in the absence of long-term supportive relationships.

Altered sexuality

Clinical experience suggests that adolescents and adults who have been abused as children are very likely to have problems in their sex lives (Maltz, 1988). Such problems may include:

• sexual dysfunction, related to fear of vulnerability and revictimization;
• a general distrust of sexual partners, expressed by both men and women (Courtois, 1979, Jehu et al; 1984-1985; Meiselman, 1978);
• a tendency, out of fear and suspicion, to depend on or idealize those with whom the abused person has romantic relationships (Courtois, 1988; Elliot & Gabrielson-Caboush, 1990; Herman, 1981);
• preoccupation with sexual thoughts and a tendency to sexualize relationships that would not normally be sexual;
• experience of multiple, superficial and brief relationships that end with the emergence of real intimacy (Courtois, 1979, Herman, 1981).

Based on childhood experiences of victimization by one or more guardians, a large number of abused adults appear to associate close relationships with maltreatment. As such, they may either:

• avoid interpersonal intimacy altogether;
• accept a certain amount of aggression in interpersonal relationships as normal or natural.

The conversion from child victim (boy) to adult abuser is considered to derive from:

• the likelihood that the child abuser was also male, and thus served as a model for aggressive behaviour in subsequent interpersonal relationships;
• the susceptibility of these individuals to social messages involving the use of violence, or at least the domination of the weaker by the stronger.

Aggressive behaviour

Empirical studies and clinical experience suggest that children’s aggression towards others – often expressed by hitting, dominating or attacking other children – is a frequent transition stage to various types of maltreatment: physical abuse (e.g. George & Main, 1979; Reidy, 1977), sexual abuse (e.g. Erickson et al; 1989; Gomes-Schwartz et al, 1990), psychological abuse and emotional insensitivity (e.g. Egeland, 1989; Vissing et al; 1991). In general it appears that this behaviour represents a generic externalization of the child’s trauma caused by abuse and depression, and probably the effects of copying the abusive parent’s behaviour. As noted by some authors, the clear effect of this abuse is often social isolation and lack of popularity (e.g. Egeland, 1989).

Some adolescent and adult victims of sexual abuse seem to be more inclined to victimize children or women (e.g. Langevi, Handy, Hook, Day & Ruson, 1985; Rokous, Carter & Prentky, 1988; Stukas-Davis, 1990), while most studies of child abuse and adult abuse have found links to childhood incidents of physical maltreatment (e.g. McCord, 1983, Pollock et al; 1990, Widom, 1989).

Bibliography:

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Briere, J.N. (1992), Child abuse trauma, London, Sage Publications, Inc.

Fischer, G., Riedeser, P. (2001), Tratat de psihotraumatologie, București, Trei Publising.

Ionescu, Ș. (2001), Copilul maltratat – Evaluare, prevenire, intervenție, București

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