Child Abuse Detection, Reporting and Treatment > Chapter 11- Part A -Treatment Issues

Chapter 11: Treatment Issues for Abused and

Neglected Children and Specialized Interventions

Part A - Treatment Issues

There are a number of concerns or issues common to children who have been abused and/or neglected. This section presents some of the most common treatment issues for maltreated children and identifies some related interventions.

PHYSICAL HEALTH CONCERNS

Children often have a number of health or health related concerns that are generated by abuse or neglect. A child who has been physically abused may complain of difficulties opening and closing his/her mouth, noting that he/she was slapped or hit on the side of the head. The child may also complain of earaches or stomachaches, fearing that these areas of the body were damaged when the child was beaten. The child may have lost teeth or hair. He/she may have broken bones or internal injuries that require a hospital stay. A child who has been sexually abused is often concerned that any invasive sexual contact, especially vaginal or anal penetration, may have caused internal damage. The child may also fear having contracted an “invisible” sexually transmitted disease.

The issues of body integrity, sexual or physical adequacy, injury or scarring, and concerns about any changes in the body that might have resulted from abuse and neglect need to be explored with the child. Symptomatic behavior such as encopresis, enuresis, or psychosomatic aches and pains are also important to identify and explore during therapy.

Sexually Transmitted Diseases and Fear of Acquired Immunodeficiency Syndrome (AIDS)

Sexually transmitted diseases are not uncommon occurrences in child sexual abuse. Generally, diseases are determined at the time of the medical exam and treated with appropriate medication. Currently, few cases have been documented of human immunodeficiency virus (HIV) infection through sexual abuse. However, the increasing incidence of both HIV infection and sexual abuse suggests the need to follow guidelines for HIVantibody testing of pediatric victims of sexual abuse.160 A child who is known not to have experienced rectal, vaginal, or oral exposure to semen or HIV-positive body fluids can be assumed to be safe.161

Interventions related to this health concern include the following:
  • testing the child for HIV antibodies if the child remains anxious or concerned,
  • addressing the child’s fear and anxiety regarding test results, and
  • using information and services for the child if the tests results are positive.


Sexual and Physical Adequacy

Some children worry that their bodies have been damaged by the sexual or physical abuse and that they are somehow inadequate compared to nonabused children. Issues of strength, body and muscle development, and size are especially important to children who have been physically abused.

A sexually abused boy may also compare his genitalia to the adult perpetrator’s and worry that he is somehow inadequate because of the difference in size. A boy who has been molested by a female also worries that he is sexually inadequate or unable to satisfy a partner both emotionally and sexually. Many boys who have been victimized by males often worry about their sexual identity and fear that they are homosexual. A sexually abused girl often worries about “virginity” and that partners in future relationships will be able to tell that she has been sexually assaulted. Some girls fear they will not be able to have children. For adolescent girls, fears about pregnancy from sexual abuse can motivate them to begin sexual relationships with boys their own age to “cover” for the possibility.

Sexually abused boys and girls are often confused about their sexuality and their desirability to members of the opposite sex. Often, victims report initiating sexual relationships to “prove” that they are adequate and capable of having sex. These relationships may be described as voluntary but are often initiated under duress and continue the process of victimization.

To intervene with these health concerns, the therapist can:

  • address concerns about the body by having the child undergo a thorough medical exam;
  • clarify anatomy, purpose, and function of the genitalia and sex organs;
  • explain theories of sexuality and sexual orientation to the children his/her parents;
  • offer support and encouragement to change relationships that are not reciprocal or satisfying;
  • clarify age-appropriate interactions and intervene to protect the child if he/she is being exploited or abused;
  • offer support and encouragement to support the child decision to refrain from engaging in sexual activity until he/she is physically and emotionally ready for the experience; and
  • provide information on safe sex, sexual health care, and birth control to sexually active teenagers.


Pregnancy

Although pregnancy is a very rare occurrence among sexually abused children, the fear of pregnancy, the desire for an abortion, or the reality of carrying a fetus to term and undergoing delivery of the baby all provide a concrete focus for victims’ fear of the body being affected or damaged by the experience.162

In helping a child deal with the issues regarding pregnancy, the therapist should:
  • provide support and reassurance to help the child integrate the experience of sexual abuse and pregnancy;
  • address any changes in the body’s functioning or appearance;
  • address issues of guilt, blame, and responsibility; and
  • address decisions made regarding care of the baby.


Scarring and Permanent Damage

Some children have scars or disfigurement from the abuse or neglect. Damage may serve as a continual stimulus, reminding the child of the maltreatment. These reminders need to be acknowledged and discussed in therapy.

To address these issues, the therapist can:
  • have the child receive a thorough medical exam;
  • examine experiences and feelings related to any time spent in the hospital;
  • help the child who is disfigured by the abuse express his/her anger and sense of loss of a healthy and normal body;
  • explore the child’s embarrassment about injuries, possible envy of children who are not disfigured, and fear of rejection because of appearance;
  • use role play and anticipatory planning to practice replies to questions people ask about injuries or scars;
  • help the child develop responses to questions about their injuries that do not elicit fear, rejection, or pity; and
  • help the child develop an identity that is based on behavior and accomplishments, rather than on body image.


Encopresis and Enuresis

Encopresis and enuresis may be behavioral indicators of abuse. Some victims have never managed to control elimination or their bladders, but other children, who were toilet-trained, become enuretic or encopretic with the onset of abuse. The former situations often are ones of chronic family dysfunction and chronic sexual abuse.In the latter, the incontinence is a regression to an earlier developmental stage.163 The encopretic or enuretic behavior may be related to regression, anxiety, and misperceptions about the abuse and how the body functions. This behavior may also be an attempt to make the victim unappealing to protect against future assault.

When addressing these health related issues, the therapist can:
  • Determine if there are any organic problems by having the child undergo a thorough medical exam with a pediatrician. For example, if there was anal tearing from sexual abuse, the child may initiate a cycle of constipation out of fear of having a painful bowel movement.
  • Explain to parents the possible etiology of the behavior. Help the parents/caretakers understand that this behavior is related to the child’s difficulties recovering from abuse.
  • Identify and explore any unresolved safety and protection issues. A child who has mastered control of urination and bowel movements and then regresses and loses this mastery, often benefits from some extra attention, nurturing, and discussion about precautions the parents/caretakers have taken to protect and care for the child.
  • Help the parents reestablish a toilet-training program, which is responsive to the age and developmental abilities of the child. Parents/caretakers may need to patiently implement a toilettraining program that was successful at a younger age and remind the child to use the toilet. Gradually, most children resume age-appropriate behavior.
  • Explain to parents and caregivers that shame and punitive measures usually create more problems. Changing encopretic or enuretic behavior requires a strong parental alliance with the child and cooperation with medical and therapeutic professionals. Dysfunctional families may have a difficult time addressing a consistent, supportive program of toilet training with their child.


Psychosomatic Complaints

In the absence of any medical evidence, persistent fears and concerns that the child or the child’s body is somehow “damaged” or less desirable than before the abuse require interventions suitable to psychosomatic complaints or stigmatization. Psychosomatic complaints can include headaches, stomachaches, feelings of tiredness or exhaustion, and vague aches and pains.

A child who has difficulty articulating his/her anger, fear, relief, loss, or sadness may develop aches and pains that express his/her discomfort. Psychosomatic complaints can often be identified as the child recounts the details of the assault(s). The child will state that he/she doesn’t “feel good” or that he/she has a headache or stomachache. The child may state that he/she feels pain in his/her genitals or squirm in the chair or reposition him/herself to protect a vulnerable part of his/her body.


[QN.No.16.The physical issues common to children who have been abused and/or neglected is:]

To address psychosomatic complaints, the therapist can:
  • arrange for the child to have a thorough medical exam;
  • help the child recognize the connection between his/her experience of abuse and his/her body sensations;
  • facilitate the expression of emotions about abusive or neglectful experiences, including loss and depression; and
  • support the child’s need for nurturance and attention.
Sometimes, psychosomatic complaints are symbolic requests for nurturing and attention. When a child states that he/she needs to see the school nurse because he/she has a stomachache (after thinking about how much he/she misses his/her mother), the therapist can make the connection between what the child was thinking about and how he/she felt by asking the child what he/she was hoping for from the nurse. The therapist can validate the importance of having someone pay attention to the child’s pain and the special need that the child has to be nurtured. Hopefully, the child will be able to recognize that his/her needs for attention and nurturing are legitimate and learn to negotiate to have those needs met without having to become physically ill or being vulnerable to abuse or exploitation.

In addition, the therapist can:
  • Help the child learn to interact and socialize in a manner that facilitates receiving appropriate attention and nurturing. When a child’s dependency needs and needs for acceptance and appreciation are met, the child may not need these symptoms. It is also helpful to ask the child to try to identify the area of the body that is the source of the pain or discomfort. Sometimes, a child will have misconceptions about the abuse, perhaps thinking that his/her stomach was injured from penetration. The child may also worry about disease or damage.
  • Explain to the child how the body operates and what kinds of stress the body can accommodate. Some of the child’s fears may be alleviated when he/she understands how the body functions.

DEVELOPMENTAL ISSUES

As stated previously, child abuse and neglect does not appear to affect each victim in a predictable or consistent fashion.164 From the perspective of the child’s psychological development, child abuse is more than an assault. The physical consequences are typically overshadowed by the associated disruption in the child’s critical areas of attachment and development.165 166

Attachment

Some argue that it is the disruption in attachment that is the main source of symptom formation and future problems. Many of the fundamental aspects of a person’s emotional well-being, including trust, esteem, worth, efficacy, identity, relationships, and intimacy rest on a foundation of attachment to a responsive caretaker.

To deal with attachment issues, the therapist can:
  • Ensure that the child experiences a consistent figure to whom he/she can relate. An ongoing relationship that is built over time is most useful in developing the trust that facilitates attachment. A child who establishes a connection and relationship with a responsive adult may be able to recover some of his/her ability to accomplish developmental tasks. This responsive adult can be the therapist, caretaker, teacher, or other appropriate adult available to the child on a regular basis.
  • Model protective parenting and soothing responses to distressful experiences. The child can learn to nurture and respond to his/her feelings by practicing on dolls in the therapy room. As an example, the therapist can “play” with the doll and nurture the doll after the doll “experiences pain” from a doctor’s shot. At first, the child may be the doctor and be impervious to the doll’s pain. However, with the therapist modeling protective parenting and enacting soothing responses to the doll’s tears and cries, the child learns how adults respond when a child is hurt.
  • Reinforce the child’s right to appropriate nurturing, attention, and protection. The therapist can ask, “Who took care of you when you were crying or hurt?” Often, the child will withdraw, become angry, or say he/she never needed any help. Then, the therapist can respond that all children need help sometimes and say, “I’m sorry no one was there to help you when you were crying or hurt. It is really hard to take care of yourself when you are small.”
  • Help the child explore the therapeutic relationship as a model for quality interaction.
  • Educate the child about social behavior, including reciprocal relationships and prosocial responses to others. This kind of education facilitates a child’s acceptance by peers and adults in the community and gradually decreases the child’s dependence on the therapist as an attachment figure.


Mastery and Control

Abused and neglected children attempt to understand and manage fear, anxiety, and overwhelming feelings generated from the abuse. A children can feel shame and rage over his/her vulnerability. The inability to prevent abuse and the overwhelming feelings that are part of an abusive experience are often identified by the child as weakness and loss of control.

The therapist has two simultaneous tasks related to mastery and control issues ? clarifying the limitations regarding the child’s ability to care for and protect him/herself and identifying the strengths and acknowledging the child’s attempts to care for and protect him/herself.

The therapist can:
  • Help the child acknowledge and accept his/her limitations by offering information about developmentally realistic behavior.
  • Identify and acknowledge the child’s attempts to protect or take care of him/herself during and after the abuse. This may include describing the child’s symptoms and behavior as his/her attempt to call attention to the abuse or the child’s attempt to manage his/her feelings about the abuse.
  • Identify and support the child’s abilities to accomplish developmentally appropriate tasks. Sometimes, a child will fantasize that he/she used extraordinary measures such as kicking, hitting, or knocking out the perpetrator to ward off the abuse or retaliate. The child may fantasize or repeatedly act out elements of the abuse in an attempt to gain some understanding and control over the experience. Talking about what a child his/her age is capable of doing, compared to what he/she wanted to do during the abusive experience, is one way of helping the child be realistic about his/her abilities. Acknowledging and describing his/her fantasies as a wish for power and a need for help can enable a child to accept his/her limitations and express his/her feelings about his/her powerlessness.
  • Use interventions that help the child learn and master new skills. Support the child’s willingness and attempts to learn new skills. Children need to know that everyone must learn how to do certain tasks. A child often benefits from hearing that the need to practice is a part of being human and that people are not born perfect. The therapist can connect making mistakes with being human and help the child learn to laugh and learn from his/her behavior.
  • Use interventions that allow the child to practice decision making and experience a sense of control. The choices need to be constructed so that the child is not left with repercussions of shame or doubt about his/her abilities to handle situations.
  • Help the child recognize dangerous situations and teach the child whom to ask for help. Helping a child connect with and use strong, appropriate, and protective adults can diminish his/her sense of vulnerability and powerlessness.


Impulse Control

A child with overwhelming fear and anxiety, as well as feelings of vulnerability and powerlessness, has difficulty managing his/her thoughts, feelings, and behavior. Thoughts may include suicidal ideation, destructive wishes, and fantasies with themes of retaliation and revenge. Feelings can include envy, hatred, fear, and anger. Often, a child who has been abused or neglected cannot manage his/her behavior and has difficulty delaying gratification of wishes. Sometimes, the child’s behavioral reactions to situations seem to be out of his/her control. The child’s behavior and communication may appear impulsive and unrelated to what is happening at the time.

Impulsive behavior includes exhibiting temper tantrums, being argumentative, and challenging authority or rules. Some children may verbally or physically attack their parent or caretaker, siblings, or peers. A child can feel angry with other children who have not been abused, whether family members or strangers. The abused or neglected child may damage property or hurt pets or younger children.

The therapist can:
  • Help the child express the anger and rage associated with victimization. A child needs to learn how to express strong emotions. Discharging his/her feelings can reduce some of the intensity and overwhelming effects on behavior. Pounding on pillows, using action figures to fight out anger, tearing up paper, or smashing cans to demonstrate his/her feelings can sometimes free the rage and help the child identify his/her fears.
  • Help the child develop vocabulary and language skills so that he/she can express his/her feelings. When a child can use words to express his/her feelings, he/she will not need to act out and dramatize his/her anger to the same degree. Once the child is more comfortable talking about his/her feelings, he/she can begin to think about how to express those feelings appropriately.
  • Help the child identify the thoughts and feelings that precipitated his/her actions. Making the connection between the experience of abuse and subsequent behaviors can help the child begin to monitor his/her impulses.
  • Address the issues of loss and powerlessness and, particularly with adolescents, probe for suicidal thoughts and plans.
  • Support and educate caregivers to respond appropriately to acting-out behavior. The concept of regression can help the caretaker understand change in the child’s behavior. The child will often revert to an earlier stage of behavior when he/she is feeling overwhelmed and unable to cope. This regression allows the child to depend on his/her caregiver and relearn that adults can be there to help him/her with problems or difficulties. Modifying behavior, teaching natural and logical consequences, and structuring the child’s interactions and environment so he/she can better manage his/her behavior are important.167 168


Identity

A child develops a sense of who he/she is and how to behave from the experiences that occur in his/her life. These experiences form a sense of self that affects how the child feels about him/herself and how he/she behaves toward others. The necessary components in establishing a positive identity include love, attention, nurturing, affection, intimacy, autonomy, power, and control. The experience of abuse or neglect impacts each of these areas. An abusive experience affects the child’s identity, how the child behaves in order to have his/her needs met, and how the child responds and interacts with other people.
 
Child Abuse Detection, Reporting and Treatment > Chapter 11- Part A -Treatment Issues
Page Last Modified On: September 7, 2014, 11:14 PM