Treatment for Abused and Neglected Children: Infancy to Age 18

Treatment for Abused and Neglected Children:

Infancy to Age 18

Anthony J. Urquiza

Cynthia Winn

U.S. Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

National Center on Child Abuse and Neglect

This manual was developed and produced by Circle Solutions, Inc., McLean, VA, under

subcontract No. HHS 105-89-1730 with Westover Consultants, Inc.

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TABLE OF CONTENTS

Page

ATTRIBUTION i

PREFACE iii

ACKNOWLEDGMENTS v

INTRODUCTION 1

CHILD DEVELOPMENT AND PSYCHOPATHOLOGY 3

Categories of Development 3

Intrapersonal Development 3

Interpersonal Development 4

Physical Development 6

Sexual Development 7

Behavioral Conduct 9

Developmental Psychopathology 11

CONSEQUENCES OF ABUSE AND NEGLECT 13

Physical Abuse 13

Consequences Within the Intrapersonal Category 13

Consequences Within the Interpersonal Category 16

Consequences Within the Physical Category 16

Consequences Within the Sexual Category 17

Consequences Within the Behavioral Conduct Category 17

Child Sexual Abuse 18

Consequences Within the Intrapersonal Category 18

Consequences Within the Interpersonal Category 18

Consequences Within the Physical Category 18

Consequences Within the Sexual Category 19

Consequences Within the Behavioral Conduct Category 19

Child Neglect 20

Consequences Within the Intrapersonal Category 20

Consequences Within the Interpersonal Category 21

Consequences Within the Physical Category 21

Consequences Within the Sexual Category 22

Consequences Within the Behavioral Conduct Category 22

ASSESSMENT OF CHILD MALTREATMENT 23

Assessment of the Child Within the Context of His/Her Environment 23

Issues To Be Considered in Assessment 24

Ethnicity and Socioeconomic Status 25

Social Desirability and Reporting Bias 26

Professional Roles in the Assessment Process 26

Use of Standardized Measures 27

Multiaxial Assessment 27

Assessment Information from Children 27

Behavioral Report and/or Observation 28

Casual Observations 28

Projective Assessments 28

Projective Drawings 29

Projective Storytelling/Apperception Tests 29

Rorschach 29

Cognitive Assessments 30

Bayley Scales of Infant Development (BSID) 30

Wechsler Series of Intelligence Tests for Children 31

Kaufman Assessment Battery for Children (K-ABC) 31

Clinical Interviews 31

Nondirective Play Sessions 31

Structured Psychiatric Diagnostic Interviews 32

Assessment Information from Parents 33

The Child Behavior Checklist (CBCL) 33

The Vineland Adaptive Behavior Scales (VABS) 33

Family Assessment 33

The Purpose/Intent of Family Assessment 34

Standardized Measures of Family Assessment 34

Clinical Interviews 35

Supplemental Information 35

Teachers/School Personnel 36

Child Behavior Checklist—Teacher Report Form 36

Child Welfare Caseworkers 36

Foster Parents/Supplemental Caretakers 36

Assessing Risk of Harm to Self and/or Others 37

Suicide 37

Self-Destructive Behavior 37

Danger to Others 38

Revictimization 38

THERAPY 39

Theoretical Orientations 39

Role of the Therapist 40

Clients’ Rights in Therapy 41

Abuse-Free Environment 41

Protection and Limit-Setting 42

Terminology and Communication 42

Information 43

Helpful Interventions 43

Individuality 43

Therapist Responsibilities 44

Confidentiality 44

Release of Information 45

Clarification of Fees and Services 45

Evaluation of Progress 46

The Therapeutic Relationship 46

Trust 46

Safety 46

Physical Safety 46

Emotional Safety 47

Resistance 49

Organization and Structure of Sessions 50

Format 50

Use of Time 50

Content 51

Process 52

Stages of Therapy 52

Intake Phase 52

Determining the Child’s Need for Treatment 52

Taking a History 53

Developing a Treatment Plan 54

Determining the Prognosis 54

Beginning Phase 56

Middle Phase 56

Accessing the Abuse Memories 57

Sensations 57

Thoughts and Feelings 57

Beliefs 58

Termination Phase 59

Long-Term Issues 60

Treatment Modalities 60

Primary Prevention Programs 61

Play Therapy 61

Individual Therapy 61

Group Therapy 62

Family Therapy 62

Summary 62

TREATMENT ISSUES FOR ABUSED AND NEGLECTED CHILDREN AND

SPECIALIZED INTERVENTIONS 63

Physical Health Concerns 63

Sexually Transmitted Diseases and Fear of Acquired Immunodeficiency Syndrome (AIDS) 63

Sexual and Physical Adequacy 63

Pregnancy 64

Scarring and Permanent Damage 65

Encopresis and Enuresis 65

Psychosomatic Complaints 66

Developmental Issues 67

Attachment 67

Mastery and Control 68

Impulse Control 69

Identity 70

Interpersonal Issues 70

Identification With the Aggressor 70

Victimizing Behaviors 71

Intimacy 71

Betrayal 72

Intrapersonal Issues 73

Fear 73

Trauma 73

Anxiety 74

Depression 75

Lack of Expression of Feelings 75

Guilt, Blame, and Responsibility 76

Loss and Grief 78

Self-Worth, Self-Esteem, Self-Efficacy 79

Stigmatization/Damaged Goods 80

Learned Helplessness 80

Behavioral Issues 82

Avoidant Behavior 82

Dependent Behavior 83

Aggressive Behavior 84

Hypersexual Behavior 85

Suggestive Sexual Behavior 85

Masturbation 86

Summary 86

CASE MANAGEMENT 89

Family Members 89

Parents 89

Siblings 89

Relatives 90

School 91

Teacher 91

School Counselor 91

School Psychologist 92

Child Welfare Agencies 92

Juvenile Court 92

Substitute Care Placement 92

Visitation 93

Reunification 93

Law Enforcement 93

Prosecution 94

Conclusion 95

NOTES 97

GLOSSARY OF TERMS 111

SELECTED BIBLIOGRAPHY 117

OTHER RESOURCES 119

LIST OF TABLES AND FIGURES

FIGURE 1. The Ecology of Human Development 14

TABLE 1. Determinants of Abuse: Compensatory and Risk Behaviors 15

ATTRIBUTION

The Department of Health and Human Services acknowledges the contribution of Harold P. Martin, who was the

author of Treatment of Abused and Neglected Children, August 1979 and Bruce Fisher, Jane Berdie,

Jo Ann Cook, and Noel Day, who were the authors of Adolescent Abuse and Neglect: Intervention Strategies,

January 1980.

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PREFACE

The Child Abuse Prevention and Treatment Act was signed into law in 1974. Since that time, the Federal

Government has served as a catalyst to mobilize society’s social service, mental health, medical, educational, legal,

and law enforcement resources to address the challenges in the prevention and treatment of child abuse and

neglect. In 1977, in one of its early efforts to achieve this goal, the National Center on Child Abuse and Neglect

(NCCAN) developed 21 manuals (the User Manual Series) to provide guidance to professionals involved in the

child protection system and to enhance community collaboration and the quality of services provided to children

and families. Some manuals described professional roles and responsibilities in the prevention, identification, and

treatment of child maltreatment. Other manuals in the series addressed special topics, for example, adolescent

abuse and neglect.

Our understanding of the complex problems of child abuse and neglect has increased dramatically since the user

manuals were developed. This increased knowledge has improved our ability to intervene effectively in the lives

of troubled families. Likewise, we have a better grasp of what we can do to prevent child abuse and neglect from

occurring. Further, our knowledge of the unique roles key professionals can play in child protection has been

more clearly defined, and a great deal has been learned about how to enhance coordination and collaboration of

community agencies and professionals. Finally, we are facing today new and more serious problems in families

who maltreat their children. For example, there is a significant percentage of families known to Child Protective

Services (CPS) who are experiencing substance abuse problems; the first reference to drug-exposed infants

appeared in literature in 1985.

Because our knowledge base has increased significantly and the state of the art of practice has improved

considerably, NCCAN has updated the User Manual Series by revising many of the existing manuals and creating

new manuals that address current innovations, concerns, and issues in the prevention and treatment of child

maltreatment.

This manual is intended to serve as an orientation to the issues surrounding the treatment of sexually abused,

physically abused, and neglected children. It is intended to primarily assist:

� Beginning therapists (or therapists unfamiliar with child maltreatment) who are interested in acquiring

a greater understanding of treatment issues related specifically to child maltreatment.

� Individuals (e.g., social workers, probation counselors, law enforcement officials, health care

professionals) who may not be involved in therapy with abused children, but who desire a greater

understanding of therapeutic issues and processes.

� Therapists providing services to maltreated children, who wish to improve their skills, knowledge,

and abilities in conducting therapy.

Additional information on the treatment of child sexual abuse and child neglect is available in two other manuals

in this series, Child Sexual Abuse: Intervention and Treatment Issues and The Role of Mental Health

Professionals in the Prevention and Treatment of Child Abuse and Neglect.

It is important to note that this manual does not substitute for formal training in providing psychotherapy for

abused and neglected children.

iii

ACKNOWLEDGMENTS

Anthony J. Urquiza, Ph.D., is a child clinical psychologist and Clinical Assistant Professor at the Child Protection

Center, Department of Pediatrics, University of California Davis Medical Center (UCDMC). Dr. Urquiza has

extensive clinical experience with children, adolescents, and adults in a variety of inpatient and outpatient settings.

His primary clinical and research interests and publications center on all types of family violence, with specific

focus on family violence and ethnic minorities, the sexual victimization of males, the treatment of child and adult

survivors of childhood sexual abuse, the development of children’s sexuality, and mental health psychodiagnostic

issues as they apply to child maltreatment. Dr. Urquiza is the coauthor of the National Center on Child Abuse and

Neglect User Manual, The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse

and Neglect.

Cynthia A. Winn, L.C.S.W., is a member of the UCDMC Pediatric Social Services. She is also Treatment

Coordinator of the UCDMC Child Protection Center. Ms. Winn’s areas of interest and expertise include

assessment and treatment of children and adolescents who have experienced physical and emotional trauma,

including sexual and physical abuse and neglect, major medical diagnoses, and the witnessing of violent behavior.

The Department of Health and Human Services acknowledges the contribution of Harold P. Martin, who was the

author of Treatment of Abused and Neglected Children, August 1979 and Bruce Fisher, Jane Berdie, JoAnn Cook,

and Noel Day, who were the authors of Adolescent Abuse and Neglect: Intervention Strategies, January 1980.

The following were members of the Advisory Panel for Contract No. HHS-105-89:

Nainan Thomas Peter Correia

Child Welfare Division University of Oklahoma

Prince George’s County Tulsa, OK

Department of Social Services

Hyattsville, MD Howard Davidson

American Bar Association

Shirley Davis Washington, DC

Child Development and Family

Guidance Center Anthony Urquiza

St. Petersburg, FL University of California

Sacramento, CA

Michael Nunno

Family Life Development Center Janet Hutchinson

Ithaca, NY University of Pittsburgh

Pittsburgh, PA

Judee Filip

National Resource Center

Child Abuse and Neglect

Denver, CO

John Holton

Greater Chicago Council for

the National Committee for

the Prevention of Child Abuse

Chicago, IL

Sandra Hodge

Department of Human Services

Augusta, ME

Marsha K. Salus

Chair

User Manual Advisory Panel

Alexandria, VA

INTRODUCTION

Providing therapeutic interventions for abused and neglected children requires:

� an understanding of normal child development and the processes of abnormal development or

psychopathology as well as an ability to assess the severity and types of behavioral, emotional,

developmental, and psychological problems that abused children present;

� familiarity with the major issues common to abused children; and,

� the skills necessary to manage these types of cases.

Providing treatment to abused children is a significant undertaking requiring clinical training and education. This

manual provides an overview of the therapeutic issues for professionals in the fields of social work, family

therapy, psychology, psychiatry, criminal justice, and child development; it may serve as a supplement for

students and professionals interested in this area of practice. It does not substitute for training in providing

psychotherapy for abused and neglected children. Throughout this manual, multiple references have been used

to encourage readers to continue their education and training in the areas of child development, child maltreatment,

assessment of children, and therapeutic interventions with children.

This manual provides an overview of child development followed by a description of the relatively new field of

developmental psychopathology that “refers to the study of clinical dysfunction in the context of maturational and

developmental processes.”

Developmental psychopathology is founded on recognizing the value of normal

development throughout childhood and acknowledging that many childhood life events and experiences (i.e.,

maltreatment) can distort this development. Therefore, it is the responsibility of the therapist to:

� understand the various contexts in which the abused child/client exists;

� assess clients within their environments and identify dysfunctional behaviors, emotions, and

cognition; and,

� provide interventions that address identified problems and assist adaptation and a return to healthy

functioning.

In addition, there is special emphasis on several unique issues that have been found to be common “disruptions”

to abused and neglected children.

In most cases, the framework for this manual consists of classifications of child development into:

� intrapersonal development (developmental processes within the child);

� interpersonal development (developmental processes between the child and others in his/her life);

� physical development (physical, body, and motor development);

� sexual development (development of sexual behavior, thoughts, and feelings); and,

� behavioral conduct development (management of behavior, self-control, and regulation).

It is acknowledged that the developmental processes of children cannot adequately be separated into such

categories, primarily because the process of healthy functioning relies on the integration of these factors and

because these classifications overlap in many areas.

Additionally, for the convenience of readers of this manual, these categories have been separated into some, but

not all, of the major developmental processes that occur throughout childhood. For example, it has long been

argued that the development of a child’s self-concept, self-esteem, or self-image is a product of one’s perception

of him/herself, based on the perception of others, which is also called the “looking-glass self.”

2 3

To assert that

the developing child’s self-concept is based solely within any single domain would be false. A child develops an

image of him/herself as a thinking and feeling individual (intrapersonal), as an individual in relation to others

(interpersonal), as big, strong, small, or weak (physical), as a sexual being (sexual), and understands that his or

her behaviors have consequences for him/herself as well as for others (behavioral conduct). Therefore, these

classifications are used for the purposes of presenting an overview of development, examining the maladaptive

consequences of child maltreatment, and discussing therapeutic interventions.

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CHILD DEVELOPMENT AND PSYCHOPATHOLOGY

To understand abused and neglected children, it is important to have a basic understanding of the common

developmental tasks of childhood. Without this understanding, the inexperienced clinician may draw erroneous

conclusions regarding problems that are in the realm of normal behavior, or he/she may fail to identify a problem

that could have significant consequences for the child’s current or future adjustment. For example, attempting

to provide therapeutic intervention for a 3-year-old boy with nocturnal enuresis may cause frustration, anger, and

undue pressure on the child, resulting in continued problems in bladder control and possibly exacerbating

problems in other areas of his life. However, an understanding of child development would indicate that it is

common for a 3-year-old male not to attain complete nocturnal bladder control. Such understanding would enable

the clinician to explain to the child’s parents that this situation is not abnormal and thus, remove the inappropriate

perception of the child as having “a problem.” On the other hand, the failure to identify or treat this same

condition occurring in a 9-year-old child may contribute to his/her sense of despair or embarrassment about the

“problem,” possibly impairing the older child’s social and emotional development. It is vital, therefore, that all

child clinicians should have a basic understanding of child development in order to provide therapeutic services

to children, especially those who have been abused and neglected.

CATEGORIES OF DEVELOPMENT

The categories of child development are grouped into intrapersonal development, interpersonal development,

physical development, sexual development, and behavioral conduct development. Brief descriptions of the

process of child development are provided, followed by a description of the major achievements/milestones

according to each category. It is the intent of this section to give an overview of common patterns in child

development.

Intrapersonal Development

Central to the process of human development is the organization, representation, and stability of an intrapersonal

or “self” system.

Many different theories of this self system exist. For example, Freud identified the individual’s

structural system (i.e., the id, ego, and superego); Erikson depicted it as ego; and attachment and object-relations

theorists described it as the process of separation and individuation (e.g., internal representation, object

permanence). This is not to suggest that these are the only explanations for the intrapersonal process in human

development. Several theorists assert that primary influences to an individual’s human development are partially

or exclusively external to the self. The work of these theorists includes many of the behavioral, cognitive-

behavioral, and social learning descriptions of human development.

5 6

Kegan states that the process of intrapersonal development is central to all other forms of development, but that

it cannot be simply encapsulated within a single unifying domain.

He also indicates that individuals progress

through life with specific goals and through specific eras or stages. The theme of this progression is the

achievement of several age/development-related tasks, supported by ever-changing environments or cultures, with

the goal being development of self. For children, intrapersonal development progresses from the infant’s capacity

to create a preliminary concept of identity, to a sense of self, to his/her relationship with a primary caretaker.

� An infant’s world consists almost entirely of his/her relationship with his/her caretaker and the

environment provided by that caretaker. Eventually this identity, the evolving self, changes and

becomes qualitatively different from past forms as the child enters new relationships and internalizes

past relationships. This includes the infant’s departure from his/her perception of the world from

the perspective of the primary caretaker to newer and broader environments, and a greater reliance

on a developing sense of self.

� For a toddler, this is initially a reformulation of self as a member of a family, in which the young

child has an opportunity to practice interpersonal relations within a secure and confined (bounded)

set of relationships and then as a child within a group of same-age children (i.e., peers at school).

� For a school-age child, intrapersonal development is manifested as a more independent agent with

the capacity for the child to produce, negotiate, and achieve in a form yet further separated from

his/her early primary relationships. There is again the reliance on internal capacities and his/her self,

rather than on past relationships such as those with the child’s mother or father. In a sense, a

school-age child becomes his/her own agent, rather than a member of a family or a child of a parent.

� With the coming of adolescence, a child begins to establish a formal sense of identity wherein higher

order processes engage and truly become internal. Typically, self-sufficiency will not occur until

late adolescence. Teenagers usually practice independent decision making, relationships, and

emotional processes while under the domain of the parent. By late adolescence or early adulthood,

however, it is the expectation within our culture that individuals should possess the capacity to

function independently, manage emotions and behaviors, cope or adapt to adversity, and begin their

own families. The hallmark of this period is the establishment of a meaningful interpersonal

relationship (e.g., cohabitation, marriage) and the development of a family.

Interpersonal Development

Interpersonal development is the ongoing process by which a child relates to others in his/her life and creates and

adapts to relationships.

� Immediately after birth, an infant demonstrates the capacity to engage in interpersonal relationships.

Although the first few weeks of life are characterized by a minimum of initiated interpersonal actions

toward others, the newborn is actively engaged in relationships. Simple responses such as crying,

tracking visual stimuli, and responding to voices are attempts by the infant to interact with others

within his/her environment. Although relatively unsophisticated, these attempts are important in

obtaining attention and caretaking. Failure to receive attention could result in neglected conditions.

For example, an infant who cannot elicit regular responses from his/her primary caretaker is less

likely to be held, picked up, nurtured, fed, have his/her diaper changed, or receive other types of

assistance.

As an infant matures, his/her ability to interact socially with others becomes more sophisticated. At

2 months of age, an infant responds with a social smile evoked by a familiar face. The relationship

with a primary caretaker is the infant’s first meaningful interpersonal relationship. This relationship,

often described as the primary attachment relationship, is the source of security from which the

infant begins to explore the world and other relationships.

The attachment process is fundamental to the interpersonal development of the individual.

An infant

who is securely attached to his/her primary caretaker (when this relationship is stable, consistent,

and nurturing) has more freedom to begin to establish other relationships, broaden opportunities for

new experiences, and develop important interpersonal skills (e.g., maintaining eye contact, cooing,

reaching out). An infant who does not possess a secure attachment to his/her primary caretaker

demonstrates difficulties in interpersonal relations ranging from passivity to increased anxiety and

avoidance in the presence of strangers to decreased responsiveness.

� During the preschool years, a child begins to broaden his/her relationships to include all immediate

family members (both parents and siblings), some extended family members, and substitute

caretakers (preschool teachers and day care staff). These are the dominant interactions of a

preschool-age child. When a preschool-age child begins to understand his/her position in relation

to others, he/she separates out his/her relationship with his/her primary caretaker. The child

establishes him/herself in roles of playmate, brother or sister, grandchild, etc. The child is also

provided some rudimentary expectations of how to relate to these individuals. For example, a

preschool-age child is expected to share, take turns, help a sibling, and not hurt other children.

He/she learns that obedience to these expectations results in praise and acceptance, while failure to

obey results in disapproval and punishment. When he/she begins school, the child is expected to

broaden his/her relationships with others. However, a school-age child begins to function as an

independent individual and separates from prior familial relationships.

� A school-age child, acting as his/her own agent, establishes, develops, and maintains relationships

with peers. The emergence of “best friends” is often seen at this age, a preference toward playing

with specific peers because of their unique attributes or similar interests. While there is a continued

sophistication in the development of relationships with family members, the school-age years mark

a period during which a child’s interests are often directed toward friends and classmates. There

are also indicators of continued complexity within the relationships the child has with peers, including

the expectation of mutuality; inclusion and exclusion from groups (which gives rise to cliques, clubs,

and social groups); beginning development of trust and shared secrets; and interpersonal alliances

(e.g., buddies, pals, best friends). These alliances serve as the foundation for the next major advance

in interpersonal relationships during the adolescent years—the development of complex interpersonal

relationships.

� Adolescence begins the period in which children first have the capacity to engage in relationships

with others focused on shared internal thoughts and feelings. This may be accomplished initially by

extending prior “best friend” relationships. Friends expect that both will provide intimate information

and respect the rights and vulnerabilities of holding such information. This relationship characteristic

is the basis for relationships with the opposite sex, specifically the beginning of meaningful

boyfriend/ girlfriend relationships.

During adolescence, interpersonal constructs such as peer groups, “dating,” and “going steady” are

established. Being part of a same-sex group and conforming to the group’s norms are significant

aspects of the adolescent’s life. The adolescent begins to explore interpersonal characteristics such

as mutual attraction, affection, sexual arousal, and the consistent appraisal of a relationship.

Although these early boyfriend/girlfriend relationships occasionally result in long-term relationships,

more frequently they are short-term. As a result, they become a means to explore the capacity of

existing within an intimate interpersonal relationship; developing skills (communication, problem-

solving, etc.); and maintaining relationship satisfaction. These skills become indicators of later

successful marital relationships, which serve as the foundation for the establishment of a family.

As many human development theorists have noted, the forming of a satisfactory and functioning

marital relationship completes a cycle—birth of a child within a family, development of this child

within the family, the child as an adolescent or young adult selecting a partner, and the creation of

a family from which another generation of children will be born.

Physical Development

� Infants are totally dependent at birth. Visual acuity is poor, eye muscles are weak, and the infant’s

field of visual focus is short and limited. Hearing is developed in the uterus, with newborn infants

displaying a capacity to turn their heads toward sound almost immediately after birth. Average infant

length and weight is approximately 20 inches and 7 1/2 pounds, respectively. Boys are slightly

longer and heavier than girls. Survival of the newborn is enhanced by several innate reflex abilities

(protective head turning, startle reflex, grasp, rooting, and sucking), but the newborn infant is almost

completely dependent on a caretaker to provide nutrition and comfort.

As the infant begins to grow, physical changes are dramatic, with significant gains in most areas

made during the first few weeks and months. With this rapid rate of physical development, there

is a pattern of development from the general to the specific—from the overall use of the body to a

gradual acquisition of use of distinct body parts (e.g., arms to hands to fingers).

Infants typically double their birth weight after 5 months and triple their birth weight by their first

birthday. At 1 year of age, they have increased in size by 50 percent (approximately 30-35 inches)

and grow an additional 5 to 7 inches during the second year. Sleeping patterns are often irregular.

The infant possesses a short sleep cycle and wakes one to three times during the night. The age at

which infants begin to sleep through the night varies considerably, although this is typically

accomplished by the age of 1 to 2 years. Motor development makes rapid gains during the first 2

years of life, with the achievement of sitting without support and standing (at approximately 6

months of age), crawling (at around 7 months of age), walking (at approximately 1 year of age), and

climbing stairs (at approximately 18 months of age).

� As the toddler grows older and begins to master walking, there is an increase in exploration, which

facilitates even greater physical development. Through exploration, the toddler begins to improve

both gross motor skills (arms and legs) and fine motor skills (hands, fingers). Although there

continues to be wide variation in height and weight, an established pattern of growth begins that is

distinct for both boys and girls. This growth trajectory has been plotted for children 2 to 18 years

by the National Center for Health Statistics.

By the age of 2 1/2, the toddler is able to throw a ball, jump in place, hop on one foot, and display

rudimentary drawing skills. By age 4, the child can catch a bounced ball, draw a figure, and walk

heel-to-toe. During this period, a child also acquires the ability to provide for his/her own health

maintenance (under the supervision of a parent). He/she can dress him/herself, brush his/her teeth,

and comb his/her hair. A well-balanced diet is essential for continued physical development. For

many parents, this may be difficult because some children develop irregularities in their eating

patterns (e.g., avoidance of certain foods, craving for favorite foods). Sleep patterns become more

stable; at this age, a child typically sleeps through the night and requires 10-12 hours sleep each

night.

A common problem for preschool-age children is the risk of accidental injury. This may be the

result of the child’s ability to explore his/her environment without having the cognitive capacity to

make risk judgments. Therefore, the caretaker must ensure that dangerous materials are kept out

of reach, that consistent supervision is provided, and that the home environment is adapted to reduce

accidental injuries (e.g., electric outlets have protective covers; breakable or glass objects are moved

out of reach, etc.).

There is a broad range of ages during which children become toilet trained; boys are typically slower

to train than girls. Pediatricians recommend that toilet training be initiated no earlier than 18 months

of age. This is due primarily to the physical limitation of the child (muscle control). But the process

of toilet training is far more than physical capacity. The process also involves intellectual, emotional,

and family supportive resources to manage this complex developmental task.

� Most school-age children (ages 5-10) have established gross and fine motors skills, consistent

control of their bowels and bladders, and can demonstrate physical mastery in a variety of areas.

Both gross and fine motor skills become considerably more developed as the child grows older. Eye-

hand coordination and manual dexterity become precise as is demonstrated by the development of

printing and cursive writing skills. Gross motor skills have developed to enable the child to master

complex tasks such as riding a bicycle, skating, swimming, climbing, and running. A child of this

age is expected to maintain a broad range of daily living skills, including caring for his/her own

personal hygiene (dental care, bathing, grooming, etc.) and selecting appropriate clothing (casual

versus formal, cool versus warm weather).

Although there is still risk of accidental injury, this risk is no longer based on issues related to the

household environment (e.g., ingestion of poison). During this period, accidental injuries tend to

occur more as a result of the external environment and the child’s involvement in dangerous versus

safe activities. Bicycle riding safety skills, fire safety, and prevention of water-related accidents

should be stressed.

Sleep patterns have been established; 10-12 hours of sleep are required each night. Because children

of this age are so active, it is essential that they maintain a regular and balanced diet.

� The adolescent years mark significant changes in a child’s physical development, primarily because

of the onset of puberty. These changes include development of primary sexual characteristics (i.e.,

changes in males and females that contribute to reproductive maturity) and secondary sexual

characteristics (e.g., the growth of additional body hair and changes in voice pitch and body shape).

Sexual Development

One of the most fundamental aspects of every individual is his/her sexuality. The process of sexual development

and its relationship to the knowledge, behavior, and attitudes of children is a natural and complex interactive

phenomenon. From birth, children are exposed to an ever-changing sexually oriented society that profoundly

influences their development in a variety of ways. Factors such as intrafamily dynamics, extended and

intergenerational family relationships, school relationships, peer relationships, and the media may have an

immediate and long-term impact on a child’s total development. Sexual adjustment results in individuals who, at

every stage of their life cycle, are confident, competent, and responsible in their sexuality.

The discussion that follows describes milestones in the individual’s sexual development:

� During infancy, many children engage in repeated self-stimulation of the genitals, with periodic

erections for boys and vaginal lubrication with girls. Children at such a young age also seek physical

affection and closeness (e.g., hugging, touching) through contact with their primary caretakers.

This behavior is not directly sexual, but it is a source of physical contact that is pleasurable to the

infant and young child.

� During the preschool years (ages 2-5), children have developed a sense of their ability to stimulate

their genitals and will frequently engage in “masturbatory” behavior. A child’s verbal skills have

developed to the point that he/she can identify and label body parts and functions, although these

terms are usually rudimentary in form. Many young children enjoy the physical sensation of

nakedness and often display a sense of “body exhibitionism” (especially around bath time). Perhaps

most importantly, it is common for children of this age to begin to explore their bodies and compare

their anatomies to their peers. Within a school or day care setting, this behavior often occurs in

places such as shared toilet facilities.

The combination of verbal ability, cognitive development, and sexual/body exploration also marks

the beginning stage of inquiry. Children may begin to ask their parents about differences in bodies,

where babies come from, and about appropriate terms for body parts. This phase is often the first

and most natural opportunity for parents to begin to communicate with children about reproduction,

sexual norms and communication, and the family or cultural values associated with sexual behavior

and ideas (e.g., hugging, touching, cuddling).

� For school-age children, the level of sophistication has increased significantly. Both boys and girls

have the interest and verbal capacity to exchange sexual ideas and feelings. Additionally, for most

children, the process of self-stimulation or masturbation may continue, although typically this

behavior is relegated to a more private situation. Sexual exploration may continue within sex play

or sexual modeling, although much of this behavior is kept hidden from the view of adults.

� During adolescence, the onset of puberty and physical changes occur in boys and girls between 10

to 14 years of age. Girls tend to progress through pubertal changes earlier than boys. This is

facilitated by a broad range of hormonal and physical changes, including breast development,

menarche, and hair growth for girls, and viable sperm production, facial hair growth, and voice

change for boys. Traditionally, adolescence also brings about a significant increase in the need for

privacy and a shift away from discussing sexuality with parents. Concurrently, there is an increase

in talking about sexual thoughts and feelings within the same-sex adolescent peer group. The

establishment of opposite-sex intimate relationships (i.e., boyfriend/girlfriend) also brings the

opportunity for sexual expression and sexual relationships.

Behavioral Conduct

In examining the developmental process of a child’s behavioral conduct, it should be noted that there are a wide

range of behavioral styles and patterns of behavior. However, there are at least two major themes consistent

throughout the child’s and adolescent’s development—the acquisition of self-control or self-discipline and the

adoption or adherence to rule-governed behavior.

In general, it is the responsibility of parents, the family, the school, peers, and other groups in the child’s

environment (e.g., neighbors, relatives, youth groups) to assist the developing child to gradually acquire the ability

to control his/her own behavior and adhere to specific rules. To achieve satisfactory late adolescence or

adulthood, the individual must have acquired these characteristics to a sufficient degree so he/she can maintain

and regulate his/her own behavior within interpersonal relationships. This ability enables the individual to

participate in relationships such as friendships, intimate spousal relationships, coworker relationships, and/or

continuing relationships with the family of origin.

There are a broad range of behaviors that demonstrate the child’s transition through the process of acquiring these

skills and several periods throughout childhood with common behavioral conduct issues. This section identifies

some of the major developmental transitions through the use of several common behavioral examples:

� One characteristic of infants is the absence of any sense of self-control or adherence to rules.

Thus, a newborn is completely dependent on his/her primary caretaker and must rely on the

caretaker to regulate almost all aspects of his/her life, including eating, sleeping, protection from

danger and harm, etc. However, a few days after birth, caretakers begin to impose changes to the

infant’s schedule to comply with adult behavioral patterns and social dictates. These changes may

take the form of encouraging the infant to stay awake during the day in order to sleep more at night,

beginning to schedule eating or nursing to regular intervals, and being involved in daytime activities

and play rather than at night. Gradually, during the first 2 years of life, caretakers impose rules and

begin to expect the infant to regulate his/her own behavior within certain specific limits (e.g., eating

at mealtimes, engaging in interactive play, sleeping through the night).

� With toddlers, caretakers face the challenges of oppositional and defiant behavior, characterized by

the child’s frequently saying “no” to requests or directions. Kegan states that this phase of childhood

is the demonstration of a very healthy developmental change.

As a representation of his/her

autonomy, a 2-year-old child learns that he/she has the capacity to make decisions independent of

the primary caretaker. Although few would argue that a 2-year-old child should make any decisions

of importance, it is important to recognize that the child is no longer completely dependent on his/her

primary caretaker for all aspects of life. By strongly asserting “no,” the toddler establishes his/her

right to make decisions on his/her own, and thus, takes an important step away from complete

dependence on his/her caretaker. The child is symbolically asserting that he/she is no longer a

dependent, voiceless infant. Making decisions is very important for the child’s emerging autonomy.

� The objective for preschool-age children is the acquisition of self-control within the domain of their

immediate family as well as understanding and complying with family rules. Many family rules

imposed on a preschool-age child are manifested in a manner unique to each family, but are built on

common family themes. For example, parents may have a household rule that the child is to stay

out of the garage unless supervised by an adult—the underlying theme being that “certain places or

things are for adults and may be dangerous to young children.” In a second example, the parents

do not allow their preschooler to strike another child in the family. Here, the underlying theme is that

“it is not acceptable to hurt others.”

By providing rules and the expectation that stated rules are to be obeyed, the family begins to help

the preschool-age child master his/her own behavior. The family is providing a structure within

which rules can be tested and followed. Not only must parents provide rules and expectations for

young children, they must be rational and consistent in the enforcement of those rules. Fairness and

consistency help to promote self-control and positive self-esteem. Additionally, by providing reasons

for the rules, parents help the preschool-age child benefit from sound decisions as well as begin to

serve as behavior models. The child also soon learns that he/she may suffer the “natural

consequences” of impulsive behavior and poorly reasoned decisions. An important aspect of this

stage of development is the ability of the parents to gauge what decisions their child is capable of

making (i.e., those involving minimal risk) and what decisions they should make for their child (i.e.,

those involving high risk).

� As children enter the school-age years (approximately age 5 to adolescence), they begin to assert

themselves as individuals separate from the family. During the school day, the child is required to

continue this process of behavioral self-control and adherence to rules imposed by school teachers

and other school personnel. Typically, the school replaces the structure of the home, with teachers

acting as substitutes for parents by establishing and enforcing environmental rules. Throughout the

elementary school years, teachers impose greater expectations for the child by demanding that he/she

spend more time completing academic tasks, decreasing the amount of free-time or play time, and

expecting the child to regulate his/her own behavior (with close supervision). Ideally, the parents

and family are developing parallel expectations for the child within the home and school environment.

As a form of assistance in structuring their world and managing impulsive behavior, children often

spend an inordinate amount of time establishing themselves in comparison to their peers. During this

stage, the child becomes very concerned with his/her physical abilities compared to the physical

abilities of his/her classmates, often attending to status concepts such as “best,” “last,” “worst,”

“smallest,” etc. A child is perceived as having high status if he/she has a socially desirable quality

(e.g., if the child is the fastest runner or the smartest in class). On the other hand, the child is

perceived as having relatively low status if he/she exhibits a socially undesirable quality (e.g., poor

eyesight, obesity).

The comparison process also creates important changes for school-age children with regard to

interpersonal relations. Competition is often the hallmark of school-age children because they view

it as a test of who is best at a given task. Rules surrounding competition reflect a child’s attempt

to manage his/her own behavior through the adoption of his/her own self-governed rules. The

establishment of groups from which the child is included or excluded is another example of the

comparison process. Boys may build forts, which have prohibitions against girls, while girls may

engage in activities at the exclusion of boys. Such actions continue to provide for the development

of self-control and adherence to socially tied rules. Many of these rules, however, are created by

the child or his/her peers and are supported by adults and the media.

� Adolescents have some ability to regularly maintain behavioral control and relatively superficial

relationships. An adolescent can satisfactorily manage most aspects of his/her life and make daily

decisions without consulting his/her parents. An adolescent should have a basic understanding of

the reasons for culturally or environmentally imposed rules as well as an ability to adhere to those

rules.

Two significant changes occur during adolescence. The first concerns the transition from externally

imposed to internally regulated rules and expectations. That is, rather than complying with demands,

expectations, or instructions provided by parents, teachers, or other authorities, an adolescent begins

to shape his/her own self-defined demands, expectations, and instructions. In many situations, these

self-imposed rules may be the same as those imposed by others (e.g., compliance within a school

setting, managing health status), but some rules may be significantly different from those previously

imposed. Adolescents often desire and require greater personal freedom, resulting in greater

autonomy in making decisions about such issues as music, clothing, and social contacts.

Parent/adolescent difficulties often arise when the authority of the parents to manage the adolescent’s

life conflicts with his/her newly developed authority to manage him/herself.

As stated previously, successful parenting of an adolescent requires that the parents relinquish some

authority and allow the adolescent to make age-appropriate decisions (i.e., those that involve

relatively low risk). However, the parents retain the right to make other decisions (i.e., those that

involve relatively high risk). This process involves the second major change for developing

adolescents—the ability to communicate with others from a position that assumes to regulate their

thoughts, emotions, and involvement in interpersonal relations.

By demonstrating internal control, an adolescent begins to assert him/herself as capable of

maintaining intimate relationships with others (e.g., girlfriends and boyfriends). The adolescent is

able to negotiate relationships independently with parents and others. The demonstration of this

internal control is not always consistent or stable, which suggests periods of perceived instability,

irrational thinking, and/or emotional overload. Often, an adolescent perceives the involvement of

authorities (especially parents) as an insult to his/her integrity (the adolescent sees him/herself as

independent from parental domain) and rebels against such perceived intrusions. With consistent

regulation of both external behavior and internal representations of him/herself, an adolescent begins

the transition to adulthood.

Developmental Psychopathology

Everyone experiences some type of problem, trauma, disadvantage, or distress during their childhood. If trauma

or distress is common to childhood, it becomes important to examine the manner in which children cope with

these experiences and the ways in which they continue to function and interact with themselves and with others.

Some children appear to be devastated by these types of events, whereas other children appear to thrive and

continue regular daily functioning with relative ease under what would usually be considered severely adverse

conditions.

What is clear is that there are many common events that pose risks to a child’s ability to manage adequately

him/herself and his/her relationships with others. What remains unclear is how a child may manifest abnormalities

or psychopathology. Additionally, to be aware of what is “abnormal” or “pathological,” it is essential for the

professional to understand what is “normal” or healthy within the individual. With children, development results

in frequent and regular changes according to some general patterns and trends. Therefore, any attempt to

understand the relationship between normal and abnormal within an individual child must also take into account

his/her developmental status. If professionals assume that adaptation (the ability to alter one’s typical method of

functioning to fit new circumstances) is a normal and healthy part of a child’s development, then it could be

argued that maladaptation is the failure of the child to cope with events in his/her life and/or exhibit a means of

coping, which results in dysfunction.

CONSEQUENCES OF ABUSE AND NEGLECT

Child maltreatment is a multidimensional and interactive problem involving the child and the multiple environments

in which the child exists. Garbarino presents the “Ecological System” (see Figure 1), which provides a means

to identify and describe the environments in which the child exists.

The first context is identified as the microsystem and is composed of individuals or structures that have ongoing

and daily contact with the child. “For children, microsystems are the places they inhabit, the people who live there

with them, and the things they do together.”

Therefore, common microsystems for the developing child might

include home and family, school, neighborhood friends, and peer groups.

The next system, the mesosystem, is defined as the relationships between microsystems. It is optimal for a child’s

development to live within an environment in which there are many mesosystem connections, such as parental

involvement in school and church functions, multiple child and sibling social contacts within the neighborhood,

etc. In contrast, the deprived child’s environment might have relatively few mesosystem connections and consist

of problems that may detract from the child’s life, such as parents’ chronic complaints about school and the

child’s teacher, neighborhood suspicion and distrust, and few neighborhood peer relationships.

The last system, the macrosystem, consists of the broad ideological or institutional patterns within a particular

culture or subculture. These patterns may be easily identified by common factors, such as ethnicity or religion,

or they may be more difficult to determine, but still important, factors within the culture such as attitudes toward

corporal punishment, the value of education, gender-based perceptions of family roles, etc.

Garbarino’s model also views the child as an active part of his/her environment, facilitating change while being

responsive to external stimuli. This model addresses the ever-changing and developing environments of the child,

rather than viewing the child as a static organism. Finally, this model enables clinicians to identify those factors

that increase the likelihood of abuse occurring (i.e., risk factors) and decrease the likelihood of abuse occurring

(i.e., compensatory factors). (See Table 1.)

The following sections describe consequences of each form of child maltreatment (i.e., physical abuse, child

sexual abuse, and neglect). The previously described categories of intrapersonal, interpersonal, physical, sexual,

and behavioral conduct are used to describe the consequences of maltreatment.

PHYSICAL ABUSE

Salter, Richardson, and Kairys state that, “Abused children have learned that their world is an unpredictable, often

hurtful place. The adults who care for them may be angry, impatient, depressed, and distant. Further, they can

be transformed, without warning, into hostile, violent persons.”

Consequences Within the Intrapersonal Category

Our knowledge of child development tells us that the most significant factor within a child’s life is his/her

relationship (i.e., attachment) to his/her parents. Within our society, this attachment is typically a

mother/infant/child relationship, because most fathers have not yet taken equal responsibility for the caretaking

of young children. Given the significance of this relationship, much has been written about the consequence for

the intrapersonal development of a child when his/her parent is physically abusive.

13 14

Figure 1.

The eeology

human

development

Macroayatem

(e.g., ideology)

Mlcroayatem

(e.g.,

home}

Meaosystem

Microayatem

(e.g., school)

Exoayatem

(e.g., employment}

Organism

Exoayatem

(e.g.,

local government)

t.tlcroayatem

(e.g., church)

Meaosystem I

Microayatem

(e.g., peer group}

Macroayetem

(e.g.,

cultur&}

Reprinted with permission from: Garbarino, James, et al. Children and Families in the Social Environment, 2nd edition. (New York:

Table 1

Determinants of Abuse: Compensatory and Risk Factors

Reprinted with permission from: J. Kaufman and E. Zigler, “The Intergenerational Transmission of Abuse,” in D. Cicchetti and V.

Carlson, eds., Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect (New York:

Cambridge University Press, 1990).

Crittenden and Ainsworth argue that it is the need and goal of the human infant to establish and maintain an

ongoing relationship with an adult caretaker.

Through this relationship, the infant is able to meet his/her physical

needs (warmth, nutritional sustenance, protection, etc.) and begin to develop predictable patterns of behavior that

influence later aspects of his/her development. Typically, this relationship is very predictable and responsive (e.g.,

as in parents reacting to the cries of their infant). This relationship leads to a subjective perception of security

on the part of the infant. In the case of a physically abusive parent, the infant’s attachment to the parent disrupts

the child’s internal beliefs of him/herself and his/her world. As a result, a child develops a perception of

him/herself as incompetent, feels bad about him/herself, and considers him/herself unworthy of the love of

another. Additionally, a pattern may develop of expecting pain or injury from others, distrusting closeness, and

being wary or suspicious of others.

Older children who have been abused often demonstrate some type of affective problem (e.g., depression,

sadness, anxiety). Lynch reported that maltreated children look unhappy and take little pleasure from their

environment.

This reaction may be related to alterations in the abused child’s ability to interpret his/her own

as well as others’ emotional and social actions. Some research has found that abused children are limited in their

ability to perceive their own and other children’s intentions and actions, and they may have difficulty interpreting

the emotional expressions of others. This finding suggests that abused children may develop a pattern of denying

certain emotional responses (i.e., conflicting feelings), which often generalize to a broader range of affective

responses. Although this blunted affective ability and response may be useful in coping with the psychic pain of

Ontogenetlc

Level

Microsystem

Leve

Exosystem

Level

Macrosystem

Leve

High

Health

y children

Good

social supports

Culture

that

Awareness

pMt Supportive

spouse

Few stressful events

promotes a

sen.~

abuse

Economic sec.urity/ Strong. supportive

hared

History

a positive savings

bank

religious affiliation

responsibility

relationship

with

Positive school

carir

experiences

and

peer

one

parent

Special talents

relations as a child

children

Physical attractiveness

Therapeutic

Culture

op)l06ed

i:'

...

Good interpersonal interventions

violence

skills

History

abuse

Marital discord

Unemployment

Cultural

acceptance

Low

self-esteem

Children

with

Isolation; poor

corporal

punishment

...

Low

behavior problems social supports View

children as

Poor

interpe1Sonal

Pre

mature

Poor peer relations

possessions

...

skills

unhealth

y children as child Economic depression

Single

parent

PovertY

being abused, it inhibits the range of emotional responses, and hence, impairs an important part of a child’s

development.

Consequences Within the Interpersonal Category

Physically abused infants appear to respond adversely to maltreatment and then begin to adapt to their

environment. Crittenden found that when in interaction with their mothers, abused infants were more difficult

(e.g., crying more often, more irritable) than other infants and that this pattern of behavior was related to the

immediate interpersonal behavior, rather than the infant’s innate temperament.

Crittenden further suggests that

during the first year of life, abused infants learn to accommodate their mother’s behavior without complaint.

By establishing a pattern of behavior that transforms anger to superficial cooperation, many infants and older

children become passive, fearful, vigilant, and compliant. This finding complements research using the “Strange

Situation” paradigm, in which physically abused infants and young children demonstrate a pattern of

anxious/avoidant attachment to their abusive parent. Such infants are described as rejecting or being angry

toward their mothers, although this pattern of behavior is not always consistent. Therefore, the infant may be

angry and rejecting at one time while appearing superficially cooperative at another time. An example of this

behavior is demonstrated by an infant who alternates between wanting to be held and nurtured and then resists

attempts by his/her caretaker to hold or cuddle the child. This pattern of behavior becomes a means of adapting

and coping with his/her attachment relationship.

An interpersonal characteristic observed in many older physically abused children is their tendency to care for

their abusive parents.

That is, these children often engage in actions that serve to meet the needs of their

parents and result in the child providing some caregiving. Additionally, these children may also provide similar

caregiving to younger children within the family and thus demonstrate secondary assistance to their parents (by

fulfilling a parental role). Role reversal offers a means for the child to acquire positive meaning and appreciation

within his/her life and yet maintain closeness to the attachment figure.

Studies have shown that physically abused children tend to interact with their peers either by being overly hostile

and aggressive or by exhibiting excessive withdrawal and avoidance of other children. The reasons why one child

responds in one way while another child responds in a different way are not yet clear. Galdston suggests that

abused children have a need for recognition and attention from adults.

Green argues that heightened

aggressiveness may reflect an identification with the child’s abusive parent in an attempt to avoid anxiety and

feelings of helplessness.

Also, aggressiveness may be a result of parental modeling, with the abused child

demonstrating a pattern of behavior that he/she has learned from the abusive parent(s).

Whether aggressive or avoidant, it appears that physically abused children frequently have significant problems

in their ability to develop and sustain peer relationships. In their review, Mueller and Silverman state that “the very

heart of peer relations, a felt equality between partners, involved developing a working model of relationships that

was based on sharing, equality, and non-exploitation. The experiences of abuse and neglect seem antithetical to

developing such a model.”

Consequences Within the Physical Category

In an extensive 5-year study, Martin reported that slightly more than half of the 58 physically abused children he

studied had some type of neurological impairment.

Additionally, approximately one-third of the children studied

had an impairment that was significant enough to handicap everyday functioning. Similar neurological, sensory,

and/or psychomotor problems have also been identified by other researchers investigating the consequences of

physical abuse.

24 25 26

There are some delays in motor skills development in young children exposed to physical abuse. Martin reported

some gross motor skills deficits.

It is difficult to determine if these motor delays are the direct result of actions

related to the abuse (e.g., hitting, pushing, or punching) such as might result from neurological impairment, or

if these motor delays are the result of a home environment that does not provide sufficient opportunity to use and

master these skills. Martin suggests that physically abused children come from a home environment in which

exploration and normal risk taking are discouraged, thus impairing their development in this area.

Consequences Within the Sexual Category

Little is known about the sexual problems of children who have been physically abused. As adults, these children

may have difficulty developing trust in relationships involving sexual intimacy. Some children who have been

physically abused have also been sexually abused.

Those children may demonstrate negative consequences of

both types of abuse. Physically abused children who have also been sexually abused may possess some type of

sexual behavior problem.

Ryan presents a model of cognitive factors that may develop as sexual offending behavior.

In reviewing this

model, some of these factors (e.g., denial, minimalization, and retaliation fantasies) may also be present in victims

of physical abuse. Individuals who perceive sexual offending behavior as an assertion of power rather than solely

as a deviant sexual behavior might argue that factors that contribute to the need for a demonstration of force and

power also contribute to the development of sexual offenders.

31 32

If this is the case, physical abuse may make

such a contribution.

Consequences Within the Behavioral Conduct Category

Salter, Richardson, and Kairys argue that physically abused children do not behave any differently than other

children under another type of stress.

These researchers also report that children’s reactions to distress can

be described “in one of two ways: ‘internalizing’ or ‘overcontrolled’ (i.e., inhibited, shy, anxious) behaviors and

‘externalizing’ or ‘undercontrolled’ (i.e., acting out, aggressive) behaviors.”

Although this finding may be true,

children have a developmentally limited verbal capacity; they must rely on a specific set of symptoms to express

distress. Therefore, they may engage in internalizing behaviors, in externalizing behaviors or in both. What is

of interest are those behaviors that are unique to, or more likely to occur with, physically abused children.

One such symptom or behavior that is commonly reported as a consequence of physical abuse is the increase

in aggressive behavior. Both verbal and physically aggressive behavior have been reported by studies investigating

physically abused children. The process of being raised in an environment in which physical abuse is used as a

common response to problems, feelings, and conflicts impairs several important developmental functions (e.g.,

problem-solving, accepting delayed gratification, and impulse control).

Without the opportunity to learn these

functions, children use methods or respond in ways that utilize mechanisms modeled for them within their family

(i.e., aggression). Therefore, when placed in a situation in which he/she experiences conflict, negative affect,

or a problem, an abused child resorts to some type of verbal or physical hostility as a means to a resolution or

to fulfill his/her unmet needs.

It appears from reviewing their behavior, that there are two primary response patterns that children use in coping

with the distress of living with an abusive parent. The first response is a negative, resistant, verbally and

behaviorally hostile pattern. The second response is a fearful, passive, and compliant pattern. However, it has

not yet been shown that abused children adopt these patterns across all daily interpersonal situations. For example,

while an abused child may adopt these patterns of behavior in relation to his/her abusive parent, he/she may react

differently (outside the bounds of these patterns) when interacting with peers or other adults. Again, the common

interpersonal response and action appears to center on the relatively quick move toward aggression and hostility.

The specific reasons for this response are unclear, but they may include displaced parental anger, increased

vigilance and the expectation of aggression from others, social modeling of aggressive problem-solving, and a

limited range of conflict resolution abilities.

CHILD SEXUAL ABUSE

Consequences Within the Intrapersonal Category

In reviewing the empirical research on the responses of children who have been sexually victimized, some type

of intrapersonal disturbance is consistently reported. The reasons may be related to Finkelhor’s traumagenic

dynamics of powerlessness, betrayal, and/or stigmatization.

A victimized child may feel unable to protect

him/herself, vulnerable to invasion from others, different from others (which may lead to a sense of isolation),

and may develop a sense of low self-esteem. If the abuse is intrafamilial, he/she may also feel a sense of betrayal

from the abusive parent or sibling or betrayal on the part of nonabusive parents for failing to provide adequate

protection.

Victims of child sexual abuse also report symptoms of fear, anxiety, isolation, and a perception of low self-

esteem. Porter, Blick, and Sgroi suggest that these symptoms may result from the child perceiving him/herself

as “damaged goods,” which is characterized by an overall sense of poor self-image.

Though these symptoms

have been supported with female victims, the evidence is less clear with male victims. Some studies appear to

support similar responses with boys, but their findings remain inconclusive.

Consequences Within the Interpersonal Category

Many problems within the realm of social functioning and interpersonal relationships have also been noted in

victims of child sexual abuse. Some of these problems include using illegal drugs and alcohol, having difficulty

in school, and running away from home. Such problems are often associated with attempts to avoid an abusive

home environment.

Finkelhor’s traumatic dynamic of betrayal is described as manifesting itself through a sense of distrust in others

and conflicted relationships with others as shown through reactions of fear and hostility.

39 40 41

Many victims of

sexual abuse possess this sense of distrust or wariness toward others, perhaps as a reaction to fear of being

victimized in the past, not trusting their decision-making abilities regarding dangerous sexual situations, and/or

attempting to avoid revictimization. Interestingly, research examining victims of abuse has shown that past

victims of sexual abuse are at increased risk of revictimization.

42 43 44

Consequences Within the Physical Category

Many studies that have examined the physical consequences to children as a result of sexual abuse indicate that

for both female and male victims there are an array of injuries including some type of injury to the genital area

that can result from sexual abuse.

45 46 47

As a result of their abuse, certain children acquire some type of direct

injury (e.g., vaginal or anal laceration or tear or acquisition of a sexually transmitted disease) that requires medical

attention or, they develop a secondary problem associated with this initial injury. Examples include the onset of

enuresis or encopresis and/or recurrent problems with urinary tract infections.

In addition to the direct injuries resulting from their abuse, many children develop some type of somatic or

psychophysiological problem that may be related to their abuse. Spencer and Dunklee describe a sample of boys

who reported somatic complaints including sleep disturbance, nightmares, or bedwetting.

Similarly, the Tufts

New England Medical Center study reported significantly more somatic complaints in the children they assessed.

In the second study, common problems identified included sleep disturbance, nightmares, and phobias.

During the past few years there has been an increase in research attempting to link child sexual abuse and post-

traumatic stress disorder (PTSD).

Many abuse victims exhibit symptoms such as dissociation, nervousness,

anxiety, and flashbacks commonly associated with PTSD. However, a clear relationship has yet to be established

between child sexual abuse and PTSD. Because of the wide range of responses to abuse, some children present

some symptoms of PTSD; others may present most or all of the PTSD symptoms (and be diagnosed as having

PTSD), and other children exhibit no symptoms.

Consequences Within the Sexual Category

A consistent finding in research describing consequences of child sexual abuse is the increase in sexualized

behavior in children. Two studies using standardized measures of assessment have indicated that abused children

tend to be more involved with sexual ideation and behavior. The Friedrich et al. study reported nearly three-

fourths of the boys and slightly more than two-fifths of the girls exhibited some type of sexual problem (e.g.,

masturbating too much, masturbating in public, talking about sex too much).

In a Tufts’ New England Medical Center study, approximately one-fourth of the younger age group (4-6-year-

olds) and one-third of the older age group (7-13-year-olds) were elevated on a sexual behavior scale (which

included items about excessive sexual curiosity and open masturbation).

In a smaller sample of 14 boys referred

to therapy for sexual aggression, Friedrich and Leucke identified 11 of these boys as having a history of being

sexually victimized.

Several clinical case studies report a variety of sexual behavior problems in children with a history of sexual

abuse, including problems with sexual acting-out, an exaggerated interest in sexuality, and an increased interest

in sexual material.

54 55 56

Finally, several researchers have argued that having a history of being sexually abused

may contribute to the development of being a sexual offender (either as a juvenile, adult, or both).

57 58 59

It is important to note that although sex offenders may possess a relatively high prevalence of child sexual abuse,

this does not mean that every child who has been sexually abused will become a sex offender. Making such an

assertion fails to account for the fact that most victimized children have no later sexual interest in children or that

there are sexual offenders without a history of having been sexually abused as a child. Furthermore, such an

assertion oversimplifies the broad range of factors that lead to the development of sexual offending behavior. For

example, Ryan states that victim responses such as “patterns of denial and minimalization, power and control

behaviors, irrational thinking, irresponsible decision making, retaliation fantasies, deviant sexual arousal,

aggression, secrecy, and preoccupation with or reenactment of one’s own victimization” may influence the

child’s development from being a victim to being a victimizer.

In summary, both empirical research and clinical case studies indicate that one consequence of being sexually

victimized is an increase in sexualized behavior. This behavioral sequela has been reported in both male and

female victims and includes an increase in sexual ideation and fantasies as well as an increase in sexualized

behavior. Although research with sex offenders suggests that there may be a relationship between being sexually

abused and being a sexual offender, conclusions suggesting a causal relationship are faulty.

Consequences Within the Behavioral Conduct Category

One of the most common findings for male victims is a wide array of behavioral disturbances. Although this

same range of behavioral disturbances is not as pronounced with girls, this does not reflect an absence of

behavioral problems for girls. Psychological research shows that boys tend to express distress through

externalization and girls through internalization. Numerous studies provide empirical support for the presence of

some type of behavioral disturbance (e.g., aggression, delinquency, hyperactivity) with sexually abused children.

62 63

An extensive study conducted by the Tufts’ New England Medical Center was one of the first to use standardized

measures in examining sexually abused boys and girls. This study reported that nearly half of the oldest age group

(7-13-year-olds) showed substantially elevated levels of hostility on scales of aggression and antisocial behavior

on the Louisville Behavior Checklist. Similarly, approximately one-sixth of the younger age group (4-6-year-olds)

were reported as having elevated scores on these same scales of aggression and antisocial behavior.

Finally,

DeFrancis reported that slightly more than half of the child victims showed behavioral disturbances such as

defiance, disruptive behavior within the family, and fighting with siblings.

In addition, there have been several

clinical reports of aggressive behavior, including firesetting and destruction of property, delinquency, verbal

explosiveness, and argumentativeness.

In summary, although not all victims of sexual abuse demonstrate problems with behavioral disturbance, research

suggests that some type of behavioral problem is a relatively common consequence. Furthermore, it appears that

this behavioral response is more common in male victims than in female victims, with parents more likely to react

to behaviors that are externally disruptive.

CHILD NEGLECT

Child neglect is the most frequently occurring type of child maltreatment and probably the least understood

because of several definitional issues as well as difficulty in substantiating anything but severe neglect.

Consequences Within the Intrapersonal Category

By failing to recruit a consistent and adequate caretaker, the infant or young child will be unsuccessful in

achieving the goal of establishing and maintaining an ongoing relationship with an adult caretaker. The

consequences of such a failure may be profound. Typically, by relating to a caretaker through a repeated series

of interactions, the infant or young child begins to develop a set of expectations regarding the nature of future

interactions. These expectations become the basis for the internal representation of the caretaker and of him/

herself.

That is, we construct ourselves, in part, from a series of interactions with individuals in our lives.

Those closest to us usually have the most significant influence.

As a child grows older, these series of interactions are integrated within beliefs about him/herself, his/her thoughts

and activities in relation to others, and perceptions of his/her competency. Harter suggests that this self-evaluation

of competency, originating in initial relationships with caretakers, becomes the source of stability for one’s self-

system. Without a stable initiating environment or consistent support from primary caretakers throughout

childhood, the development of a child’s sense of self is adversely affected.

Neglected children often experience a loss of placement of themselves in relation to other people; this may

manifest in symptoms of withdrawal, depression, passivity, and disorientation or confusion. Neglected children

may become helpless and passive; they tend to roam aimlessly when placed in a situation in which they are

temporarily separated from their parent(s).

Additionally, in their study, Howes and Espinoza report that

neglected children appeared to display less affect, either positive or negative, in their peer encounters, which

suggests a blunted affect.

Helfer argues that being raised in a neglected environment results in several intrapersonal problems, including

living within an environment where needs are not consistently met. This type of environment disrupts the child’s

ability to develop the capacity for delayed gratification.

Additionally, decision making and problem solving are

rarely adequately modeled with the child having limited opportunities to practice these skills. Finally, a neglected

child never fully develops the capacity for control over his/her feelings and actions. In other words, a neglected

child never learns that he/she can control his/her behavior. This failure may lead to impulsive behavior in

conjunction with a thought or feeling,

Consequences Within the Interpersonal Category

It is argued that many neglectful mothers have difficulty providing adequate care for their children because of

their own past histories of maltreatment.

These mothers have difficulty coping with the demands of an intimate

relationship, and they may not understand the necessary cues and interactions because of their own emotional

instability. Therefore, because of their inability to function effectively as well as their impaired relationships, these

mothers do not have the capacity to engage in healthy attachment relationships with their children. Consequently,

their children never acquire basic interpersonal skills and may grow up to perpetuate an intergenerational

transmission of relationship dysfunction.

Main and Goldwyn state that the dysfunctional characteristics identified with abusive mothers (e.g., poor or

unsympathetic response to distress, self-isolation, or poor impulse control) are found in neglected children as

young as 1 to 3 years of age.

Further, women with histories of victimization in childhood, but who did not

maltreat their own children, had strong marriages, positive self-esteem, and had made a conscious acknowledg-

ment of their past maltreatment. This finding suggests that one road to recovery from maltreatment is the

development and maintenance of intimate relationships in adulthood and the acknowledgment of past mal-

treatment.

When interacting with peers, neglected children tend to be withdrawn from schoolmates or to relate to peers in

a disorganized, active, or aggressive manner. These children may exhibit fewer positive play behaviors such as

offering, sharing, showing, accepting, throwing, and following. A problem in peer relationships is supported by

Hoffman-Plotkin and Twentyman, who report that neglected children tend to be more withdrawn than physically

abused children and nonmaltreated children.

Additionally, their research suggests that both physically abused

and neglected children exhibit less prosocial behavior than nonmaltreated children.

Such findings are consistent with other research that reports that neglected children directed fewer positive

behaviors toward their peers, initiated fewer interactions, and were involved in simpler forms of play.

Problems

in peer relationships are consistent with Helfer’s description of what occurs when a child is raised in an abnormal

environment. That is, if denied a healthy environment, a child never learns to trust others, has difficulty in

selecting friends, and is often engaged in conflicts with others because of limited interactional skills.

Consequences Within the Physical Category

One obvious physical consequence of being neglected is deprivation of the fundamental nutritional needs required

for healthy development. Very little has been written on the nutritional deficits associated with neglected children.

Helfer discusses some of the consequences of malnutrition and growth retardation in the context of child abuse

and neglect and identifies a variety of child and family problems associated with deprived backgrounds.

Excluding diseases and medical problems, which are associated with some type of growth failure or malnutrition

(e.g., metabolic disorders, intestinal disorders, or hepatic diseases), Helfer reports that many studies that identify

physical problems associated with a significantly reduced caloric intake indicate that neglected children tend to

make significant gains in both weight and nutritional status after identification and implementation of a medically

related treatment regimen. However, throughout their childhood (and probably adulthood) their stature remains

short and their physical health is identified as somewhat fragile.

Secondary to malnutrition are the numerous developmental limitations and incapacities related to neglected

children. Several studies indicate that the presence of severe neglect, usually associated with malnutrition, has

major consequences for the achievement of many important early childhood developmental milestones as well as

for intellectual and psychological functioning later in the child’s development. Elmer, Gregg, and Ellison report

that many of these children experienced behavioral disturbances and mental retardation.

This finding is

supported by other research that has identified school and academic problems, delays in the development of

language abilities, and social immaturity as effects of child maltreatment.

It appears that neglected children suffer long-term consequences if their neglect includes some type of

malnutrition. These consequences appear to impair physical growth and development as well as intellectual and

psychological functioning throughout childhood.

Consequences Within the Sexual Category

Finkelhor suggests that an important risk factor for child sexual abuse is parental absence and/or unavailability.

He states that characteristics such as parental separation or divorce, mother’s employment outside the home, and

a disabled or ill parent may increase the risk for sexual victimization. This seems a reasonable assertion, given

these characteristics play an important role in the parent’s ability to act as a caretaker and supervisor of the child.

Consequently, it may also mean that parents who fail to care adequately for their children (i.e., neglectful parents)

may also place their children at risk for sexual abuse.

Consequences Within the Behavioral Conduct Category

As stated earlier, one set of behavioral responses that neglected children appear to possess is passivity, social

withdrawal, and isolation. Helfer argues that many of the child’s basic interpersonal characteristics/traits

(developing interpersonal relations, controlling behavioral impulses, and reacting to feelings without consideration

of the consequences) are affected by child abuse and neglect, and that as a result, these traits are impaired both

at the time of the maltreatment and later in life.

Problems with withdrawal and passivity are also suggested by

Crittenden, although this research focused on mother/infant relations.

The reasons for a pattern of passivity,

withdrawal, and isolation are unclear. However, one possible reason is that neglected children do not have a

strong sense that they can have a meaningful impact in obtaining the cooperation of others. As has been

demonstrated in interactions with their neglecting caretaker, neglected children learn that individuals are

nonresponsive to their needs. This realization leads the neglected child to believe that relationships with others

are not an effective means to have his/her needs met or that his/her needs cannot be met by others. This results

in a decrease in attempts to initiate or develop relationships and a perspective that such behavior may be futile.

The final step in this process, then, becomes passivity and withdrawal characteristic of ineffective interpersonal

relations.

ASSESSMENT OF CHILD MALTREATMENT

The primary consequence of child maltreatment is the development of “dysfunction” within the developing child—

that is, the “functioning” of abused children is set apart or becomes difficult as a result of having experienced

abuse and/or neglect. Dysfunction may result in immediate impairment, problems in adjusting to the abusive

experience, or it may occur as problems later in development. Therefore, the goal of therapeutic intervention is

to address the problems or conflicts within the child’s current functioning and/or conflicts that are likely to impair

functioning in the future.

Therapists work toward providing abused or neglected children with skills or understanding so that they may be

better equipped to interact successfully with others (e.g., family, friends, teachers) and deal with their own

thoughts and feelings. As stated earlier, in order to do this, therapists must understand basic child development

(so they can know what is normal or typical) and psychopathology (so they can know what is not normal or

typical). From this base of information, the informed therapist is able to discern which presenting problems are

“dysfunctional” and determine if these problems require therapeutic intervention. A careful assessment of the child

in his/her environment is key to this process.

Typically, the complexity of cases involving child maltreatment requires multidisciplinary input. Many

communities have established teams to assist in the assessment of child abuse and neglect cases. These teams

may include a pediatrician or other health care provider, a child protective services (CPS) caseworker, a law

enforcement officer, an educational psychologist, a child development specialist, a substance abuse specialist, a

mental health counselor, and other social service professionals. In conducting an assessment, the therapist needs

to tap the resources of the team. If a team does not exist, consultation with professionals representing the key

disciplines is strongly recommended. If the therapist and family represent different cultures, it is equally

important for the therapist to consult with a professional knowledgeable about the family’s culture.

ASSESSMENT OF THE CHILD WITHIN THE CONTEXT OF HIS/HER ENVIRONMENT

The maltreatment of children does not occur within a vacuum. In nearly every case, it is important to assess the

functioning, strengths, and needs of a child within several contexts. Usually the dominant context of the abused

child is the child’s immediate family. However, there are also many other contexts or cultures that may have a

greater or lesser influence on the abused child depending on the child’s age (social networks, extended family,

etc.).

In many cases of child maltreatment, therapists have a negative perception of the family (i.e., parents) because

of the harm they have caused the child. The therapist may be angry or think less of the child’s parents if they

are the source of the child’s maltreatment. However, the therapist should negate neither the importance of the

family (from the perspective of the child) nor each family member’s ability to contribute important information

concerning the child’s level of functioning. Whether or not they are involved in the abuse, parents are usually

one of the most informed sources of information about the child’s daily functioning and presenting problems.

Similarly, an assessment of the child’s functioning within settings such as school, social gatherings, daily after

school activities, and day care provide information about the maltreated child from several sources and in several

environments. One benefit of developing a multienvironment, multisource assessment of the child is that patterns

of behavior, identified across contexts, increase the validity of the presence of a particular behavior or

characteristic. For example, reports from a parent that a child is frequently belligerent and noncompliant might

be supported by reports from his/her teacher that indicate that the child is frequently involved in physical fights

with peers, has temper outbursts, and refuses to complete schoolwork. A valid conclusion that could be drawn

from these reports is that this child possesses a relatively stable pattern of oppositional or defiant behavior.

Using multiple sources of information to assess an individual’s functioning is not unique to clinical assessment

or to child abuse.

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The rationale for this approach is fairly simple—in most cases, abused children do not

exhibit a uniform pattern of behavior in response to their abuse. In fact, the response of many children to being

victimized may not constitute a significant problem or be sufficiently problematic to require psychological

intervention. Therefore, by using multiple sources of information to identify dysfunctional patterns of behavior,

the child therapist can focus attention on those behaviors that require intervention. It is important to point out

that not all abused children require therapeutic intervention and, when provided, treatment should focus on

problems that may impair current or future functioning.

ISSUES TO BE CONSIDERED IN ASSESSMENT

As previously described, individual development progresses in an orderly manner that is common to all humans.

Additionally, there is a continuity to each person’s development, which, although it may be subject to periodic

changes or fluctuations, is present throughout his/her childhood. Sroufe and Rutter argue that “disordered

behavior does not simply spring forth without connection to previous quality of adaptation...” and that “change,

as well as continuity, is lawful and, therefore, reflective of coherent development.”

When applying these

concepts to child maltreatment, it becomes apparent that the clinical assessment of a child must examine the child

and the presenting problem (consequences of abuse) in relation to the child’s developmental status and capacity

for adaptation. This approach is essential for developing treatment plans appropriate for a specific child’s

developmental needs. For example, it would be foolish to implement a verbal mode of therapy for a preverbal

child, and conversely, it would be just as ineffective to attempt parent training (traditional child discipline skills

as might be effective with a preschool-age child) for the parents of a 16-year-old client.

As a child changes and adapts throughout his/her childhood, the manner in which he/she expresses dysfunctional

or distressing behavior also changes.

Therefore, the process of identifying psychopathology throughout

childhood must be specific to the developmental status of the child. Thus, the therapist must possess a broad

knowledge of child development (to understand normal and abnormal behavior throughoutchildhood). The

therapist also needs to use assessment instruments that are sensitive to different age groups. Most published child

clinical measures report age limitations for administration and clinical interpretation, and many offer age-specific

scores. The most common examples are measures that assess a characteristic that is expected to change

throughout childhood. These include the following:

� intelligence/development assessments (e.g., Kaufman Assessment Battery for Children or Wechsler

Intelligence Scales for Children-III);

� developmental status assessments [e.g., Bayley Scale of Infant Development (BSID)];

� adaptive behavior measures [e.g., Denver Developmental Screening Test or Vineland Adaptive

Behaviors Scales (VABS)]; and

� behavioral checklists [e.g., Child Behavior Checklist (CBCL)].

Often, measures that assess specific characteristics such as sadness, anxiety, fear, etc ., do not have age-specific

standardizations. Thus, the clinician may erroneously administer an assessment measure to a child who does not

have the intellectual or emotional capabilities to accurately report about him/herself. For example, a child’s ability

to provide information on self-esteem is inconsistent until the child is between the ages of 7 or 8.

Before age

7, the child’s developing self-esteem makes qualitative changes, and the child’s ability to provide such an

internalized evaluation is inconsistent. It is suggested that the validity and reliability of a child’s report of internal

states (e.g., feelings, thoughts, perceptions) does not become stable until the child is between 6 to 8 years of

age.

Ethnicity and Socioeconomic Status

In general, the therapist should exercise caution when assessing children and families belonging to a different

cultural, ethnic, and/or socioeconomic group. Assessment measures typically do not account for different

ethnically or culturally based behaviors, such as language usage and culturally based belief systems. For example,

it may be easy to interpret quiet and withdrawn behaviors on the part of a client as passivity and/or dependency

when, in fact, the origins of the behavior may stem from culturally derived beliefs about polite and respectful

interactions with perceived authority. In part, this may mean that the assessment instruments are not well suited

for populations that are different from the majority population. For example, children engage in a variety of

diverse behaviors along many different continua, including age, sex, and ethnic group. As a result of

socioeconomic, cultural, and familial factors as well as association with traditional beliefs and a limited awareness

of existing mental health systems, different ethnic groups may encourage or discourage a specific form of child

behavior. Thus, ethnically diverse children may exhibit ethnically diverse behavior.

A problem results when assessing a child for the presence of a behavioral, emotional, or psychological problem.

By failing to be culturally sensitive to the specific behaviors exhibited by a specific ethnic group (or child of a

specific cultural heritage), the clinician may erroneously identify the presence of a problem when one does not

exist. For example, a clinician may be very concerned about the sexual behavior (and possibly marriage) of a

young adolescent Laotian or Thai girl. However, within this girl’s culture, early marriages may be culturally

appropriate and expected with social stigma attached to a girl who has not become married during her

adolescence. Conversely, a child of a specific cultural group may be experiencing significant distress and

exhibiting this distress in a culturally acceptable manner, but the clinician may fail to acknowledge or identify this

distress because of his/her lack of knowledge about the cultural group. Assessing children and families who are

not a part of the majority culture without regard to their ethnic, cultural, and/or socioeconomic distinctions may

result in significantly flawed information and, in turn, result in decision making and case management based on

flawed information.

There have been several attempts on the part of test developers to be sensitive to children of diverse cultural and

ethnic backgrounds and, in fact, a few standardized measures have developed alternative scoring and norms

specifically for different subgroups. Examples of these scoring techniques include the addition of sociocultural

percentile ranking for the Kaufman Assessment Battery for Children and supplementary norms for emotionally

disturbed children on the VABS. The VABS also has supplemental norms for hearing-impaired children. Other

researchers have developed ethnically specific norms for child assessment measures already in use. Some

researchers have developed translated versions of commonly used instruments, while other have developed ethnic-

specific norms for these same groups.

Finally, a few assessments have been developed to specifically address

the unique characteristics and qualities of different subgroups [e.g., alternative means of assessment such as the

System of Multicultural Pluralistic Assessment (SOMPA) and the Black Intelligence Test for Cultural

Homogeneity.]

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Although there have been many efforts to make the assessment of children more ethnically

and culturally sensitive, these tools have yet to demonstrate reasonable validity and reliability.

Social Desirability and Reporting Bias

When acquiring assessment information from any source, it is always important to attempt to explore and

understand potential bias in the reporting of the data about a client. One source of bias involved in acquiring

information directly from clients is known as social desirability, that is, the likelihood that people will provide

information so that they will be perceived favorably by the interviewer, assessment administrator, or therapist.

This phenomenon also has been reported and investigated in clinical research involving children.

An example of how a child might exhibit socially desirable behavior is demonstrated by the child who is very

compliant, polite, and attentive during the initial contact with the therapist. This is often described as a

“honeymoon phase”—the child is not yet comfortable within the therapeutic relationship and exerts control over

his/her “typical” behavior to present him or herself as “likeable” or “pleasing.” Even this phase offers clinical

information because it demonstrates that the child has the ability to exert some short-term control over his/her

behavior.

Another source of reporting bias involves a parent who denies the existence of a problem and/or is reluctant to

provide complete information to the clinician. When parents are accused of harming their child or placing their

child in a dangerous situation, they may be very suspicious of the clinician’s intent and/or involvement. For

example, parents may deny the presence of a significant behavioral problem because they are concerned that their

child may be removed from their care. By limiting the amount of information they disclose, these parents may

be attempting to protect themselves from the perceived or real threat of losing custody of their child.

Furthermore, although parents may be good reporters of behaviors and events concerning their child (e.g., fights,

bullying, being suspended from school), they may not be as accurate about less tangible characteristics (e.g.,

sadness, anxiety, fears). Therefore, a parent may evaluate his/her child on the basis of significant or major events

(e.g., noncompliance, chronic fighting) rather than present a more comprehensive representation of the child.

Finally, although children usually demonstrate a consistent pattern of behavior, some children respond well in

some environments and less well in other environments. For example, a child can be cooperative and compliant

within the daily routine and structure of the classroom environment, but he/she has chronic problems in less

structured environments (e.g., playground, home, neighborhood play). In circumstances such as these, a teacher

may report that a child has no problem in completing schoolwork, getting along with peers, or in relating to adults.

This report results in a limited and incomplete picture of the child and his/her behavior.

Professional Roles in the Assessment Process

Because of the multidisciplinary nature of child abuse and neglect, effective case management, assessment, and

treatment require that the professional has a clear understanding of his/her own and other professionals’ roles and

responsibilities. Because professional roles often overlap and provide similar or the same services, these

distinctions are often difficult to make. For example, when interviewing a maltreated child, many professionals

may interact with the abused child in a similar manner, but for different purposes. Law enforcement officers may

interview the child to determine if the offender should be arrested; attorneys may interview a child to determine

whether to prosecute a case; child welfare caseworkers may interview a child to determine whether the child’s

safety in the home is at risk; a psychologist may interview a child for an assessment; and a therapist may

interview a child to begin to understand the child’s perspective about the abuse and to support the child’s resilient

responses.

Acknowledgment and respect of the unique responsibilities of the professionals involved in cases of child abuse

and neglect is essential. The management of each case requires establishing and maintaining open communication

among professionals to minimize the duplication of services, obtain complete assessment information, and develop

treatment and case management plans. The amount of cooperation and coordination among professionals directly

affects the experiences of the child in “the system.”

Use of Standardized Measures

During the past 30 years, there has been consistent debate regarding the benefits of the clinician’s judgment

versus the use of actuarial methods.

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Using standardized assessment techniques and combining these

techniques with sound judgment based on clinical experience and training has been shown to be the best

approach. Therefore, the clinician must become familiar with assessment instruments, their development,

applicability to different populations, psychometric properties, and limitations. The clinician can obtain this

knowledge by attending special training sessions or workshops, by pursuing formal education, and/or by having

formal supervision. Usually, it is sound clinical practice for a clinician to use an unfamiliar measure under the

supervision of some other professional who is familiar with its use. The clinician should also invest some effort

to acquire understanding of the applications of the measures to be used. By using a new or unfamiliar measure

in conjunction with a familiar or more well-known measure, the clinician can begin to develop an understanding

of the new instruments in relation to a well-understood instrument.

Multiaxial Assessment

Multiaxial assessment is comprised of information from many different sources including the following:

� direct assessment of the child,

� projective assessments,

� cognitive assessment,

� clinical interviews with the child,

� parents’ reports,

� family assessment,

� other professionals’ reports, and

� physical assessment.

With the exception of physical assessment (typically conducted by trained medical personnel), discussion follows

on all of these sources.

ASSESSMENT INFORMATION FROM CHILDREN

Perhaps the most important single source of information comes from the abused or neglected child. Often,

information about the child’s level of functioning, skills, needs, and/or problems can be acquired simply by asking

or observing the child. There are several standardized instruments that can be administered directly to the child

and interpreted by the trained clinician. Although obtaining assessment information directly from the child may

present problems concerning validity and reliability (especially with younger children), the experienced clinician

can still acquire much information from this process, especially when this information is supplemented by parent,

teacher, or other assessment data. The following is a brief overview of some common techniques and measures.

None of the instruments described in the following sections should be considered exhaustive nor comprehensive.

Rather, they are simply a sample of techniques within several common categories. The reader is cautioned that

the material in this manual represents an overview of issues related to child maltreatment and is in no way meant

to replace formal training in social work, psychology, counseling, psychological assessment, or any other

discipline.

Behavioral Report and/or Observation

A few behavioral/observational and screening measures for the more common childhood disturbances are

presented in this section. It is important to note that the results of a single measure should not form the basis for

diagnosis or treatment recommendations. Rather, proper assessment involves cross-situational data from multiple

sources.

� Anxiety. Several behavioral/observational tools measure such as the Behavioral Avoidance Test,

Teacher’s Rating Scale, and the Observer’s Rating Scale of Anxiety have been found to be reliable

and valid measures of child anxiety. Additionally, there are several child self-report measures that

appear to be valuable, including the State-Trait Anxiety Inventory, the Children’s Manifest Anxiety

Inventory, and the General Anxiety Scale for Children.

� Depression. The CBCL and the Personality Inventory for Children assess a variety of symptoms

commonly associated with childhood depression. The Child Depression Inventory is designed to

acquire information directly from the child by inquiring about the presence and severity of most of

the childhood depression symptoms.

� Attention Deficit Hyperactivity Disorder (ADHD). One of the most frequently used measures

of assessment of ADHD is the Conners Rating Scale, which has been shown to be fairly accurate

in discriminating hyperactive from nonhyperactive children. This measure is typically administered

to parents and/or teachers and is often supported through clinical interviews with the child, parent,

and teacher. The CBCL has several items that reflect symptoms associated with ADHD and has a

specific factor that has been labeled hyperactivity.

Casual Observations

Within the therapeutic or assessment setting, one of the more informative sources of information involves direct

observation of the child before and after the appointment. This approach may include observing the child and

the parent or caretaker sitting in the waiting room, walking to or from the appointment, interacting with other

children and agency personnel (e.g., receptionist, other therapists). These observations allow the clinician to

examine how the child engages with other individuals while not being formally evaluated. These pseudonatural

observations are often informative because they reveal behaviors and actions that the child may conceal or inhibit

during the assessment or therapy session.

PROJECTIVE ASSESSMENTS

Although empirical research has consistently demonstrated that projective techniques fail to demonstrate an

adequate level of reliability and validity, clinicians continue to use these forms of assessment. Therefore, the

question regarding why clinicians continue to use a form of assessment that has consistently proven to yield

unreliable or invalid data. One possible reason is the relative ease of use of these instruments, supported by the

ease with which they can be informally interpreted. Similarly, when using a projective assessment instrument,

a clinician may selectively interpret the test materials, adapting them to “fit” the case. Therefore, after repeated

administrations and selective interpretations, a clinician may develop the belief that the projective measure has

accurately provided valuable information about several cases and thus, artificially elevate the validity of the

projective measure.

Projective assessment techniques offer a unique opportunity to interact with the child in a semistructured format.

These techniques allow the child to direct the conversation by either responding to a stimulus presented by the

clinician or to direct the topic through a drawing or action. The following projective assessment techniques can

all be adapted to facilitate communication either as part of the formal administration or immediately afterward in

conjunction with an interpretation.

Projective Drawings

There are several variations of projective drawings that incorporate the use of a figure, person, or other images

(e.g., house, tree, family). Each of these forms of assessment centers on providing the child with a basic set of

instructions, which is typically kept to a minimum. The child is provided with paper and a pencil, crayons, or

markers. The child is then provided the opportunity to draw a representation of what was asked of him/her. For

example, Hammer suggests requesting the child to draw a house, then a tree, and finally, a person.

The house

is drawn to elicit or arouse associations with the home or family and consequent familial relationships. The tree

symbolizes life and growth, and is reported to reflect the child’s relatively deeper and more unconscious feelings

about him/herself. Finally, the person is reported to represent the self-representation of the child within the family

and/or environment. Other forms of human figure projective assessments include Kinetic Family Drawing and

the Draw-A-Person.

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Projective Storytelling/Apperception Tests

The Thematic Apperception Test (TAT), for 5- to 18-year-olds, developed by Murray, and the parallel Children’s

Apperception Test (CAT), developed by Bellack, are designed to reflect internal states or constructs of the child.

With the TAT, the test administrator shows the child a card with a drawing or photograph and asks the child

to tell a story about what he/she thinks is happening in the picture. The child then creates a story, which is

believed to be representative of his/her cognitive-emotional processing. The TAT has approximately 20 separate

pictures or cards, all or some of which may be administered to the child. The CAT, administered in a similar

manner, was designed specifically for children and has themes more common to children. CAT presents animals

in the pictures rather than human representations.

Rorschach

The Rorschach, for use with 5- to 18-year-olds, consist of 10 cards with black on white or multicolored images

on each card. The test administrator gives each card, one at a time, to the child and asks the child what he/she

sees in the inkblot. The child then describes his/her perception while the administrator records the verbatim

response. The child may see a single percept or several connected or unconnected percepts on each card. After

completing this phase, the test administrator then reviews each card again, asking for clarification about how the

child perceived each card. There have been several different scoring systems developed for the Rorschach, with

specific scoring for children. The most popular scoring system has been developed by Exner.

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COGNITIVE ASSESSMENTS

The overall objective of intelligence testing is to provide an index of a child’s intellectual functioning in relation

to other children within his/her age group. Because intelligence is such a significant factor in a child’s

development, any concern about cognitive deficits should be identified and addressed. The child’s intellectual

functioning influences the approach to treatment. Certainly, not every abused or neglected child should receive

an intellectual assessment. But if limitations in the child’s intellectual capacity impair the ability to obtain, process,

or retain information acquired from therapy, then alternate therapeutic plans may be necessary. For example, a

child with a significant learning disability and a poor ability to verbally mediate thoughts and ideas is probably not

well-suited to a verbal or didactic therapeutic plan.

In addition to the overall objective of providing information about intellectual functioning, intelligence tests offer

a means of assessing other areas of the child’s functioning. By providing a structured environment, the evaluator

can assess the child’s ability to stay on task, follow directions, and change from format to format. Because most

intelligence tests begin with relatively simple items and then become increasingly difficult, the evaluator also has

the opportunity to observe the child’s response to frustration and failure.

Finally, intelligence tests often use items that require some type of social judgment. For example, on the Wechsler

Intelligence Scale for Children-III (WISC-III), the subtest on comprehension asks questions about how a child

might react in certain situations (e.g., “What would you do if you were at the movies and you saw a fire?” “What

would you do if a child, smaller than yourself, tried to fight with you?”). This scale asks the child to provide an

underlying rationale for common phenomenon (e.g., “Why should you trust a friend?” “Why is it better to give

money to a well-known charity than to a beggar on the street?”). By responding to these questions, the child

often reveals his/her values, cognition, and perceptions of the world and others.

A common criticism of intelligence tests involves their applicability to children of ethnic minorities. Several

studies have demonstrated that intelligence tests are inappropriate and unfair for lower socioeconomic groups and

children of ethnic minorities. Although these biases appear to be relevant to all intelligence tests, some test

developers have attempted to minimize this phenomenon by reducing the culturally biased items, decreasing the

verbal component of the tests, and providing specific norms for certain ethnic minority groups.

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Nevertheless,

the clinician should be cautious when using intelligence tests with lower socioeconomic groups and children of

ethnic minorities.

As a rule, the use of intellectual assessments for clinical purposes is restricted to professionals (psychologists,

psychometrists) who have formal training in the application, administration, and interpretation of these assessment

tools. However, some professionals without formal training may attempt to interpret or reinterpret reports of an

intellectual assessment. Obviously, this practice is unethical and belies the underlying rationale for all

assessments—the careful and informed use of an assessment measure for specific and appropriate purposes.

Bayley Scales of Infant Development (BSID)

The BSID is used to acquire a multidimensional assessment (i.e., mental, motor, and behavior indices) of infants

and toddlers from birth through approximately age 2 years. A highly trained administrator presents the infant with

a series of brief, individual tasks that increase in developmental complexity. By determining how many of these

tasks the infant can perform successfully, the administrator compares the infant’s demonstrated developmental

ability to standardized scores. Although the BSID is the most popular measure of infant development, it is only

indirectly related to intelligence and has not been shown to be a good predictor of later intelligence for all infants.

However, infants who score very poorly on the BSID have demonstrated significant difficulty in later years.

Wechsler Series of Intelligence Tests for Children

These intelligence assessment instruments, the Primary Preschool Scale of Intelligence-Revised (WPPSI-R) for

3- to 6-year-olds and the WISC-III for 6- to 15-year-olds, were developed to yield an overall intelligence score

(full-scale IQ) and to provide a means to assess both verbal and performance IQs. Both of these instruments are

administered directly to the child by a trained clinician (typically a psychologist, educational psychologist,

psychometrist) and yield three scores—a performance IQ, a verbal IQ, and a full-scale IQ. Both the performance

and verbal IQs consist of several subtests that assess different cognitive abilities. The full-scale IQ is a

combination of the performance and verbal scores. (All three scores have a mean of 100 and a standard deviation

of 15.)

Kaufman Assessment Battery for Children (K-ABC)

The K-ABC, for 3- to 12-year-olds, was developed to more accurately reflect research in the area of children’s

intelligence, which suggested that an individual’s intelligence was better assessed by examined mental processes

than by verbal and performance domains. As a result, the K-ABC has a mental processing composite score

consisting of simultaneous processing and sequential processing. In addition, the K-ABC yields an achievement

score, based on six school-related subtests. The K-ABC also provides supplemental norms for hearing-impaired

children and children from different sociocultural backgrounds.

CLINICAL INTERVIEWS

The clinical interview is a common method for obtaining information directly from a child. The interview may

take on a variety of forms, including a nondirected play session, an open-ended dialogue, a verbal account of

client history and presenting problems, and a structured psychiatric diagnostic interview. Perhaps most

frequently, a clinician may combine several of these interview approaches in developing a broad base of

information (both observational and reported) concerning the child. Interviews are also dependent on the

developmental status and abilities of the child.

Nondirective Play Sessions

Play sessions that are nondirective and that require little verbal information from the child are most beneficial for

young children. Typically, during the play session with a preschool or early school-age child, the clinician will

assess the child’s expressive and receptive language ability. The play session will help to answer questions such

as the following:

� Does the child have the capacity to engage in pretend or symbolic play?

� Can he/she adopt roles and characteristics during play?

� Does the child engage easily during the first assessment session?

� Does he/she require a period of reacquaintance at the beginning of each assessment/therapy session?

(For example, frequently children who are angry or hostile exhibit play behaviors that reflect these

feelings; they may attempt to break or destroy toys, attack or attempt to injure the clinician, and

engage in extensive discussion of killing or fighting.)

With children of all ages, it is usually best to use toys as a part of the clinical interview. These toys may include

dolls, small play figures, drawing equipment (e.g., pens, markers, crayons), blocks, marbles, cars and trucks,

etc. Because it is difficult to predetermine which type of toys a child might enjoy playing with, it is usually best

to have a small assortment of toys that have traditionally appealed to a child.

For the evaluator, one objective is to use toys as a means of eliciting conversation from the child and to engage

the child in some type of cooperative activity. Certain toys or objects are more conducive to this task than others.

For example, dolls, play figures, and blocks can easily be incorporated into play involving people, homes, friends;

musical instruments and computer games may inhibit the interaction between the child and the evaluator. By

using a limited assortment of toys and manipulative objects, the experienced clinician/evaluator can also develop

a common set of expectations regarding a child’s interaction with those toys. For example, when provided with

a small house and a family of play figures, most children will begin to manipulate these toys in a manner that

reflects their perception of family interaction. Stereotypically, this interaction may include the mother cooking

dinner in the kitchen, the father going off to work, etc. If the child begins to use these toys in an atypical manner,

this behavior may reflect the child’s perception of a family constellation or structure. This might be exemplified

by the child living with a divorced single-parent mother who chooses to exclude the father in play and have the

father on the periphery of the play session.

There are two important issues to remember when conducting a play session with a child. The first issue is that

there are no specific goals or objectives within the session, other than the careful observation and examination

of the child. It may not be beneficial to establish a specific task as part of the play session because this approach

may inhibit the child’s demonstration of internal processing in favor of accomplishing the task. The second issue

involves incorporating or facilitating the child as the leader of the play session. This can be structured by having

the therapist/evaluator demonstrate that he/she will follow the lead of the child in playing with whatever toys the

child would like to use. For some children, the process of taking the lead in a play situation may not be easy or

comfortable. Certain children may require encouragement to explore the boundaries of what they can play with

and to test their freedom to choose a pretend situation in which to play. It is important that the therapist/evaluator

refrain from interjecting the direction or form of play and that they remain as a willing and responsive playmate

(and an observing and examining evaluator).

Structured Psychiatric Diagnostic Interviews

One alternative in obtaining information about a maltreated child is the use of a structured diagnostic interview.

Typically, these instruments involve administering a detailed set of questions about the child by first interviewing

the parent or child’s caretaker and then interviewing the child. Because they require the child to report about

internal states and to respond to questions primarily within a verbal format, these interview methods are not

appropriate for children who have not reached school-age.

Most of these instruments have adapted the child psychiatric diagnoses of the Diagnostic and Statistical Manual

of Mental Disorders, Third Edition, Revised (DSM-III-R) to specific behaviors and then developed a set of

questions that determine if the behaviors presented by the child fulfill specific diagnostic criteria.

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These

interviews commonly are administered to the parent or caretaker; this information is then confirmed,

supplemented, or rejected based on a second interview with the child. The final determination of whether the

child has a formal DSM-III-R diagnosis is based on information acquired from either or both of these sources

of information.

Three of the most common structured diagnostic interviews are the Diagnostic Interview Schedule for Children

(DISC) for 6- to 18-year-olds, the Schedule for Affective Disorders and Schizophrenia (K-SADS) for 6- to 18-

year-olds, and the Diagnostic Interview for Children and Adolescents (DICA).

103 104

Clinicians and evaluators

familiar with these instruments will have a general format by which to inquire about specific troublesome

presenting behaviors. By being familiar with one or several of these instruments, the clinician or evaluator can

quickly identify or eliminate the presence of a psychiatric disorder or, if necessary, question further about a

problem area. The basic format of these interviews is typically sequential and information-oriented (versus

rapport-oriented). However, they can be adapted to fit the needs of the individual clinician. For example, a

clinician concerned about the presence of an affective disorder can begin asking questions from the affect/mood

disturbance portion of the K-SADS. However, parents appear to be better at reporting external, behaviorally

manifested problems about their children (e.g., aggression, crying) than they are at reporting problems that are

more intangible (e.g., low mood, anxiety, grief).

ASSESSMENT INFORMATION FROM PARENTS

One of the most common sources of information about a child is the child’s parents or caretakers. Usually,

parents have the most consistent and reliable perspective of their child and are invested in providing valuable

information. For a comprehensive assessment of a child, it is essential to interview each parent and obtain

information about the child’s functioning in a variety of settings (e.g., home, neighborhood, school, or church).

Parents, like all reporters, are subject to bias in providing information about their child. Therefore, it is important

to assess both the information provided by a parent and the parent’s ability to provide valid and reliable

information. Several standardized child assessment measures have been developed for parents to complete

concerning their child. Some of these measures are discussed below.

The Child Behavior Checklist (CBCL)

Developed by Achenbach and Edelbrock, the CBCL is a 118-item instrument that asks parents to report the

presence and frequency of a wide range of behavioral problems.

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This instrument has different norms for both

boys and girls within three different age groups (2- to 3-year-old children, preschool-age children, and school-age

children). It yields different scores on several factor-analytic narrow-band scales (e.g., delinquent, sex problems,

withdrawal, or hyperactivity) as well as three social competence scales. Scores are plotted on a child behavior

profile, which has T-scores in which clinically significant problem behavior is indicated by more than 20 points

above the mean (T>70). The benefits of the CBCL are the frequency of its use with child clinical populations,

its application to a large and diverse number of children, separation of norms with regard to both age and sex,

and the relative ease of administration. The CBCL may be used as a means to assess both pre- and posttreatment

functioning to determine the effectiveness of the treatment program and achievement of individual treatment goals.

The Vineland Adaptive Behaviors Scales (VABS)

The VABS is usually administered within a structured interview format, asking parents about behaviors of their

children.

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The VABS provides developmental information about the child’s level of functioning within three

domains—communication, daily living skills, and socialization. For children younger than age 6, the VABS also

provides information about gross and fine motor skills. There is an adaptive behavior composite, which reflects

scores in each of the individual domains. For children aged 5 and older, the VABS identifies maladaptive

behaviors in relation to an age-appropriate normative group.

FAMILY ASSESSMENT

One of the most essential elements in understanding a child is the assessment of his/her family. Traditionally, the

family is the most consistent and important contributor in a child’s life. It is important for clinicians to remember

that as children develop within their family system, the family as a whole goes through a process of changing and

adapting. In addition, interactions and dynamics within a family are multidimensional. Parents not only have an

important influence on their children; children also have a significant influence on their parents. Given this

information, an accurate assessment of a child should also include information from and about the child’s family.

It is acknowledged, however, that with abused and neglected children, such an assessment may not always be

possible.

The Purpose/Intent of Family Assessment

Without a clear understanding of the problems, capacities, and abilities of the entire family, it is difficult to

determine a treatment plan for the child. The general purpose of a family assessment should be to acquire a more

complete understanding of the child within the environment in which he/she lives. This assessment includes

gathering information about the family’s values and experiences, particularly experiences related to loss and grief

in recent years. Additionally, because one of the primary outcomes of the assessment process is the identification

of problems, strengths and needs, and capacities, the parents (and family as a whole) reflect these characteristics

for the child. For example, it would be unwise to identify a problem and suggest a therapeutic response to that

problem that is beyond the capacity of the child or the family. Thus, a recommendation to increase the structure

and responsiveness to a child-related problem of noncompliance is inappropriate if it is beyond the parents’

abilities to implement the recommendations because of poor parenting skills and/or the parents’ own

disorganization. Finally, through a family assessment, the clinician has the opportunity to examine the parents

and assess their abilities and problems.

Standardized Measures of Family Assessment

Several measures of assessment are available that reflect many different areas of family functioning. Most of

these measures assess constructs such as family cohesion, independence, power, and adaptability. Two of the

more common standardized measures of family assessment are the Family Adaptability and Cohesion Evaluation

Scales (FACES) and the Family Environment Scale (FES). The FACES consists of 20 items and measures 3

dimensions of family behavior as follows:

� adaptability—the extent to which the family system is flexible and subject to change,

� cohesion—the emotional bonding that family members have towards one another, and

� communication.

The FES consists of 90 items and has 10 subscales that assess different social and environmental characteristics

within a family. These include the following:

� Relationship dimensions

– cohesion

– expressiveness

– conflict

� Personal growth dimensions

– independence

– achievement orientation

– intellectual

– active/recreational orientation

– moral/religious emphasis

� System maintenance dimensions

– organization

– control

There are many other valuable, standardized family assessment measures that are not included in this section. The

interested reader is encouraged to explore texts that assess family assessment measures.

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Clinical Interviews

In conducting a clinical interview with a family, it is important to use many skills concurrently. The clinician

must be able to:

� observe interactions between family members;

� assess relative position and power within a family in terms of hierarchy, roles, and boundaries;

� provide and respond to specific questions;

� record information about family history, background, symptoms, and characteristics; and

� attend to their own position within the clinical interview.

Perhaps foremost among these tasks is the observation of each family member separately as well as the

observation of the family as a combined unit.

Because the standardized assessment of family interactions are typically beyond the ability of many clinicians, a

less formal assessment of family interactions is usually undertaken. By conducting a clinical interview with the

child and family together, the clinician can assess a variety of child/family interactions and factors. For example,

if a family member is absent, this raises the question of position within the family, commitment to family

activities, and perceived sense of membership in the family.

Often during a family clinical interview, one individual emerges as a spokesperson for the entire family. Typically,

this is a parent who responds to general family-directed questions or takes the lead in clarifying information.

However, the clinician should be alert to an imbalance in relationships within the family (e.g., a single member

dominating the conversation, speaking over other members, responding to questions directed to other family

members, or reframing responses in his/her own words).

In many cases, adults and older children present themselves (either verbally or behaviorally) in a socially

acceptable and desirable manner, but some children, especially very young children, may be less skilled or

conscious of this process. Children often talk and act in a manner that is more consistent with their actions in

a nonclinical or natural setting. Therefore, it is important that the clinician refrains from focusing solely on the

identified child or on the parents throughout the family assessment session. The clinician must also incorporate

all members into the interview, either by direct questioning or by requesting their perspective on the topic being

discussed.

SUPPLEMENTAL INFORMATION

In addition to the child and the child’s immediate family, other professionals are able to provide important

information about abused and neglected children. This section identifies the potential contributions that school

personnel, social service workers, and foster parents can make in assessing the functioning of the child,

developing treatment plans, and assisting in case management.

Teachers/School Personnel

Because a child spends a great deal of time within the school setting, teachers and school personnel have the

opportunity to observe him/her within a variety of school-related settings. Interviewing teachers about a specific

child often yields information about social skills, peer relations, intellectual ability, cooperative skills, behavior

management techniques, attentiveness, emotional stability, and response to authority. Teachers can provide

information about their observations of a child within a classroom setting, on the playground, at the cafeteria, and

before and after school. Teachers are also able to provide general information about the child’s daily living such

as cleanliness, eating habits, grooming, and problems related to encopresis or enuresis. Furthermore, because

schools typically attempt to maintain regular contact with parents, teachers are often able to provide supplemental

information about their interactions with the child’s parents. This may include an assessment of the parents’ level

of involvement, concern about parenting ability, and overall stability of the parents.

The Child Behavior Checklist/Teacher Report Form

This behavioral checklist was developed as a parallel form of the parent version of the CBCL. It has similar

behavioral problems scales and internalizing and externalizing factors. By comparing a child’s score on both the

parent- and teacher-reported version, the assessor can acquire a more comprehensive assessment of the identified

child.

Child Welfare Caseworkers

Typically, child welfare caseworkers are required to obtain sufficient information about children in their caseload

to be able to determine the level of risk to the child and the child’s treatment needs, offer opinions to the court,

and develop and administer therapeutic and reunification plans. To accomplish these tasks, caseworkers must

rely on information provided by a broad spectrum of sources familiar with the maltreated child. These sources

may include foster parents, caretakers who are relatives of the child, home visiting agencies, or law enforcement

agencies, etc.

Because caseworkers usually have large caseloads, it is difficult for them to maintain intensive and consistent

contact with all their cases. Therefore, caseworkers may not be able to provide abundant direct information about

a child, but be an excellent source of indirect information. Because of their position, caseworkers are often the

center of the flow of information about a child. Therefore, they may be informed of the child’s behavior from

a variety of sources and be able to integrate this information in making informed case management decisions.

Foster Parents/Supplemental Caretakers

One assessment problem for children in substitute care (e.g., those in foster care or those receiving care or

temporary shelter care) concerns the ability of a new caretaker to provide valid and reliable information.

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situations in which a child is exhibiting a severe or acute problem such as suicidal ideation, hallucinations, or

aggressiveness, this becomes fairly easy to identify. However, most problematic behaviors require consistent

exposure to the child in order to assess the severity and stability of possible problem behaviors.

An example is the child who, after being placed in a foster home, demonstrates a poor appetite and gradually

begins to lose weight. This reaction might be the child’s expression of distress as a result of being separated from

his/her family or reflective of sadness or depression, anxiety resulting from not feeling safe in an unusual

environment, a lack of familiarity or dislike of a new type of food, or the beginning of an eating disorder. Without

consistent exposure to the daily activities of this child, it would be difficult to determine the cause of the appetite

and weight loss. However, a foster parent or supplemental caretaker (i.e., family friend, grandparent or other

relative) may be able to provide such information after having this child in his/her care for a sufficient period of

time. The minimum amount of time for a caretaker to be able to report on a child’s behavior is approximately

4 to 6 weeks.

109 110 111

This time frame enables the child’s caretaker to report on a pattern of daily behaviors (i.e.,

daily living skills) as well as a range of potential dysfunctional behaviors.

ASSESSING RISK OF HARM TO SELF AND/OR OTHERS

As part of the assessment of any new client, it is essential to determine the client’s potential to harm him/herself

and/or others. The difficulty in acquiring clinical information directly from the child client may require

consultation with other important people in the child’s life (e.g., parents, teachers, child care providers). It is

important to investigate both the child’s behavior and the motivations or cognitions related to his/her behavior.

Because of the child’s limited intellectual abilities, he/she may engage in dangerous or harmful behavior without

a clear understanding of the consequences of his/her actions. For example, a younger child may be excited by

fire and be very interested in playing with matches. However, he/she may have a poor appreciation of the

potential damage he/she could cause by burning him/herself or property. The assessment of danger to self and/or

others should be conducted directly with the child and with other people who have contact with the child. In

addition, the mental health professional should inquire about any prior aggressive, suicidal, and/or other

dangerous/harmful behaviors (e.g., playing with knives, playing with matches, climbing tall trees). This should

be done in the early stages of therapy (optimally during the first session), and any potential harm to self or others

should be incorporated into the treatment plan. In addition, any concern about harm to self or others requires

regular reevaluation and specific actions to address this concern (e.g., increased supervision, evaluating placement

appropriateness).

Suicide

Although the threat of suicide among children is relatively low, it is nonetheless important to make a clear and

focused inquiry regarding the child client’s potential to harm him/herself. The mental health professional should

directly ask the child if he/she has ever thought about hurting him/herself in any manner and/or taken any action

that could result in death or serious harm. Although some professionals may feel uncomfortable about such a

line of questioning, the difficulty in correctly predicting suicidality based only on behaviors and reports from

others is great. It is not unusual for a child to harbor thoughts of self-harm and not discuss them with friends,

parents, or siblings. Therefore, it is strongly recommended that the therapist make a direct inquiry of the child’s

threat to harm him/herself. Similarly, the therapist may also want to inquire about past thoughts or desires that

are reflective of hopelessness, sadness, having “given up,” and passive statements about suicide (e.g., “Maybe

it would be better if I weren’t around”). Careful and conscious inquiry should also be made of parents and other

individuals who are familiar with the child. This line of inquiry should include questions about dangerous

behaviors (e.g., running into the street, playing with sharp objects) and previous statements concerning suicide.

Whenever a concern is raised about suicide, it is important to carefully evaluate the situation and take appropriate

action. This may involve increasing supervision, removing dangerous objects from the child’s environment,

increasing therapeutic contact, and/or evaluating the need for psychiatric hospitalization.

Self-Destructive Behavior

In some situations, the child may have no discernable intent to commit suicide, but nevertheless engages in

behaviors that are dangerous, potentially harmful, and/or “risky” (e.g., climbing tall trees or buildings, ingesting

nonfood substances, cutting skin with a knife or other sharp object). These types of behaviors may reflect

underlying self-destructive tendencies and should also be carefully assessed in a manner that is similar to the

assessment for suicide. While the intent of these behaviors may not necessarily be suicidal, they may result in

significant injury and/or death.

Danger to Others

Often, a child who experiences intense hostile affects but has limited ability to verbally mediate his/her feelings

may express him/herself through behavior. This may result in acts of aggression directed toward specific

individuals (i.e., the individual with whom the child is angry) and/or displaced anger towards others. Special

concern is raised about actions of aggression that may be directed toward younger or weaker individuals in the

child’s environment (e.g., a younger sibling, babies). The therapist should inquire about the history of aggression,

whether the aggression is planned or impulsive, the seriousness of the assault on others (i.e., whether injury

occurred), the use of weapons, and the frequency of such aggressive acts. This may also require investigation

into the child’s living environment and the parents’ ability to manage acts of aggression (e.g., level of supervision,

assessment of parenting skills). A specific plan should be developed to ensure that the aggressive child will not

have the opportunity to become aggressive to younger children and that he/she can be placed in a setting that can

manage his/her assaults. This may require an evaluation of the appropriateness of the child’s placement and

alternative living situations. Special concern is raised for a child who has a history of engaging in sexually

aggressive acts. Such a child may require extra supervision and careful case management decisions.

Revictimization

A frequent symptom of some children who have been sexually abused is to engage in sexually inappropriate

behaviors. These behaviors may include increased masturbation, exposing themselves, increased sex play with

peers, and/or being seductive with adults. Such behaviors, which arise from the child’s distorted perceptions of

appropriate interactions with others, may result in this child being at increased risk of being revictimized. The

therapist should inquire about the presence of any type of sexually inappropriate behavior and carefully observe

the child during the clinical interview for behaviors that may be inappropriate. Parents should be asked about the

type and frequency of their child’s sexual behaviors within the home, with specific attention to the family’s sexual

attitudes and values. In addition, the parents’ ability to recognize inappropriate sexual behaviors should also be

assessed. This may include an examination of the parents’ ability to supervise their child and degree of concern

of their child’s sexuality. As with other forms of harm to the child, a specific program should be developed to

address sexuality, sexual safety, and appropriate sexual boundaries.

THERAPY

Therapy is the art and science of helping children make sense of their feelings, thoughts, and behavior and learn

how to control their behavior and improve interactions with others. It is art because it calls on the therapist’s

creativity, intuition, and spontaneity. It is a science because therapy with abused and neglected children is based

on theory, research, and clinical studies. The goals that need to be accomplished and the techniques or

interventions that help children address and grow beyond the experience of abuse and neglect are gleaned from

theory and clinical literature, research, and experience. This chapter addresses theoretical orientations to therapy,

the role of the therapists, rights and responsibilities in therapy, the therapeutic process, the stages of therapy, and

treatment modalities. Some of the most common treatment issues and concerns about children who have

experienced maltreatment are discussed in a later chapter.

THEORETICAL ORIENTATIONS

A number of theoretical orientations offer useful insight for working with abused and neglected children.

Developmental theories deal with the following:

� normal child development,

112 113 114 115

� effects of attachment and loss on children,

116

and

� impact of normal and abnormal life experiences.

117 118

Interpersonal theories include:

� how significant relationships influence the child’s identity, perceptions, beliefs and interactions, such

as object relations theory, self psychology, and ego psychology;

119 120 121 122

and

� the function of the therapeutic relationship and the use of countertransference.

123 124 125

Cognitive and behavioral theories explore:

� the relationship between feelings and behavior and how changes can occur;

126 127

� how negative feelings become associated with the child’s perceptions of the abuse;

128

and

� how developmental sequencing of phenomena such as cognition, motivation, and affect impacts a

child’s power to reorganize experience.

129

System theories deal with:

� the importance of the family and the society in which the child lives;

� interrelationships and their impact on the child;

130 131 132

and

�

useful and practical interventions with family, school, and community.

Abuse and victimization theories explore:

� the effects of sexual and physical abuse on children,

� prevalence and vulnerable populations,

133

� perpetrator dynamics,

134 135 136

� grooming behaviors,

137

and

� long-term effects of abuse and neglect.

138 139 140

ROLE OF THE THERAPIST

The therapist has an important role in helping a child recover from the effects of abuse and neglect. The therapist

serves a number of functions, including:

� helping the child address issues related to abuse and neglect,

� serving as a model for appropriate adult/child relationships,

� working to improve family relationships, and

� supporting positive and productive peer relationships and support systems.

The therapist’s initial function is to establish rapport and develop a trusting relationship that will help the child

address the thoughts, feelings, and behaviors that are generated by abuse and neglect. The therapist promotes

the child’s awareness and understanding of abuse dynamics, encourages growth and development beyond the

role of victim or the inappropriate identification with the offender, and supports the child’s individuality and

personal integrity. The therapist teaches the child to care for him/herself, think about his/her behavior, and make

choices that maximize his/her safety. The therapist also needs to help the child regain trust, faith, and investment

in meaningful relationships.

As an adult, the therapist models appropriate behavior including nurturing, affection, and the expression of

feelings. The therapist gives the child the opportunity to explore issues of trust, acceptance, affiliation, and

emotional intimacy. The child can integrate the therapist as a role model for safe and nurturing relationships. The

therapist also shares the child’s hope, excitement, and curiosity about life in order to help his/her client reinvest

in his/her future.

The therapist models and maintains good clinical boundaries. He/she understands the vital bond between child

and parent and does not attempt to take the place of the parent. Instead, the therapist helps the child and parent

interact appropriately and offers alternative problem-solving models for parent-child relationships. The therapist

also helps the child to be as realistic and practical as possible when relating to parents with problems. It is a

difficult task to help a child to be realistic, while not taking away his/her hope for change and improvement in

his/her parents.

Although clinical interventions and psychotherapy with parents is beyond the scope of this manual, it is vital that

every effort be made to improve and maintain the child’s relationships with family members. Children need to

express a full range of feelings regarding their family members. The therapist can be more helpful by remaining

neutral and empathetic to the child’s situation than by taking angry and punitive stances toward parents and

unavailable family members. Conjoint therapy with a parent and child, family therapy, or role-playing family

interactions when no parent is available can help the child attain a realistic and pragmatic approach to his/her

parents and family. Formal training in the processes and dynamics of these various treatment modalities is

encouraged prior to their use.

One of the most important functions of the therapist is to facilitate the child’s investment in a positive and

protective support system that continues to be available to the child when therapy ends. Children who have been

abused or neglected may not know how to interact appropriately with people who could be supportive, helpful,

and appropriate for social interaction. Children need to learn social and interpersonal skills that will facilitate their

interaction with peers and adults. Individual therapy can begin this process by offering a supportive environment

in which to address the child’s experience, needs, and abilities and by allowing the child to learn to interact

appropriately with an adult. Therapy offers the child an opportunity to verbalize and explore many of the issues

or concerns typical of victims of abuse and neglect. It also offers the child an opportunity to practice expressing

feelings and to learn behaviors that can generate appropriate responses from adults and peers. Group therapy can

further this process by allowing a child to participate in a group of his/her peers who have had similar

experiences. This group experience can help the child realize that many of his/her behaviors or reactions are

typical for children who have been abused or neglected. Group therapy allows the child to practice and modify

many of the skills he/she has learned in individual therapy. These skills include listening, sharing, responding with

interest and empathy, and demonstrating age-appropriate concern and affection. It is much easier to insert

corrective information or action when a therapist witnesses a problematic interaction than when he/she learns

about that problem later. Many of these skills that can be utilized in a neighborhood or school setting increase

the child’s likelihood of finding appropriate and responsive friends.

Participation on team activities can increase cooperation and appropriate social interactions and can offer esteem-

building experiences for the child. Participation in social and school groups allows the child an opportunity to

apply and practice his/her acquired social skills and relate to other children as a peer rather than as a victim of

abuse or neglect.

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CLIENTS’ RIGHTS IN THERAPY

Children, and all consumers of therapy, have certain rights that must be maintained during the course of therapy.

These include the right to an abuse-free environment, the right to ask questions about therapy and receive an

answer that they understand, the right to expect that therapy is helpful, and the right to be treated as a unique

individual.

Abuse-Free Environment

An abused child comes to therapy with the knowledge that some adult misused his/her knowledge, power, and

experience to take advantage of the child. As an adult, the clinician is in a position of implied power and has

knowledge and experience that can help the child. This power, knowledge, and experience differential needs to

be clarified and used appropriately. The role of the therapist is to protect the child; listen and respond to the child

in a manner that generates growth and development; model appropriate adult/child interaction, and help the child

learn safety, protection, problem-solving and communication skills. The therapist will need to set appropriate

limits and adhere to boundaries that protect the child as well as him/herself.

A national survey found a significant number of cases of therapist/client sexual intimacies involving minor

children.

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The ages for boys who were abused ranged from 1 to 16, with age 12 1/2 the average. The ages

for girls who were abused ranged from 3 to 17, with 13 3/4 the average. This is an issue that must be monitored

carefully. Children must also be made aware that there is possibility of being sexually abused by a professional.

Therapists must report this type of abuse to the proper authorities.

Protection and Limit-Setting

The therapist may need to define appropriate and inappropriate behavior for the child. A child who attempts to

expose his or her private body parts needs to be stopped. The therapist needs to explain that behavior is not

necessary or acceptable. The therapist can explain that children only need to show their body parts under special

occasions such as medical exams. Attempting to touch the therapist’s private body parts or peeking under

clothing also needs to be defined as unacceptable behavior. Natural consequences, logical consequences,

shortening the session so the child can behave appropriately for a short period of time, taking a “time out” to

relax, or stopping the session are all methods that can be used effectively with children. Threats to end the

session or to discuss a child’s behavior with the parents are usually ineffective. However, the child’s parents

need to be informed of the therapist’s plan for addressing problematic behavior. The therapist will need the

parents’ cooperation, support, and willingness to follow up with a discussion. Parents will also need to support

the need for therapy and insist that the child return to subsequent sessions. It is important to clarify the rules and

discuss the consequences with the child so that he/she understands the intention and purpose of discipline. This

discussion should take place before the therapist imposes any consequence. It should be made clear that the

therapist will continue to work with the child to help him/her use therapy. The overriding goal is to demonstrate

to the child that no problem or behavior is so disturbing that it cannot be addressed.

Within the therapeutic relationship, a child will often attempt to create the same power structure found in the

abusive family. Many children can be demanding and authoritarian, and they may make threats or suggestions

that challenge the therapist’s authority and role. Usually, these actions are the child’s attempts to find out how

the therapist will respond. Often, a therapist will feel angry or powerless and may feel that he/she is being bullied

or manipulated by the child. It is important for the therapist to identify the type of behavior that elicits these kinds

of reactions. Feelings about the behavior need to be expressed to the child with the therapist also demonstrating

problem-solving responses to that behavior. Thus, the child can become aware of how his/her behavior may

generate strong reactions in others and begin to expect consequences that do not include abuse. At these times,

clinical supervision is particularly helpful to the therapist in processing his/her reactions to the child/family and

in developing strategies for future sessions. Sometimes a child does not have the skills to develop a relationship

based on reciprocal interactions and respect. In these cases, the therapist can educate the child about

relationships, manners, and social skills.

Terminology and Communication

The therapist needs to use words and terms that are understandable to the child. A 3-year-old child will need to

hear different words and phrases than a teenager. It helps to be able to understand and utilize many different

developmental and experiential languages in order to translate psychotherapeutic concepts into explanations that

make sense to children.

A therapist who works with abused and neglected children need to use words and terms that accurately describe

abuse and neglect. Words and expressions that either minimize or overdramatize the experience can create the

impressions that the therapist just doesn’t understand the child’s situation. Exaggerated statements, such as

“Well, you survived abuse; you can survive anything,” or “I’m so mad at your dad for doing that to you,” say

more about the therapist than about the child’s experience.

Categorizing and reacting to the child’s experience or feelings before the child has had a chance to express

him/herself often confuses the child or elicits a response the child feels is expected by the therapist. It is often

more productive to ask the child to describe what happened and how he/she felt about the experience. The

therapist should then help the child come to his/her own estimations of the experience by asking the child if the

experience was helpful or hurtful, happy or sad, scary or pleasant, or any combination that helps the child identify

and express his/her feelings. The therapist can ask, “How do you feel about that?” or “Do you ever feel angry

about what happened?” or “What would you say to a child who was in that situation?” The therapist can also

help the child talk about the experience by asking “What is the most frightening thing that ever happened to you?”

or “When was a time that you felt strong and powerful?” In this way, the therapist can get a sense of the child’s

inner world and gain some insight into the child’s thoughts and feelings.

A willingness to entertain the possibility that “bad” or harmful experiences can happen to children allows a

therapist to attend to the indicators of abuse and neglect. The therapist’s ability and willingness to ask about

abuse and neglect gives children permission to talk. The therapist’s ability to explore the experiences related to

abuse and neglect, including any pleasurable feelings associated with sexual abuse, allows the child to evaluate

and correct any distortions and inaccurate perceptions he/she may have about acceptable or unacceptable

behavior. The child also learns to manage his/her fear, anxiety, sense of powerlessness, and anger.

The therapist needs to be able to talk explicitly about sexuality with the child, the family, and with other

professionals.

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Therapists who work with children who have been sexually abused need to feel comfortable

talking about the maltreatment, feelings of shame, injuries, secondary gains, sexuality, and sexual feelings. It is

important for the therapist to be able to explain these processes to the child and the parents in language they can

relate to and understand. A therapist who is comfortable clarifying adolescent slang terms or a young child’s

descriptive phrases for his/her body parts or behaviors will help the child feel comfortable when talking about a

difficult subject.

Information

Children, as do all clients, have the right to ask questions about their treatment and receive answers that make

sense. This allows them to experience some sense of control in the therapeutic process, something they did not

experience during the abuse. This means speaking a language that children and parents understand when

discussing symptoms and effects of abuse and by refraining from using therapeutic jargon or terminology that

is not familiar to most clients. Children need to have their symptoms explained to them in developmentally

appropriate language. Often, metaphors or examples are helpful for explaining the repercussions of abuse or

neglect. Clients need to have a clear answer to their questions and therapists can fulfill this need by asking the

child or parent if the answer was helpful to them.

Helpful Interventions

In addition to information about the purpose of therapy, the therapist needs to tailor interventions to the client’s

needs and abilities. Interventions must be useful to the child and parent or they will lose their motivation to attend

the sessions. Clarifying the purpose and intent of the intervention and making it relevant to the child’s current

situation are two methods that facilitate the client’s interest and involvement in therapy. Asking the child or parent

to evaluate the effectiveness of therapy also helps the therapist learn if the interventions are useful.

Individuality

Children and parents have the right to be treated as individuals who have issues and experiences that are unique

to their experience. By making assumptions or telling the client how he/she feels, the therapist overlooks the

client’s need to be treated as a special person. Asking the client to confirm or deny a hypothesis helps the client

feel that he/she is part of the discovery process. Mentioning that some victims have felt a certain way about what

has happened to them can give a child permission to consider if he/she feels that way too. Telling a child how

all victims think, feel, or behave is presumptuous and decreases the child’s sense of integrity and individuality.

THERAPIST RESPONSIBILITIES

There are certain responsibilities that the therapist must fulfill that need to be clarified and discussed with children

and parents. These responsibilities include client confidentiality and the therapist’s reporting requirements, clear

discussion regarding eligibility and payment for services, specific appointment times and cancellation policies, and

periodic discussion regarding the length of therapy and the need for services.

Confidentiality

Clients need to trust the therapist, feel free to confide information and concerns, and feel comfortable exploring

difficult issues and subject matter. Explaining different forms of confidentiality (e.g., doctor/patient,

attorney/client, priest/parishioner) to children and parents will facilitate their understanding of the scope and

purpose of treatment. In statements about confidentiality, therapists should be certain that their clients are aware

that the following must be reported by professionals (as specified by State law) if they are suspected:

� child abuse,

� intention to commit suicide,

� intention to commit homicide, or

� threat of homicide.

The therapist needs to tailor his/her explanations about reporting responsibilities to the child’s ability to understand

what needs to be done. For example, a therapist might tell a young child that part of his/her job is to make sure

that the child is safe and that no one is hurting the child or touching him/her in ways that are wrong. The

therapist needs to clarify with the child the types of touching that are inappropriate and make sure he/she

understands the concept of inappropriate or hurtful “touch.” There are many books about safety, touch, and

prevention that can be useful for teaching this concept. The therapist should explain that if the child says that

someone is hurting him/her, the therapist will tell someone, such as the police or caseworker, so that the abuse

will stop. The therapist can reiterate that it is not “ok” for someone to hurt or abuse a child, and that it is

important for the child to tell someone if he/she needs help with this problem.

It is important that the child know that the therapist will not disclose information without notifying the child of

the need to do so. It is also important that the child understands that the confidentiality privilege is held by the

parent or adult guardian; the therapist will not keep secrets about the child’s safety and well-being. However,

parents do ask about therapy and want to know how their child is doing and if their child is making progress.

The therapist can explain to the child and to the parents that he/she will update the parents and keep them aware

of the child’s progress in therapy by talking about the issues that are being addressed. The therapist can also help

the child learn to talk to the parents about certain topics and concerns by having the child present during

discussions about the child’s progress with the parents.

A child also benefits from knowing that information will not be discussed with his/her friends or acquaintances.

In small towns, or even in large cities, it may be important to discuss with the child what kinds of behavior

would be appropriate if the therapist and child meet in a public place. It is especially important to discuss

confidentiality when a child in therapy may be involved in activities, such as sports or dance, in which the

therapist’s family members also participate. In such cases, it is important to respect the child’s statements

regarding privacy and his/her need for anonymity while maintaining the importance of the therapeutic relationship.

Often, a child will feel more comfortable acknowledging his/her therapist in public after he/she has been in

therapy for a period of time, and what initially seemed problematic is no longer an issue. The child may have

disclosed his/her situation to enough friends that he/she is no longer self-conscious, or the child feels secure

enough to acknowledge the therapist, wave, and move on to a more compelling activity.

Adolescents may appreciate knowing that the therapist will not approach them in public or discuss the therapy

outside the therapeutic setting. An adolescent may feel more comfortable if he/she knows that he/she does not

need to acknowledge and greet his/her therapist if they should meet in a public place, especially if the therapist

is with friends or family members.

Children may also need to know that the therapist is not available for social activities or to fill the role of foster

parent or friend. The therapist is an ally, resource, and role model for appropriate adult/child relationships; he/she

is a professional who maintains appropriate boundaries and abides by rules and regulations.

Release of Information

Children often feel more comfortable talking about their issues and behaviors when they know that the therapist

does not talk about his/her client outside the treatment setting. Only certain professionals, such as caseworkers

or other professionals working with the family, should be privy to knowing if the child is in therapy. This

information is exchanged after a release of information has been signed by the appropriate person, either the child

or the child’s legal guardian. Issues regarding access to the client’s files need to be discussed, including the

possibility of information being subpoenaed in the event of a criminal or juvenile court investigation.

Clarification of Fees and Services

Therapists need to be clear and specific about charges for services, including fees for written reports, court

involvement, and extended telephone conversations. It is helpful to have written agreements with clients and

referring agencies (e.g., city and county government, CPS, foster care, or adoption) about fees for services,

sliding scales, billing procedures, and cancellation policies. A periodic review and evaluation of the fees that are

owed for therapy allow the client to plan for payment and make decisions that are responsible and practical. Each

State has specific rules and regulations about how old a child must be before he/she can contract for services.

Clients need to know the date and time of their next appointment. The therapist needs to explain the cancellation

policy and the impact that cancellations have on the client’s access to services. The therapist also needs to give

advance notice when he/she will not be able to meet with the child. Except in emergencies, a notice of at least

1 week allows the client to prepare for the therapist’s absence. The therapist has a responsibility to inform the

client of planned vacations or leaves of absence and allow enough time for the child to explore any feelings that

may be related to interruption of therapy. The therapist may want to make arrangements for a colleague to be

available if the child needs attention. This consideration enables the child to feel confident that his/her therapeutic

needs will be met and that his/her needs are important.

Evaluation of Progress

The therapist has a responsibility to discuss the approximate length of time the child or parent may require

therapy. The therapist also needs to allocate time with the child or parent/guardian to evaluate the need for

continued service. Premature termination can be damaging to the child or adult; likewise, prolonging therapy

beyond the client’s need for treatment is also unethical. Periodically discussing the goals and objectives of therapy

and evaluating progress helps the client feel that he/she is making progress and is capable of making decisions

and accomplishing the tasks of therapy.

THE THERAPEUTIC RELATIONSHIP

A number of factors contribute to a successful therapeutic relationship with a child. The following concepts are

especially important in developing the kind of relationship that supports a child’s exploration of the issues related

to abuse and neglect.

Trust

Trust is a difficult issue for many abused and neglected children. A child who has been physically or sexually

abused by a known or trusted person may be cautious in developing relationships. An abused child needs to form

a trusting relationship with the therapist; that relationship must be secure enough to allow the child to begin to

explore the actual abuse. The establishment of such a relationship requires great patience from the therapist, who

may feel pressure from other parties involved with the child (e.g., CPS caseworkers and parents) to “make the

child deal with the ... abuse” before the child is ready to do so.

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A child will test the therapeutic relationship,

calling upon the therapist to repeatedly demonstrate that he/she is willing to respond and attend to the child’s

needs and behaviors.

Safety

Two very important goals in helping children recover from abuse and neglect relate to their future safety:

� Help the child internalize the right to safety and protection.

� Find ways to help the child cope with similar events in the future.

Attending to the child’s physical safety and emotional safety during therapy helps the child begin to address these

issues and fosters the development of the therapeutic relationship.

Physical Safety

Physical safety is often missing from the abused or neglected child’s experience. Parents or caretakers may not

have paid attention to the child’s environment or behavior that was dangerous to the child’s safety and well-being.

Thus, physical safety in the therapy room and during the session is often necessary and symbolic for the child.

Abused and neglected children often come to believe that they are unworthy of attention or that their safety and

protection is not important. Some children develop a facade of invulnerability and take risks that can be

dangerous or life threatening. Abused and neglected children may not care about the outcome of their behavior

or may try to hurt themselves. Some children may not have learned to recognize that some actions and behaviors

are dangerous and life threatening.

Assessing the child’s self-destructive behaviors and need for protection is an ongoing process. A young child,

or a child with limited experiences or capacity to process information, may seek protection from the therapist as

a primary means for establishing trust and a sense of security. Physically abused children may use provocative

behavior to test the therapist to see if the relationship will include physical pain or punishment. Abandoned or

neglected children may be surprised to find that the therapist is capable and willing to pay attention to their needs

and behaviors. Sexually abused children may behave in a seductive manner or make inappropriate statements or

comments to test the therapist’s boundaries and reactions to see if he/she will respond to the child in a sexual

manner.

The therapist needs to assure the child’s physical safety in the following environments:

� Home and Social Environment. A child must be safe in his/her home and social environment in

order to benefit from therapy. The therapist needs to ensure the safety of the child in the home at

the initial intake and periodically throughout the therapeutic relationship about the safety of the child.

� Therapeutic Environment. The clinician can ensure physical safety in the therapy session by

maintaining an accident-free therapy room and by watching the child carefully as he/she uses the

therapeutic toys and furniture. The clinician should help the child in and out of chairs; reach for toys

and items on top shelves; and manage climbing, aggressive, and destructive behavior. The clinician

must intervene in aggressive acting out between peers and help the child resolve conflicts in violence-

free ways. Interventions that demonstrate that the therapist is there to protect the child from injury

and attend to his/her physical and emotional needs help the child begin to internalize his/her right to

safety and protection. The therapist becomes a role model for adult awareness and introduces

behavior that attends to the child’s safety and well-being.

The therapist can use many methods to help the child understand and internalize the concepts of

safety and protection. For example, “What if” games are useful for determining the child’s self-

protective capacity and emotionally charged concerns regarding safety. In addition, Kreiger notes

the following:

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� Communicate in word and action that the child is worthy of protection.

� Discuss past traumas and possible ways to avoid those dangers in the future.

� Enter into the child’s fantasy play and, within that context, introduce a protector.

Emotional Safety

A child separated from his/her family, or whose family has been disrupted by the discovery of abuse or neglect,

needs to focus his/her energy on determining what will happen next and on maintaining emotional equilibrium.

Some children who have experienced a loss may feel frighteningly sad, alone, and needy. Other children may

feel strongly hostile toward themselves and others. Other children may have feelings of despair, worthlessness,

and defectiveness.

Schmale and Engle add a fourth state that is much less intense in emotional tone and more energy-conserving.

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This state is characterized by withdrawal and vague sensations of numbness, emptiness, and hypochondriacal

concerns. These various stances may indicate that the child’s energy for responding and interacting is depleted.

The child needs to feel that his/her world is safe and somewhat predictable before he/she will have the physical

or emotional energy to attend to the tasks of therapy. In such cases, the therapist or other professional can use

the following to help children feel emotionally safe:

� Help the child become familiar with his/her new surroundings and circumstances.

�

Remind the child of his/her strengths and accomplishments.

� Teach and practice problem-solving skills, including:

– asking questions,

– seeking help from adults and peers,

– identifying choices and options within the new situation, and

– planning for contingencies.

� Acknowledge the frustration and challenges of a difficult situation.

It is important to identify and support the methods or strategies that the child uses to care for him/her self during

and after the abuse. A child can begin to take pride in those attempts and recognize that he/she did the best he/she

was capable of doing in a difficult situation. This supports the child’s attempts at managing an unmanageable

situation and allows the child to hear that his/her attempts were important and worthy of recognition. When a

therapist identifies and focuses on a child’s weaknesses or inadequacies, the therapist loses a means of connecting

with the child based on strength, respect, and esteem. The therapist also risks forcing the child to deny or defend

his/her thoughts, feelings, and behaviors. As a result, the child may become entrenched in counterproductive

behaviors and may resist intervention.

Pacing the exploration of the abuse over a period of time and placing the abusive experiences in the context of

the child’s overall life experience is more therapeutic than listing all the details and memories in one or two

sessions. Most children will not have access to all the details or memories on demand and it is overwhelming for

a child to confront the entire abuse experience at one time. Most children will resist.

A therapist monitors and addresses emotional safety by paying attention to the clues the child gives about his/her

ability to manage his/her feelings and behavior during therapy. A child will not benefit from being pushed to

his/her emotional or cognitive limits. When a child is pushed beyond his/her cognitive/emotional limits, he/she

will have little or no energy left to soothe or comfort him/herself. The child may demonstrate this depletion of

ego strengths or defenses by regressing, acting out at home, or refusing to participate in therapy. The following

clues may indicate that the child is having difficulties with the subject:

� behavior changes, including distracting or avoidant behavior;

� attempts to change the topic of conversation;

� somatic complaints;

� complaints of boredom; or

� change in affect.

The therapeutic experience can be organized so that it does not overwhelm or exhaust the child. Some ways in

which the therapeutic session can be structured are as follows:

� Examine one aspect of the abuse at a time.

�

Create cycles of work and rest or play.

� Break the discussion into small increments that provide a sense of accomplishment at completing a

task.

� Incorporate esteem-building experiences into the therapy session.

� Differentiate between past and current experiences.

� Allow the child time to reflect and think about new information.

� Allow the child to choose and discuss emotionally manageable subjects.

Identifying and attending to life experiences that were not abusive or neglectful is also an important part of

therapy. This helps the child place the harmful experience in context and shows that maltreatment is only one

of many factors or experiences that has impacted his/her life. The child then can identify skills and arenas that

he/she is competent enough to manage or master.

Focusing on both positive and negative experiences can enhance the child’s sense of self. Attending to life

experiences that do not include being abused helps the child expand his/her sense of self and identity. This allows

the child to integrate the experience into an overall sense of self that is not based solely on victimization. It also

initiates the grief process that many children need to experience in order to let go of old images, expectations,

behaviors, and feelings.

Resistance

Many behaviors that are initially perceived as resistance are really behaviors that are geared to monitor and manage

anxiety generated by recall of the abuse experience. Fidgeting, fooling around, interrupting, asking inappropriate

questions, and straying from the topic or task all need to be considered as possible coping behaviors that help a

child disengage from his/her painful feelings and thoughts generated by the abuse.

The ego defenses or defensive maneuvers that a child uses to protect him/herself from overwhelming stimuli or

memories related to the abuse experience need to be acknowledged and used so the child feels validated, capable,

and able to survive in the best way he/she knows how. A child seldom lets go of a defense mechanism, a

defensive shield, or protective maneuver simply because he/she is told to do so. Tailoring interventions that

facilitate the child’s ability to process the experience and manage the anxiety and stress that are generated are

important. A child will change his/her behavior when he/she feels capable of managing his/her world without that

behavior. Most children will often do this at their own pace.

A child who is not willing to participate in therapy will not benefit from the therapeutic experience. However,

there are many ways to help a child feel more comfortable about participating in therapy. These include the

following:

� empathizing with the child’s frustration or fears about therapy;

� clarifying therapy and what will happen, including providing information that therapy does not mean

the child is “crazy”;

� setting goals that are useful to the child; and

�

contracting for a certain number of sessions with the option to continue counseling if necessary.

It is important to note, however, that not all resistant behavior means the child is unwilling to participate in

therapy. Furthermore, the child may not understand what is expected of him/her within the therapeutic

relationship. The child will benefit from clear descriptions of the purpose and benefits of therapy as well as

clarification of how to think about and respond to questions, including the options of “not knowing” or “not

wanting to say (yet).” It is also helpful for the clinician to explain and delineate appropriate behaviors in therapy,

including appropriate therapist/child behavior. The clinician should also explore any fears or concerns that the

child might have about therapy.

ORGANIZATION AND STRUCTURE OF SESSIONS

The organization, structure, and process of the therapy can make major contributions to the therapeutic

relationship. Developing a format for the session, clarifying the use of time within the session and attending to

content and process experiences are important in effective therapy.

Format

Developing a format or routine for the therapeutic session allows the child to accomplish the tasks of

remembering, talking about the abuse, and discharging accumulated emotions. The child will begin to depend on

the format established by the therapist. The format helps the child organize his/her thoughts, feelings, and

behavior and feel comfortable about discharging his/her emotions, exploring their circumstances and history, and

learning how the abuse has affected him/her.

It is important to clarify the topics that will be covered, such as “What happened to you, and how you feel about

it?” The therapist needs to emphasize repeatedly that he/she is there to help the child. The therapist can tell the

child that his/her role as therapist is to help the child with any questions or concerns he/she might have about the

abuse. This allows the child to begin to expect help from the therapist and to challenge the therapist when the

child does not feel that the therapist is being useful. Clarifying how time will be used within the therapy session

is also important.

Use of Time

Most therapy is organized within a specific time frame, usually the therapeutic hour. Within this time frame the

therapist needs to accomplish the following:

� reestablishing rapport and exploring current issues with the child,

� addressing issues relevant to abuse or neglect,

� making the therapy relevant to the child’s daily life,

� exploring the child’s feelings about the therapeutic experience, and

� providing closure on the therapeutic experience.

The therapist and child need enough time to reestablish rapport, catch up on what has happened during the week,

discuss and evaluate the work done in the last session, address current issues relevant to the child’s growth and

development, discuss and explore issues relevant to the abuse or neglect, and generate closure so the child can

function effectively after completion of the therapeutic session. The therapeutic session should include time to

organize the new information gleaned from the session and discharge some of the emotions that may have been

generated during the session. Developing a pattern of interaction that facilitates the beginning, middle, and end

of the session is a useful tool for socializing the child into the therapeutic process.

Opening and closing rituals can facilitate the process of disclosure and help the child manage his/her emotions.

By turning on the light in the therapy room, pushing the young child’s chair in and making sure he/she is safe and

comfortable, asking an adolescent how he/she feels, the therapist demonstrates rituals that connote to the child

that the session is going to begin.

Closing rituals help the child “put away” the work completed during the counseling session. Closing rituals

symbolize that the work of therapy, including the remembering, reexperiencing, and processing has been

accomplished. The child can then move on to routine tasks and activities. Putting toys away symbolizes that the

therapy session has been concluded.

When a child has used anatomical dolls for demonstration or learning about body parts, it is important to reclothe

the dolls and put them in a location that the children notes is safe. Often, a child will want to separate the doll

that represented him/herself in the demonstration from the doll that represented the abuser. Allowing the child

to determine where the dolls need to be placed in order to be safe can symbolize to the child that he/she determine

what needs to be done so the child can be safe and protected.

Asking the child what he/she did in therapy and helping the child identify the issues he/she explored leaves him/her

with a sense of accomplishment. Asking an abused or neglected child if he/she has any questions can give the

child a sense of control over the final topic to be discussed in the session. It also allows the child to seek

information that may not have been addressed during the session. When it becomes a routine, the question-and-

answer period reminds children that the session is almost over.

When the session has been concluded, the therapist can say: “I am going to turn off the light and close the door

on the work we have done today.” Some children will want to turn off the light and shut the door themselves.

The therapist may want to remind the child of what to do in order to have a safe and happy week, such as “Tell

someone if you need help.”

Content

The content of sessions includes the discussed topics, the details of the conversations between child and therapist,

and the information the child shared with the therapist about the abusive or neglectful incidents. Exchanging

information and helping the child feel comfortable about recalling details of the abuse or sharing feelings about

the experience is the cognitive work of therapy. Addressing the facts of the experience helps the child gain insight

and perspective about the abuse or neglect.

Process

Process focuses on the child’s interaction over time. It attends to the ways in which the child invests and reacts

to the relationship with the therapist. The child’s behavior and ability to interact with the therapist change over

time. During the early phase of therapy, the child may be anxious and have difficulty attending to content-related

tasks. The child will need to be encouraged and reinforced for participating in therapy.

During the middle phase of therapy, many children express their appreciation of and dependency on the therapist.

The child may experience feelings of abandonment or rejection when the therapist is not available for a session.

During this phase, the difficult work of internalizing role models and grieving for losses is completed.

When the child enters the termination phase he/she is investing in outside relationships and developing interests

in activities that may interfere with therapy. The children may need to renegotiate the session time when it

interferes with a group or school activity. This investment in activities and relationships in the “real world” is an

indication the child has benefitted from the therapeutic experience. He/she has learned and is willing to trust that

there are people who can and will respond to him/her in a satisfying manner. This coming together and separation

is a natural process of growth and development, and both the child and therapist should have positive feelings

about the occurrence.

STAGES OF THERAPY

The process of therapy is often divided into four distinct phases—intake, a beginning phase, middle or processing

phase, and consolidation or termination phase. However, the work of the various phases is often woven into the

session and is carried out throughout the entire therapeutic process.

Intake Phase

In most cases, a child is brought to therapy for two basic reasons:

� The child is showing symptoms of having been abused or neglected.

� The parents are concerned about how the child is affected by the abuse or neglect.

The intake assessment determines the child’s need for therapy. This determination is based on the symptoms

generated by the abuse and the conditions that were part of the abuse. The intake assessment involves learning

as much as possible about the presenting problem as well as the child’s symptoms and their severity.

Symptoms are changes in the child’s usual demeanor and behavior. These changes can be subtle or dramatic.

The immediate symptoms that the abuse generates are often manifested behaviorally. They may be similar to

symptoms in the DSM-III-R for PTSD, anxiety disorders, depression, or conduct disorders. A child’s attitudes

about him/herself or about the people in his/her life may change. These deeper esteem and belief-related

symptoms can affect character formation and generate long-term and lasting effects.

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These symptoms, or

changes in behavior or attitudes, are communicating to the world that there is a problem and that the child needs

help.

Determining the Child’s Need for Treatment

Not every child needs therapy; therefore, it is important to determine the child’s need for treatment during the

intake stage. A range of factors may offset the child’s confusion, anger, and fear following an abusive incident

and allow the child to resume a regular lifestyle with little repercussions from the abuse. These include the

following:

� stable and responsive parents/caretakers;

� the ability to communicate the experience to a caring, responsive listener;

� parents’/caretakers’ ability to tolerate and respond appropriately to the child’s expression of feelings;

� stable yet flexible home environment;

� history of appropriate nurturing and protection; and

� absence of major problems in the parental/caretaking relationship.

If the parents are concerned about the child’s well-being or are having difficulty managing their own feelings

about the abuse of their child, it is often useful to offer support and information that will help them cope with the

disclosure of abuse. Educating the parents about how to respond appropriately to their child and identifying

behaviors that might indicate the child would benefit from therapy at a later date can offset some parental fears.

Taking a History

Before initiating therapy, it is essential to acquire some basic information about the client, the circumstances of

the maltreatment, current functioning, and the current living situation. Taking the time to discover what all the

significant adults in the child’s network think “happened” is a good strategy for learning about the family.

A psychological evaluation can be an invaluable tool for understanding the child’s social, emotional, and cognitive

realms. A thorough psychological evaluation includes contact with the relevant parties who have information and

insight into the child’s behavior and emotional state. Specific testing can clarify emotional function and

impairment as well as identify cognitive strengths and limitations. This type of information enables the treatment

provider to tailor interventions to the child’s emotional and cognitive abilities. Although this is most easily

accomplished as part of a complete psychological evaluation, often therapists do not have access to the resources

for such an evaluation.

When a formal evaluation is not possible, it is strongly recommended that the therapist acquire extensive

information during the intake process. The intake process incorporates the acquisition of significant child and

family background information and assesses various aspects of this information to determine the potential impact

on the delivery of therapeutic services. This may include an assessment of subtle factors that may support

therapeutic efforts (e.g., family stability, parental coping skills) or basic factors (e.g., transportation, family

finances).

A good tool for gathering a complete family history is developing a genogram/family tree with the family. A

clinician can assess specific, intergenerational information in many areas by asking appropriate questions as part

of the development of the genogram. These areas include marital histories, the role of extended family, the

educational norm for the family, use of drugs/alcohol, history of mental illness or criminal activity, significant

losses for the family and the child, and significant relationships in the family system. The process of gathering

the information also allows the clinician to identify the family historian and spokesperson.

Developing a Treatment Plan

After completing the assessment or intake phase, the clinician should prepare a plan that outlines the goals and

objectives of treatment and lists the methods that will be used to address the symptoms of abuse or neglect. The

estimated time for achieving the objectives should be noted. Whenever possible, the child and parents/caretakers

should participate in the development of the treatment plan. Participating in the plan’s development helps the child

and parents feel part of the therapeutic process. Often, children and parents are more willing to participate for

the length of time necessary to complete the treatment plan when they have had a part in clarifying the symptoms

and learning about the tasks necessary to address those symptoms. The treatment plan should be reviewed

periodically and modified when necessary. Again, this process should be undertaken with the help of the child

and parents.

The major goal of therapy is to address the symptoms generated by the abuse. The goals and objectives of

therapy need to be concrete, practical, and realistic. Expected changes in behavior should be quantified so that

progress can be monitored in objective, observable terms. Therapists must make the presenting problem

understandable to the child and family. Placing the symptoms in a context removes the negative assumptions

attached to behavior that seems out of control and arbitrary. Addressing the conditions that contributed to the

abused or neglected child’s vulnerability to victimization is another important goal of treatment. An additional goal

is to enhance the child’s strengths and abilities that will enable him/her to accomplish developmental tasks.

Determining the Prognosis

Therapists determine the treatment prognosis or outcome by the parent’s, family’s, and child’s ability to use

therapy.

Parental factors that affect the child’s progress in therapy include the following:

� ability and willingness to respond adequately to the child’s needs;

� willingness to learn new behaviors that support safety and protection of children;

� ability to address issues related to child abuse and neglect, including personal issues related to their

own childhood victimization; and

� minimal impairment of functioning, especially substance abuse and other addictive behaviors.

Family factors that affect the child’s progress in therapy include the following:

� willingness to accept the abuse as a family problem;

� a solution-oriented approach to the problem rather than a blame-oriented approach to the victim;

� commitment and affection among all family members, including the victim; and

� ability to communicate in a manner that facilitates sharing thoughts, feelings, and problems.

Child factors that affect the progress in therapy include the following:

� willingness to participate in therapy;

� ability to acknowledge the experience of abuse or neglect;

� capacity to use therapy, including genetic make-up, level of functioning, and phase of development;

� the content and intensity of the event(s); and

� accumulated life events and history of prior trauma.

Some factors may interfere with the parents’ and child’s ability to benefit from treatment and may contribute to

further victimization. It is important to address the following factors at intake or early in treatment so they do

not interfere with the therapeutic process:

� confusion or lack of understanding about the purpose of therapy;

�

unrealistic expectations regarding change;

� minimal commitment to therapy;

� lack of resources, including transportation and child care; and

� feelings related to court imposed or court-ordered therapy.

At the initial intake, as in all stages of therapy, it is important that the therapist create a strong alliance or

connection with the parent or caretaker. Parents need to understand that they are very important to the child and

that their support and behavior will often determine how a child utilizes therapy. The parents’ cooperation will

give the child permission to trust the therapist and disclose and discuss difficult information about him/herself,

the family, and the abuse. The therapist must convince the parents that their input is needed and valuable and that

therapy is most beneficial when parents share their ideas and concerns as well as support and participate in the

experience.

The child also needs to know that his/her needs will be addressed in the treatment plan. It is important the child

understand that the goal of therapy is to help him/her understand what has happened and he/she was affected by

the experience. The child also needs to understand that the goal of therapy is not to “change” him/her so that the

parents are happy.

Gil notes three tasks that must be accomplished by the end of the initial interview:

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� First, the caretaker needs to be validated for his/her interest in the child’s well-being and willingness

to take the risk of making an appointment, keeping it, and sharing his/her feelings and concerns with

the therapist.

� Second, it is important to summarize the content of the interview so that the caretaker and child

recognize that they have been understood.

� Third, it is important to set a context for ongoing therapy. The therapist needs to outline a normal

course of treatment for the child.

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Beginning Phase

The beginning phase of therapy focuses on establishing trust and rapport, determining the child’s current level

of functioning and coping style, and making therapy useful to the child. As was discussed in the first section of

this chapter, establishing rapport and trust are the first steps in developing a therapeutic alliance.

The therapist needs to establish a relationship with the child based on the child’s interests and needs. In this way,

the therapy is child-centered and determined by the child’s interest, capacity, and willingness to participate.

However, therapy cannot be child-driven. The child must be guided into understanding and awareness; he/she

benefits from a clear plan and appropriate interventions. Being able to show how therapy can be useful in all

realms of life facilitates the child’s willingness to utilize the various therapeutic tasks.

As stated previously, it is important to be able to communicate with children of all ages. Understanding the

number of words and ideas that a child can tolerate and respond to assists the therapist to plan his/her educational

and therapeutic interventions. Repeating key phrases and connecting thoughts and feelings with symbolic

representation helps the child incorporate the therapeutic experience on all levels. Metaphors based on a child’s

interests and stage of development help the child relate to his/her experience with perspective and objectivity.

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It is also helpful if the therapist is familiar with the music, movies, and activities that interest various age

groups. Information about important subjects such as television shows, action figures, sports, cars, and clothing

styles helps to establish rapport and offers a medium by which to communicate values, behavior, and the future.

Middle Phase

In the middle or processing phase of therapy, there are two major tasks that the therapist helps the child

accomplish—identifying how the child has been affected by the abuse and identifying ways to cope productively

with his/her symptoms. In carrying out these tasks it is important for the therapist to prepare the child for

“reliving” or “reexperiencing” the abuse and the feelings which may arise as a result of the abuse or neglect.

Those struggling to recover from the trauma of abuse attempt to resolve four fundamental questions:

� What happened?

� Why did it happen?

� Why did I behave as I did, then and since then?

� What will I do if something like this happens again?

Even a child who exhibits no current symptoms of the abusive experience benefits from help in answering these

questions.

Facilitating resolution of the abuse includes clarifying insights, correcting distortions, placing responsibility for

the abuse more objectively, acknowledging attempts to manage the abuse experience(s), and supporting positive

and productive behavior.

In order to accomplish this objective, the therapist needs to help the child access the memories of abuse or

neglect; identify the sensations, thoughts, feelings, and beliefs that were generated by the abuse or neglect; and

develop productive responses and behavior that enhances a positive self-image.

Accessing the Abuse Memories

Discussing the details of the abuse helps the child think about his/her experience. As the child articulates his/her

unexpressed feelings and hidden thoughts, the child shares his/her personal experience of the abuse. Discussing

details of the abuse can help children dispel some of the myths that were created about disclosure such as, “No

one will believe you,” or “People will laugh and think it’s your fault.” Talking about the abuse diminishes the

intensity of the memories and allows the therapist to join with the child in understanding his/her experience.

Sensations

Physical and/or sexual abuse assaults the body with stimuli and creates sensations that can be fearful, painful, or

overwhelming. Abuse arouses all the senses—sight, sound, touch, smell, and taste. These sensory memories

are stored and may become stimuli for flashbacks, nightmares, phobic behavior, or panic attacks. Various factors

such as lighting, location, temperature, presence of other people during the abuse, as well as physical sensations

need to be noted. Pleasurable sensations (sexual abuse) can be overwhelming for the child and can become

frightening, especially when the child understands that the occurring behavior is wrong. These stimuli need to

identified, assessed, and explained to the child so that he/she understands that his/her reactions are often related

to actual experience.

Thoughts and Feelings

The ability to think about the harmful experience and recognize feelings and behavior generated by those thoughts

allows children to make distinctions, decisions, and choices. Thinking about their experience means gathering

information that explains why the abuse occurred. It means comparing information and assessing the accuracy

of that information. Thinking about the experience, discriminating between feeling safe or unsafe and recognizing

abusive behavior enables the child to identify problematic situations and make choices that can help him/her

remain safe from harm. As the child recognizes that he/she has the ability to think and choose, he/she begins to

feel better about him/herself and feel more powerful and in control.

Discharging feelings generated by the abuse is an important component of the treatment process. Identifying,

acknowledging, and sharing feelings about the experience can help the child recognize the relationship between

feelings and self-esteem, self-worth, and behavior. A child benefits from therapeutic experiences that allow

him/her to act out his/her feelings, exaggerating his/her responses until those responses are intense enough that

the child feels they represent how he/she felt at the time of the abuse. Techniques, such as hitting a pillow or

punching bag, using batakas or encounter bats, or writing down all their feelings and throwing them in the

wastebasket can help the child discharge some of his/her pent up emotions and begin to let go of those emotions.

It is also important to teach the child socially acceptable means of expressing him/herself. These methods include

direct communication, assertiveness, and negotiation. A child needs to know that hitting something, such as a

pillow, may be an acceptable release for his/her feelings. However, hitting someone, such as a child or parent,

is not an acceptable outlet. Haaken and Schlaps note that the patient is not simply a vessel that has been filled up

with bad experiences, and consequently, can be emptied out and refilled with remedial messages.

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These

researchers emphasize that the manner in which the therapist listens and reacts to the child in the process is more

central to sustained therapeutic change than only abreacting traumatic experiences and reassurances.

Often, a child has heard that he/she was supposed to say “no” or “run away or “tell someone.” The child may

feel guilty that he/she did not do those things. The child may also feel inadequate. A child needs to realize that

feeling “scared” or “angry” or “confused” may have inhibited his/her ability to respond. If the perpetrator used

threats or violence, the decisions a child made at the time of the abuse may have been critical to his/her physical

or emotional survival. A child may benefit from exploring the choices he/she made during the abuse incidents

and may need to determine that he/she made the best choices possible given the nature of the situation. A child

may also need to acknowledge that the behavior necessary during the abusive incidents or before disclosure may

no longer be useful to him/her.

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Beliefs

When a child is overwhelmed by sensory stimuli, he/she attempts to make sense of or find order and meaning

for the experience. For a young child, or a child whose understanding is limited by his/her cognitive and

emotional experience, these explanations are often primitive or inaccurate. However, these explanations or

attributions are still important to identify.

Attribution theory suggests that, when negative events occur, blaming oneself for the event (internalizing

responsibility) results in depressed feelings whereas blaming others (externalizing responsibility) results in

anger.

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When a child believes that the cause of the abuse was something to do with him/her, rather than

something to do with the perpetrator, the child blames him/herself for the abuse. A child who internalizes the

cause of the abuse and believes the abuse was his/her fault has a difficult time feeling good about him/herself. The