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103

The Effects and Treatment of Childhood Sexual Abuse in Adult Survivors

Carrie J. Hale Mentor: Richard Beck Abilene Christian University

104 Abstract Sexual abuse has become a national emergency in the United States. Current statistics are alarming as they are, but thousands of cases each year are not even reported. A significant and disturbing maladaptive basis has been found in the psychological wellbeing make-up of adult survivors of sexual abuse throughout many years of research, and an avid plea for more intense study has been called for within medical and psychological fields. The goal of this qualitative study is to determine the risk factors associated with childhood sexual abuse, to identify the long-term effects of sexual abuse displayed in adulthood, and to recognize the moderators of and the most successful types of treatment for the negative consequences of this unthinkable and debilitating form of child maltreatment. The necessity and purpose of this research is to provide collaborative information on such a prevalent and important topic in order for professionals to become more aware of the pervasiveness and seriousness facets that encompasses childhood sexual abuse.

105 The Effects and Treatment of Childhood Sexual Abuse in Adult Survivors Does childhood sexual abuse generally cause enduring effects lasting throughout adulthood in survivors? Are these effects commonly adverse, or are there situations in which the abuse aids in the victim's growth and development as a functional adult? These are important questions to be presented and thoroughly researched by physical and mental health professionals alike in order for progress to be made in such a sensitive and traumatic area of child development. I agree that childhood sexual abuse has profound, long-lasting effects into adult years and that these effects can often be harmful to the survivor's psychological well-being, eliciting high rates of depression, low self-esteem, difficulties in romantic relationships, and various other negative outcomes. I do, however, believe that a percentage of sexual abuse survivors develop hardy, resilient personalities as a response to the trauma, resulting in a stable, sound, and healthy wellbeing carried throughout adulthood. The purpose of this study is to ascertain the statistics and reasoning behind this wide range of long- term effects of childhood sexual abuse and to identify certain treatment protocols that have proven successful throughout the years. Within the past several decades, the prevalence of childhood sexual abuse (CSA) has increased considerably in the United States. Whereas before the late 1970's, when CSA was regarded as uncommon, this invasive form of child maltreatment is presently viewed as a widespread and emergent statistical concern in today's society (Putnam, 2003). The U.S. Department of Health and Human Services (1996) reported a 67% escalation (from 931,000 to 1,553,800 children) in all variations of child abuse from 1986 to 1993. In the most recent data available from 2000, 10% of all legitimately reported child abuse cases were of a sexual nature, totaling to approximately 88,000 incidences, a 41% decrease

106 from estimated totals in 1992 (Putnam, 2003). The validity of this decrease is fervently debated and it is suggested that the decline is due to fewer cases reported than actual occurrences (Jones, Finkelhor, & Kopiec, 2001). Many children remain quiet and do not disclose their abuse due to shame, guilt, fear, and confusion, or they are pressured or threatened into silence by their abuser. The accurate statistics concerning CSA and other types of child maltreatment can never be known, causing what should be recognized as a widespread national emergency. Statistics regarding the prevalence of CSA are typically tabulated from retrospective accounts from adult survivors, but are also derived from accounts reported by child victims at the time of their disclosure. Community samples used in studies produced a range from 12% to 35% of women and 4% to 9% of men reporting some form of sexual abuse prior to the age of 18, with adjusted prevalence means of 16.8% and 7.9%, respectively (Putnam, 2003). In one of the most comprehensive studies of CSA to date, 2000 children, ranging from ages 10-16, participated in a telephone survey questioning the possible history of sexual abuse within the boundaries of unwanted touching, oralgenital contact, or penetration, of which results yielded a lifetime prevalence rate of 10.5% of the overall sample (Finkelhor & Dziuba-Leatherman, 1994). RISK FACTORS ASSOCIATED WITH CHILDHOOD SEXUAL ABUSE Gender Females are approximately 2.5 to 3 more times at risk than males to be sexually abused, although around 22% to 29% of all CSA victims are boys (Finkelhor, et al., 1994). Male sexual abuse victims are underrepresented in most samples, perhaps due to the reluctance to disclose to proper authorities, the large number of males forced into

107 criminal justice and substance abuse treatment systems, and the tendency for mental health professionals to fail in asking male clients about possible histories of CSA (Putnam, 2003).

Age Studies show that the risk for CSA rises with age in the majority of reported cases (Cyr, Wright, McDuff, & Perron, 2002; Finkelhor, et al., 1994; Putnam, 2003). Statistics reveal that approximately 10% of victims are between the ages of 0 and 3 years, 28.4% are between the ages of 4 and 7, 25.5% are between 8 and 11, and 35.9% are 12 years and older (U.S. Department of Health and Human Services, 1996). High risks of sexual abuse are said to begin earlier and have a longer duration for girls than for boys (Putnam, 2003). Race and Ethnicity Race and ethnicity are said not to be risk factors for CSA, although in regard to the expression of the symptoms of abuse, Latina females tend to produce more emotional and behavioral difficulties than Caucasian or African American females (Putnam, 2003). Socioeconomic Status In comparison to other risk factors of CSA, socioeconomic status has less impact than it does within the prevalence of the physical abuse and neglect of children, but an unbalanced number of CSA cases reported to Child Protective Services do come from lower socioeconomic status classes (Finkelhor, et al., 1994). Disabilities

108 Physical disabilities, such as mental retardation, blindness, and deafness, which impair a child's perceived reliability, are associated with increased susceptibility to CSA, and this vulnerability is said to be caused from the child's dependency, communication deficiencies, and possibility of being placed in an institutional care environment (Putnam 2003). One gender trend shows that disabled males are sexually abused more often than comparison groups of sexually abused children with no disabilities (Putnam, 2003).

Familial Structure The absence of one or both parents is a significant risk factor for CSA (Finkelhor, et al., 1994). The presence of a stepfather doubles the risk for girls to be abused, and in the time before a stepfather is present in a home, an increased risk that another male figure will sexually abuse a child is also existent (Putnam, 2003). Other risks associated with CSA in a family setting include severe marital conflicts, parental substance abuse, parental impairments such as maternal illness or alcoholism, parental absence, social isolation, extreme disciplinary parenting, and the presence of other abused siblings (Putnam, 2003). Generational Transmission of CSA Studies reveal that approximately one third of all abused children generally become abusive parents themselves (Putnam, 2003). Using a controlled study, quantitative research done examining the prevalence of physical abuse to be passed from generation to generation yielded a risk of 12.6% (Egeland, Jacobvitz, & Stroufe, 1988), whereas another controlled study showed no significant intergenerational risk (Putnam, 2003). Most studies of generational transmission combine all forms of child maltreatment

109 together, therefore little is known about the likelihood of sexual abuse, in of itself, being repeated throughout generations (Putnam, 2003). Although research into the transmission of abusive styles from one generation to the next is preliminary, it does suggest that fathers who were abused as children are more likely to abuse their children, and previously abused mothers are more likely to fail to protect their own children (Putnam, 2003).

THE EFFECTS ASSOCIATED WITH CHILDHOOD SEXUAL ABUSE Psychological Disorders A significant majority of CSA survivors portray negative psychological symptoms at some point in their life. In a study of 80 non-clinically referred sexually abused children, 62.8% qualified for at least one psychiatric diagnosis and 29.5% qualified for two or more diagnoses (McLeer, Dixon, & Henry 1998). The wide spectrum of psychological disorders that is diagnosed in adult survivors of CSA includes major depressive disorder, borderline personality disorder, conduct disorder, bulimia nervosa and other eating disorders, posttraumatic stress disorder (PTSD), generalized anxiety disorder, dissociative identity disorder, and social anxiety or avoidance, with each of these disorders documented in at least one study, if not more (Cyr et al., 2002; Feinhauer, Hilton & Callahan, 2003; Garcia, Adams, Friedman, & East, 2002; Meyerson, Long, Miranda, & Marx, 2002; Putnam, 2003; Trickett, Noll, Reiffman, & Putnam, 2001). The relationship between childhood sexual abuse and psychological maladjustment is found

110 not only in American community and clinical samples, but in samples abroad as well (Putnam, 2003). Lifetime prevalence of major depression is said to be three to five times higher in women with a CSA history than in women without a history, and abused women are found to reveal earlier onset of depression and are more likely to have prolonged durations of the depression than nonabused women (Putnam, 2003). In a study of 1,991 twin pairs, sexually abused female survivors revealed significantly higher rates of major depression, panic disorder, nicotine dependence, social anxiety, rape after the age of 18, and divorce than the nonabused females (Putnam, 2003). As a whole, CSA victims and survivors portray significant problems with affect regulation, impulse control, sense of self, problems with socialization, cognitive distortions, and somatization (Putnam, 2003). The strength of the relationship between depression and other psychological disorders with sexual abuse is said to be reliant on many factors, such as the severity and duration of the abuse, the proximity of the relationship to the abuser, the gender of the child, the age of onset of the abuse, the presence of physical force within the sexual abuse, the coping strategies utilized by the victim, and the environment the victim is in at the time of the abuse (Cyr et al., 2002; Putnam, 2003). Low self-esteem, poor body image, and shame are also very prevalent themes in both male and female CSA victims and survivors (Feiring, Taska, & Lewis, 2002). Biological father-daughter incest and CSA cases involving boys as the victim both yield an extended duration of and increase in negative psychological symptoms (Putnam, 2003). Behavioral Problems

111 Several problematic behaviors and lifestyles are prevalent among CSA victims and survivors. Studies show that an increased risk for sexualized behaviors, arrest for sex crimes, prostitution, truancy, running away, aggressive behavior, increased substance and alcohol abuse, the tendency to engage in abusive tactics with their own children, and relationship difficulties are more likely to occur within the lifespan of the abused than the nonabused (Feinauer et al., 2003; Garcia et al., 2002; Noll, Trickett, & Putnam, 2000; Putnam, 2003). Of these behavioral problems, risky sexualized behaviors are most closely associated with CSA, and these effects are most commonly connected with children who were abused at younger ages and those victims that were clinically examined relatively close in time to the actual abusive experience (Putnam, 2003). These sexual behaviors include preoccupation with sex, younger ages at first sexual experiences and first voluntary intercourse, heightened interest in sexual activity, fewer inclinations to block the sexual advances of others, the tendency to define relationships with sex, and the lack of birth control and protective measures during sexual contact (Noll et al., 2000; Putnam, 2003). Noll, et al. (2000) developed a comprehensive assessment of sexuality influenced by CSA which includes the five factors of "sexual permissiveness/activity, preoccupation with sex, negative attitude toward sex, feelings of internal and external pressure to engage in sex, and the belief that sex should only occur with someone you love" (p. 333). Age at intercourse, number of sexual partners, birth control use, and pregnancy and abortion histories were taken into account within this assessment. Sexually abused participants in one study using this assessment were more preoccupied with sex, were of a younger age at first voluntary sexual intercourse, and reported a greater desire to

112 conceive at an early age, (perhaps to fulfill unmet psychological needs), than nonabused comparison participants (Noll et al., 2000). Those participants that were abused by their biological father without the presence of physical force reported more positive feelings toward sex in general, greater prevalence of high-risk sexual behavior, were the most preoccupied with sex, and felt increased internal and external pressure to engage in sexual activity in comparison to participants in other clusters (Noll et al., 2000). Participants who were sexually abused by multiple offenders with the presence of physical violence reported negative feelings toward sex in general, more responsible sexual behavior, low levels of sexual preoccupation, and little internal and external pressure to engage in sexual activity (Noll et al., 2000). Those participants who were abused by a single offender with little to no physical force reported similar sexual attitudes and activity as those in a comparison, nonabused sample (Noll et al., 2000). These results portray the varied long-term effects that the relationship between the perpetrator and the CSA victim can have on an adult survivor's overall viewpoint regarding sex.

Other Effects of CSA Suicidal ideation and sexual orientation issues are recent issues being researched and documented in the study of adult survivors of CSA. In one particular study, researchers tested for relationships between these two variables and CSA and found that 43% (n=57) of all sexually abused participants reported past suicidal ideation, and 11% (n=14) reported a past suicide attempt (Garcia et al., 2002). 22% of these participants identified themselves as gay or bisexual individuals, but because this research is preliminary, a

113 statement of a true relationship between CSA and homosexual or bisexual tendencies can not be made (Garcia et al., 2002). MODERATORS OF NEGATIVE CSA EFFECTS Although there is a strong relationship documented between CSA and psychological maladjustment, some survivors portray severe personality disturbances and others do not. Studies show that the varied differences in response to abuse may be due to the protective personality characteristics of hardiness and/or resilience (Browne & Finkelhor, 1986; Feinauer et al., 2003; Feinauer, Middleton, & Hilton, 2003). Chronic internalized shame, difficulty mastering childhood developmental tasks, feelings of overwhelming helplessness, believing that the abuse is their own fault, and a having a sense that they are internally flawed are all common characteristics of sexually abused children, whereas children displaying hardiness, resilience, and invulnerability display quite the opposite (Feinauer et al., 2003). These children do not perceive that the abuse is their fault, they display an external locus of control in that they believe that the shame and blame lie outside of themselves, and they tend to adapt to traumatic experiences with less damage to their personality, resulting in fewer maladaptive symptoms (Feinauer et al., 2003). Hardiness assists individuals to view themselves as whole and intact even when stressful or traumatic situations arise, helps them see change as a productive and beneficial challenge that should be welcomed, and also allows them to transform distressing events into developmental experiences (Feinauer et al., 2003). Rather than viewing themselves as a victim and withdrawing from others, hardy people tend to believe they have control and influence over their own lives, they see themselves as competent and worthy, are able to establish and maintain close, intimate interpersonal relationships, engage themselves in

114 the world around them, and are able to overcome demanding obstacles in life (Feinauer et al., 2003). Difficulties establishing and maintaining interpersonal relationships are common symptoms of CSA survivors, which is said to be due to the decreased ability to trust others (Browne et al., 1986; Feinauer et al., 2003). As a direct result of not being able to trust those that should have been trustworthy throughout their developmental years, many victims find it difficult to, in turn, trust themselves and others, causing their capacity to engage in intimate, meaningful relationships with others to be limited and problematic (Feinauer et al., 2003). Survivors that display a hardy personality, however, are more able to trust themselves and their perceptions of others and tend to embrace everyday situations and people, judge whether the definitive outcomes involved would be beneficial for them, and follow through with their decisions rather than feeling intimidated and defeated by them (Feinauer et al., 2003). One particular study of CSA survivors showed that as hardiness increased, the level of internalized shame decreased, the level of perceived intimacy increased, and the more severe the abuse was perceived to be, the less hardiness the survivor portrayed (Feinauer et al., 2003). The greater amount of internalized shame a survivor displayed and the more severe the abuse was, the less intimacy was seen (Feinauer et al., 2003). Overall, hardiness has been shown to be an effective and protecting instrument in coping with traumatic events such as CSA and in combating maladaptive psychological and social symptoms. Existential well-being (EWB) levels in CSA survivors are also studied in the search of answers as to why there is such a wide range of behaviors and outcomes in relation to sexual abuse. EWB is defined as a security in one's personal life and interactions with

115 others, a sense of general meaning and purpose in life, and a satisfaction and connectedness with the surrounding world (Ellison, 1983). CSA survivors who participated in a study measuring EWB showed fewer distress symptoms in those with a higher level of EWB than in those with lower well-being scores, and those who were more able to retain some sense of well-being during traumatic experiences, or who learned to express it later on in life, reported less negative symptoms throughout adulthood (Feinauer, Middleton, & Hilton, 2003). This suggests that the more CSA survivors feel they are unique and meaningful in a world that poses hardships and trials, the more they may be able to cope in life and avoid psychological distress. TREATMENT Over twenty years ago, in many psychological textbooks, sexual abuse was not even discussed, little was known about long-term developmental, societal, or psychological consequences, and few treatments were readily available for victims and survivors (Mash & Wolfe, 2002). Despite the current prevalence of sexual abuse and increased information regarding its impact, little is still known on how to best treat CSA survivors, and the research concerning this treatment is in its earliest stages (Spiegel, Classen, Thurston, & Butler, 2004). Because the consequences of sexual abuse are certainly not universal and abusive experiences affect each individual unpredictably and distinctively, a variety of short- and long-term outcomes results, causing the necessity for treatments to match the needs of a vast range of survivors who may display a variety of symptoms or none at all (Mash et al., 2002). Up to 40% of sexually abused children may present few to no psychologically dysfunctional symptoms with the reasoning that the abuse was minor, internal

116 characteristics of resilience or hardiness played a role, or that the children utilized a coping mechanism which masked their distress (Finkelhor & Berliner, 1995). Longitudinal data suggests, however, that 10-20% of these asymptomatic children deteriorate within the following 12 to 18 months after the onset of abuse, and that, in some cases, those children who initially display the fewest symptoms are more likely to deteriorate to a greater degree over time than those children who are symptomatic to begin with (Finkelhor et al., 1995). The absence of symptoms after abuse, also known as the sleeper effect, creates a question of whether asymptomatic children should receive treatment or not (Putnam, 2003), or if adult survivors of CSA who have never displayed psychological problems should undergo some type of treatment as well. Putnam (2003) suggests that a psychoeducational intervention focusing on the prevention of further victimization, clarification and normalization of feelings toward the abuse, and general education concerning abuse for the victim and his or her family should be implemented for those individuals who present no symptoms. Because the majority of survivors of CSA present at least one, if not several, dysfunctional psychological symptoms at some point in their lives, a number of treatment protocols have been suggested, but not thoroughly researched or documented. In one study, a review of the literature on the treatment of sexually abused children isolated only 29 studies in which five or more children were treated with the same protocol and that utilized both a pre- and post-treatment evaluation to identify symptomatic improvement (Finkelhor et al., 1995). Although each of these studies showed significant improvement over time, whether or not this progress was actually due to the treatment or the simple passage of time was ambiguous.

117 For children, a central element of treatment for sexual abuse victims involves education and support to better help them understand why the obtrusive events happened to them, that the incident was not in any way their fault, how they may learn to feel safe and protected once again, how to prevent future sexual abuse, and how to restore a sense of personal power and dignity (Mash et al., 2002). Cognitive-behavioral methods have also proven significantly effective in attaining these goals in children (Mash et al., 2002), as well as in adult survivors (Deblinger, Lippman, & Steer, 1996; Putnam, 2003; Spiegel et al., 2004). Session-limited cognitive-behavioral therapy (CBT) shows positive outcomes in treating various symptoms seen in sexually abused children (Putnam, 2003). In a study involving 100 children, a comparison of four treatment conditions was executed in which the groups involved consisted of a 12-week abuse-focused CBT model for the child only, CBT for the parent only, CBT for the both the child and the parent, and a cluster that only experienced standardized community care (Deblinger, Lippman, & Steer, 1996). Improvement occurred in each treatment condition, with the most benefit resulting from the CBT with the child alone. Cohen and Mannarino (1996) compared CBT and nondirective supportive therapies in a study involving 3-7 year-old sexually abused children (N=67) and their nonoffending parent, with the results showing significant improvement and in PSTD symptoms, as well as externalizing, internalizing, and sexually inappropriate behaviors which were sustained over one year. Cohen and Mannarino (1998) also conducted a similar study consisting of older children (N=49), in which depressive symptoms

118 decreased and social competence increased more with CBT than with nondirective supportive therapy. Other studies also show superior improvement in PTSD symptoms and overall functioning in sexually abused children receiving CBT compared with nonspecific treatment strategies and wait-list controls (Celano, Hazzard, Webb, & McCall, 1996; King, Tonge, & Mullen, 2000). Although CBT models are the best-documented and most effective treatments for CSA, a number of symptoms, specifically aggression and sexualized behavior, are consistently resistant to these approaches (Putnam, 2003). Recent research into treating adult women survivors of CSA focuses on whether or not to conjure up and focus on the traumatic abusive memories from childhood years in order to decrease symptomology, or to remain in the present and work on current problems in everyday living (Spiegel et al., 2004). Trauma-focused group psychotherapy is a form of treatment in which clinicians encourage patients to cognitively and affectively come to terms with the meaning and influence of traumatic events, such as abuse, and emphasizes the connection between the survivor's symptomology and past environment in order to decrease distress levels by recovering and reinterpreting memories of the events that led to psychological dysfunction (Spiegel et al., 2004). Through this reconstruction of traumatic events, it is predicted that survivors are able to modify their negative self-views that originated because of the sexual abuse and integrate these experiences and recollections into their present awareness of themselves and others (Spiegel et al., 2004). Present-focused group psychotherapy carries the same goal of coming to terms with previous trauma, but centralizes on the link between symptomology and the existing and

119 immediate environment in order to assist patients in decreasing distress by modifying maladaptive and undesired behaviors without revisiting the past in the process (Spiegel et al., 2004). The here-and-now focus of this approach is predicted to help sexual abuse survivors make positive life changes without mastering an understanding of how present problems may be related to past trauma (Spiegel et al., 2004). If discussion by a group member during therapy deviates from the present focus to an in-depth description of past abuse experiences, the focus should be brought back to the present after the member has finished disclosing, with the clinician asking statements such as, "Can I bring you back to the room?" or "What was it about your feelings and thoughts today that caused you to feel safe enough to share your story?" (Spiegel et al., 2004). If current dysfunction is severe, present-focused therapy may be the most appropriate form of treatment and is commonly used among a variety of populations in group therapy settings (Spiegel et al., 2004). In a pilot study comparing the efficacy of trauma-focused group psychotherapy compared to present-focused group psychotherapy, Spiegel et al. (2004) assigned 55 female adult survivors of CSA to either one of these treatment groups or to a wait-list control group. At a twelve-month follow-up, results from measures taken involving trauma symptoms, interpersonal problems, and sexual experiences were compared to baseline results across the three groups. Possibly due to the small sample size, no significant differences were found concerning trauma symptoms, but the trauma-focused group did show a moderate effect size compared to that of present-focused and wait-list groups, suggesting that trauma-focused therapy may be effective in decreasing interpersonal problems in areas such as love, dominance, social inhibition, assertiveness,

120 and intrusiveness (Spiegel et al., 2004). Results also showed a small effect size in sexual experiences for the present-focused group compared with no effect size in the traumafocused and wait-list groups, suggesting that present-focused therapy may be effective in reducing sexual revictimization or unwanted sexual contact from others (Spiegel et al., 2004). Spiegel and colleagues are presently conducting more wide scale and in-depth research concerning the relationship trauma- and present-focused group psychotherapy has with the symptomology of CSA survivors. DISCUSSION AND NEED FOR FURTHER STUDY CSA is obviously an intensely destructive experience in not only the developmental years, but throughout adolescence and adulthood, as well. Severe psychological maladjustment is common and a general sense of poor self image is almost always coinciding. Many risk factors are involved in the propensity for sexual abuse to occur, and the short- and long-term effects are numerous. Sexualized behavior that is early in onset and dangerous in nature is likely to plague the abuse victim in his or her desperate search for love, acceptance, and safety throughout adolescence and into adulthood. An increased tendency toward substance and alcohol abuse is also a burden for survivors, in addition to propensity towards delinquency, antisocial behavior, and promiscuity. All of these consequences and many more hang like a heavy burden on the shoulders of CSA victims, yet many are not aware of the help that is available or are too ashamed to seek it. Existing prevention and treatment programs need to make themselves more readily available and prominent to the general public, and more funding should be made available through local, state, and national governments to improve and enforce these agencies. It is imperative that this national emergency be addressed, embraced, and

121 regulated. Due to the sensitivity and abhorrence of its nature, CSA is not spoken of or publicized enough in today's society. Support groups are not advertised as openly as other therapy groups due to the discomfort and stigma that is connected with sexual abuse. Information, options, and aid need to be easily accessible to children at all times, and these resources should begin within school systems. Children need to be taught what constitutes inappropriate touching and be told that unwanted contact is not their fault in any capacity. Children need to be informed and educated in ways to seek help and refuge from their abuser, and they should know that a school is a safe haven for them to feel comfortable and at ease in. This level of awareness must be initiated at a very young age, in one manner or another, and should be enforced and reinforced yearly. All programs designed for adult survivors of CSA must consistently focus on the psychological well-being of the members involved. Mental health professionals should be involved within these programs on a regular basis and a wide array of psychodynamic, cognitive, and behavioral therapies need to be integrated more effectively into existing treatments. Continued research into therapies such as cognitive-behavioral, traumafocused, and present-focused based models is essential, as well as research and pilot studies involving innovative and uncharted therapies never used before in treating sexual abuse. Efforts to promote and develop existential well-being, hardiness, and resilience should be universally implemented beginning at the time of disclosure of abuse and continued throughout adulthood. Throughout this research, a significant amount of unexpected information was discovered in relation to the severity and duration of the consequences of CSA. I was,

122 however, relieved to see the proverbial "light at the end of the tunnel" in that certain characteristics available and inherent to all human beings can be cultivated and assist in overcoming the profound effects of such tragic and devastating events in children's lives. Information is power in today's world, and further intensified research and quantitative study is imperative in the war against all types of child maltreatment, including, and specifically, CSA.

123 References Browne, A. & Finkelhor, D. (1986). Impact of childhood sexual abuse: A review of the research. Psychological Bulletin, 99 (1), 66-77. Cohen, J. & Mannarino, A. (1997). A treatment outcome study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry,36, 1228-1235. Cohen, J. & Mannarino, A. (1998). Interventions for sexually abused children: Initial treatment outcome findings. Journal of the American Academy of Child and Adolescent Psychiatry,3, 17-26. Cyr, M., Wright, J., McDuff, P., & Perron, A. (2002). Intrafamilial sexual abuse: Brothersister incest does not differ from father-daughter and stepfather-stepdaughter incest. Child Abuse & Neglect, 26, 957-973. Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment,1, 310-321. Egeland, B., Jacobvitz, D., & Stroufe, A. (1988). Breaking the cycle of abuse. Child Development, 59, 1080-1088. Ellison, C.W. (1983). Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology, 11 (4), 330-340. Feinauer, L., Hilton, G.H., & Callahan, E.H. (2003). Hardiness as a moderator of shame associated with childhood sexual abuse. The American Journal of Family Therapy, 31, 65-78.

124 Feinauer, L., Middleton, K.C., & Hilton, G.H. (2003). Existential well-being as a factor in the adjustment of adults sexually abused as children. The Scientific Journal of Family Therapy, 31, 201-213. Feiring, C., Taska, L., & Lewis, M. (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38 (1), 79-92. Finkelhor, D. & Berliner, L. (1995). Research on the treatment of sexually abused children: A review and recommendations. Journal of the American Academy of Child and Adolescent Psychiatry,34, 1408-1423. Finkelhor, D. & Dziuba-Leatherman, J. (1994). Children as victims of violence: a national survey. Pediatrics, 94, 413-420. Garcia, J., Adams J., Friedman, L., & East, P. (2002). Links between past abuse, suicide ideation, and sexual orientation among San Diego college students. Journal of American College Health, 51 (1), 9-14. Jones, L., Finkelhor, D., & Kopiec, K. (2001). Why is sexual abuse declining? A survey of state child protection administrators. Child Abuse & Neglect, 25, 1139-1158. King, N., Tonge, B., & Mullen, P. (2000). Treating sexually abused children with posttraumatic stress symptoms: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry,39, 1347-1355. Mash, E. & Wolfe, D. (2002). Abnormal Child Psychology (2nd ed.). Belmont: Wadsworth Group.

125 McLeer S., Dixon, J., & Henry, D. (1998). Psychopathology in non-clinically referred sexually abused children. Journal of the American Academy of Child and Adolescent Psychiatry,37, 1326-1333. Meyerson, L.A., Long, P.J., Miranda, R., & Marx, B.P. (2002). The influence of childhood sexual abuse, physical abuse, family environment, and gender on the psychological adjustment of adolescents. Child Abuse & Neglect, 26, 387-405. Noll, J.G., Trickett, P.K., & Putnam, F.W. (2000). Social network constellation and sexuality of sexually abused and comparison girls in childhood and adolescence. Child Maltreatment, 5 (4), 323-337. Putnam, F.W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (3), 269-278. Spiegel, D., Classen, C., Thurston, E., & Butler, L. (2004). In L. Koenig book (Eds.), Trauma-focused versus present-focused models of group therapy for women sexually abused in childhood (Vol.1). Washington, DC: American Psychological Association. Trickett, P.K., Noll, J.G., Reiffman, A, & Putnam, F.W. (2001). Variants of intrafamilial sexual abuse experience: Implications for short- and long-term development. Development and Psychopathology, 13, 1001-1019. US Department of Health and Human Services NCoCAaN (1996) Third National Incidence Study of Child Abuse and Neglect: Final Report (NIS-3). Washington, D.C.: US Government Printing Office.

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