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Treatment of victims of sex abuse is very difficult,
to say the least, difficult in the sense that we have to take the
patient very seriously. We have to be very caring, loving and supportive.
At the same time, we need to move into a realm of meticulous assessment
and scrutiny for the court system, should it be litigated. The majority
of cases, and all cases involving abuse victims under the age of
9-10, I videotape sessions of first assessment. The older the patient,
the less there is a need to videotape. Videotaping is key, because
now we have a visual record on first assessment of the individual’s
emotional reactions, degree of anxiety exhibited while performing
psych testing. This is extremely important when doing play therapy,
as well as drawings. Having anatomically correct dolls is extremely
important when assessing small children for sex abuse.
There are a variety of red flag indicators for child abuse. Examples
may include dropping school grades, nervous or acting out behavior,
sudden onset of drug or alcohol usage, withdrawal from current peer
relationships. It is important to note that any of the aforementioned
behaviors do not necessary point to sexual abuse, and may in fact
be pointing to other issues. Nonetheless, these are some that should
raise red flags in our heads. Other behavior indicators include
children who demonstrate an excessive desire to pleasure others,
feelings of guilt, verbal hints about sexual behaviors or activities,
sex play with toys, dolls, Barbies, stuffed animals, inability to
concentrate in school, anxiety, running away from home, sleep disturbances
are very common, insomnia, nightmares, regressive behavior is very
common, and possibly suicidal feelings, aggression and physical
acting out, low self-esteem, discomfort with intimacy and closeness,
as simple as hugs from immediate family members.
It is also important to note that for young children who have not
been abused, it is not uncommon for them to be very curious about
their bodies and the bodies of others, curious about other children
going to the bathroom, curiosity regarding the human anatomy, playing
doctor, “show me yours and I will show you mine” type
of behavior. There are degrees of normalcy in this behavior, and
parents should not discipline, scream or yell, but should educate
and teach their child appropriateness vs. non-appropriate behavior
with regard to their body and the bodies of others.
Physical indicators on the other hand may provide objective evidence
for sexual abuse. These indicators may include blood in the underwear,
swollen, red genitals, fissures in the anal area, vaginal tears,
rashes in the vaginal area, bruising on the inner thighs, outer
thighs, buttocks. These physical indicators should be looked at
with great suspicion.
After the initial assessment is made, as well as individual therapy,
group treatment for sexually abused children has been found to be
highly effective. There is an ability to identify with their peers,
that they are not alone in this, the other children have also encountered
similar trauma.
- It is imperative that these children know that they are safe.
They have to have the knowledge that they are safe down the road,
and that this is not going to recur. This is crucial to decrease
anxiety, and to help their psyche deal with this trauma. Nightmares
are extremely problematic, and there are appropriate times when
sleep aids may be beneficial, even for children. Over-the-counter
Benadryl may be helpful in the beginning states. Sleep disturbance
can only lead to more anxiety, and sleep deprivation is clearly
detrimental to their functioning and to the healing process.
- Children need to have an avenue to express their feelings of
anger or depression, and count on a safe environment in which
to exhibit these feelings. There are many creative ways a therapist
can facilitate this, depending on the age of the child. The therapist
can initiate and demonstrate expressions of his own anger, can
draw or paint by way of demonstration, can demonstrate expressive
techniques such as punching a pillow, role modeling to the child
that there is a totally safe environment available for the expression
of anger. This role modeling in the safety of the therapist’s
office can be very beneficial in allowing the child to express
his/her own feelings. Clay is extremely useful for demonstrating
emotions. When a child’s emotional expression seems to be
hampered, clay is a great medium to be used to allow children
to express themselves.
- Where age appropriate, the child should be educated and taught
about the law. They need to understand that sexual abuse is a
criminal offense, that it is against the law to be touched inappropriately.
This also helps them with guilt and trust.
It is important to note that we are dealing with a wholly innocent
population, children who have been violated, taken advantage of
for another’s self-gratification. We need to keep that at
the forefront of our minds. We need to be gentle, caring and supportive.
We need to create a safe environment in the therapist’s office,
as well as creating a safe environment in the child’s home.
Subsequently, at a certain stage in therapy, the mother needs to
be pulled in, and we need to teach her how to do this also.
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