Child Abuse

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Child Abuse. DistressesDisturbsConfronts us all. Physical Abuse. Any non accidental injury caused by the carerBeating, bitingStrangulationShaking

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Child Abuse

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1. Child Abuse Child Psychopathology and Clinical Assessment.

2. Child Abuse Distresses Disturbs Confronts us all Introduction You'll notice that the reference I provided speaks to sexual abuse. I will be talking about abuse in general today; however the bulk of my work has been in regards to sexual abuse and unless I point out otherwise, that's probably what I'm referring to as I speak. Now, child abuse is not the most pleasant of topics. Most people wonder how we can work in this field. Recently some colleagues and I presented papers at the 13th ISPCAN conference. Someone we met after the conference, who is not in the field asked me if I thought there was any hope for these children and I replied, without thinking which is something I'm glad of really, "Of course I do. There's no way I could work in this field if I didn't." It's important to focus on what we can do rather than the terrible things that have happened. It's very easy to become angry at the perpetrators, or to feel great sadness for the children who have been hurt. The stories we hear on a daily basis are not pleasant. I'm not going to treat you to any gore today, but still some of it may be unpleasant to hear and may leave you with a sense of discomfort. I can only ask you to look after yourselves, to day dream if it's more entertaining, to do something pleasant later and if it helps, to look for the positive in what I have to say. And if any of this sounds like denial or avoidance to anyone, remember, all defences have a purpose! Also, when I do use case examples I have changed or omitted any identifying details to maintain confidentiality. I trust that you will let me know if you think you recognize any of the cases that I might mention. You should also know that if I do use any example I have previously cleared it with the client or their parent. Introduction You'll notice that the reference I provided speaks to sexual abuse. I will be talking about abuse in general today; however the bulk of my work has been in regards to sexual abuse and unless I point out otherwise, that's probably what I'm referring to as I speak. Now, child abuse is not the most pleasant of topics. Most people wonder how we can work in this field. Recently some colleagues and I presented papers at the 13th ISPCAN conference. Someone we met after the conference, who is not in the field asked me if I thought there was any hope for these children and I replied, without thinking which is something I'm glad of really, "Of course I do. There's no way I could work in this field if I didn't." It's important to focus on what we can do rather than the terrible things that have happened. It's very easy to become angry at the perpetrators, or to feel great sadness for the children who have been hurt. The stories we hear on a daily basis are not pleasant. I'm not going to treat you to any gore today, but still some of it may be unpleasant to hear and may leave you with a sense of discomfort. I can only ask you to look after yourselves, to day dream if it's more entertaining, to do something pleasant later and if it helps, to look for the positive in what I have to say. And if any of this sounds like denial or avoidance to anyone, remember, all defences have a purpose! Also, when I do use case examples I have changed or omitted any identifying details to maintain confidentiality. I trust that you will let me know if you think you recognize any of the cases that I might mention. You should also know that if I do use any example I have previously cleared it with the client or their parent.

3. Physical Abuse Any non accidental injury caused by the carer Beating, biting Strangulation ShakingÖÖ. Iím going to start with some definitions so we all know what Iím talking about. We see a lot of children, from infants up who have serious and long term brain damage from shaking injuries. A number have die from such injuries. Some physical injuries are more obvious as indicators of abuse than others. For example, handprint marks or welts in the shape of a spoon, a stick, fingertip bruising and patterns of cigarette burns. Fractures and dilocations in children under two years of age. .Bruises to the back of the legs, the genitalia, the torso are danger signs. Of course a childís behaviour: withdrawn, overly aggressive, hiding bruises, can also be an indication of abuse.Iím going to start with some definitions so we all know what Iím talking about. We see a lot of children, from infants up who have serious and long term brain damage from shaking injuries. A number have die from such injuries. Some physical injuries are more obvious as indicators of abuse than others. For example, handprint marks or welts in the shape of a spoon, a stick, fingertip bruising and patterns of cigarette burns. Fractures and dilocations in children under two years of age. .Bruises to the back of the legs, the genitalia, the torso are danger signs. Of course a childís behaviour: withdrawn, overly aggressive, hiding bruises, can also be an indication of abuse.

4. Emotional Abuse This includes passive forms of abuse such as: Ignoring or rejecting the child Witholding affection or praise This is perhaps one of the most insidious forma of abuse and also often the most difficult areas, along with neglect in general to prove with Prtoective Applications in court and . This sort of abuse is obviously a part of physical and sexual abuse. I use the term insidious to stress how such abuse seeps into a childís sense of who they are, their sense of worth, their sense of importance or lack thereof. It can terrorize them, leave them feeling isolated and helpless (much like other forms of abuse) and whatís worse it often goes on right under the sight of others and nothing is done about it. This is perhaps one of the most insidious forma of abuse and also often the most difficult areas, along with neglect in general to prove with Prtoective Applications in court and . This sort of abuse is obviously a part of physical and sexual abuse. I use the term insidious to stress how such abuse seeps into a childís sense of who they are, their sense of worth, their sense of importance or lack thereof. It can terrorize them, leave them feeling isolated and helpless (much like other forms of abuse) and whatís worse it often goes on right under the sight of others and nothing is done about it.

5. Emotional Abuse More active forms of emotional abuse include: Constant yelling Threatening Terrorising Belittling or verbally rejecting the child

6. Neglect Failure to provide for the needs of: love and security opportunities for development new experiences praise & recognition food, housing, clothing,medical care & education

7. Non-organic Failure to Thrive Failure to meet the need for adequate nutrition and emotional stimulation decline from established pattern of growth weight below 3rd percentile psychomotor delays history suggestive of emotional/nutritional deprivation

8. Factitious Disorder (Munchausen) by Proxy The deliberate feigning of physical or psychological signs or symptoms in another person under the personís care. Victim typically the child, perpetrator typically the mother.

9. Factitious Disorder (Munchausen) by Proxy Psychological need to assume the sick role by proxy No apparent external gains (eg. financial) No other mental disorder accounts for behaviour.

10. Sexual Abuse The involvement of dependant, developmentally immature children and adolescents in sexual activities: that they do not fully comprehend to which they are incapable of giving consent or that violates boundary taboos We often have interesting dilemmas with young women who have been in sexual relationships with men much older than them.Telling them itís against the law is not exactly helpful. Sitting with their grief and anger over a lost relationship and then helping them through the realization of why would a man in his late twenties want to be spending time with a 15 year old? Is much of the work Indicators of abuse can be anything from a clear disclosure, to sexualized behaviour, to withdrawal, and the sort or symptoms you might see with depression or anxiety/PTSD. Sometimes disclosures are vague: ďUncle does funny things:. ďYes sweetie Iím glad he makes you laugh.Ē Often they are retracted. Children see the distress the disclosure causes, the police come in the Dept comes in, everything gets turned upside down and they try to stop it by saying it never happened after all. Lenore Terr has done some research on ďfalse allegations.. Most disclosures are based on actual abuse and in most cases where they have been false the child has had some form of abusive experience. Itís highly unusual for children to make this sort of stuff up and persist with it and the circus that often follows disclosure unless it has occurred or there is something else seriously wrong.We often have interesting dilemmas with young women who have been in sexual relationships with men much older than them.Telling them itís against the law is not exactly helpful. Sitting with their grief and anger over a lost relationship and then helping them through the realization of why would a man in his late twenties want to be spending time with a 15 year old? Is much of the work Indicators of abuse can be anything from a clear disclosure, to sexualized behaviour, to withdrawal, and the sort or symptoms you might see with depression or anxiety/PTSD. Sometimes disclosures are vague: ďUncle does funny things:. ďYes sweetie Iím glad he makes you laugh.Ē Often they are retracted. Children see the distress the disclosure causes, the police come in the Dept comes in, everything gets turned upside down and they try to stop it by saying it never happened after all. Lenore Terr has done some research on ďfalse allegations.. Most disclosures are based on actual abuse and in most cases where they have been false the child has had some form of abusive experience. Itís highly unusual for children to make this sort of stuff up and persist with it and the circus that often follows disclosure unless it has occurred or there is something else seriously wrong.

11. Sexual Abuse Sexual abuse includes all forms of: Intercourse Masturbation Fondling Exhibitionism Exposure of a child to pornography Unfortunately in our experience this form of abuse can and does start in early infance and certainly with toddlers. Most sexual abuse tends to start between ages 4-12, with the most common agees being 4 and 9 9 in 10 cases the abuser is known, 1 in 10 it is the father. 5% of girls and 20% of boys are abused by females.. These sorts of stats are based on existing research, most of which has focussed on father-daughter incest. They generally reflect details of substantiated disclosures. They do not consider the dynamics that confound investigations or prevent children from disclosing There is no direct causal link between childhood abuse and adult psychopathology, but such experiences present a significant risk factor for later life difficulties. The frequency of abuse in clinical samples has been found to be 50%, versus 30% in the general population.. Most research on the impact of childhood abuse has been retrospective and relied on self report. Its findings are effected by what is asked, how it is asked, who is asked about it and when it is askedUnfortunately in our experience this form of abuse can and does start in early infance and certainly with toddlers. Most sexual abuse tends to start between ages 4-12, with the most common agees being 4 and 9 9 in 10 cases the abuser is known, 1 in 10 it is the father. 5% of girls and 20% of boys are abused by females.. These sorts of stats are based on existing research, most of which has focussed on father-daughter incest. They generally reflect details of substantiated disclosures. They do not consider the dynamics that confound investigations or prevent children from disclosing There is no direct causal link between childhood abuse and adult psychopathology, but such experiences present a significant risk factor for later life difficulties. The frequency of abuse in clinical samples has been found to be 50%, versus 30% in the general population.. Most research on the impact of childhood abuse has been retrospective and relied on self report. Its findings are effected by what is asked, how it is asked, who is asked about it and when it is asked

12. Secondary Abuse This is the additional abuse by other people with whom the child comes into contact. Othersí reactions to the abuse The ignorance and confusion of professionals working with the child Children can feel abandoned by their parents who become overwhelmed by disclosures. This can be particularly so when the parents have their own history of abuse and certainly our experience and otherís research suggests that this is not an unusual situation. For example, I have worked with a few adolescent girls whose mothers were unable to even be in the room with them during their medical examinations..These mothers had their own history of abuse.Children can feel abandoned by their parents who become overwhelmed by disclosures. This can be particularly so when the parents have their own history of abuse and certainly our experience and otherís research suggests that this is not an unusual situation. For example, I have worked with a few adolescent girls whose mothers were unable to even be in the room with them during their medical examinations..These mothers had their own history of abuse.

13. Indicators Physical Abuse - Childís Behaviour states injury caused by someone is wary of physical contact seems frightened of parent/caregiver expresses little/no emotion when threatened or hurt offers unlikely explanation of injury

14. Indicators Physical Abuse - Childís Behaviour habitual absences from school cringes at sudden movements overly compliant, shy, withdrawn, passive uncommunicative nervous, hyperactive, aggressive, disruptive regressive behaviour

15. Indicators Physical Abuse - Parentsí Behaviour offers illogical/no account of the injury appears unconcerned about childís condition delays seeking medical attention attempts to conceal the injury takes child to several physicians/hospitals refuses to attend school/health centre appointments

16. Indicators Sexual Abuse - Childís Behaviour makes disclosure sexualized behaviour/inappropriate activity has detailed/sophisticated knowledge of sex excessively fearful when nappy changed or bathed fearful of a particular adult

17. Indicators Sexual Abuse - Childís Behaviour poor/deteriorating peer relationships first to arrive, last to leave at school reluctant to participate in physical activities regressive behaviour - eg bedwetting, speech loss overly protective of younger siblings

18. Indicators Sexual Abuse - Childís Behaviour loss of appetite sudden accumulation of gifts/money runs away delinquent/aggressive behaviour self injurious behaivour, eg. self harming, drug & alcohol abuse, prostitution, suicide attempts

19. Indicators Emotional Abuse - Physical signs speech disorders delays in physical development failure to gain weight/height in infants small head circumference for age dry, sparse hair, bald patches severe nappy rash cold pink/purple hands &/or feet pot belly and loose stools

20. Indicators Emotional Abuse - Childís Behaviour overly compliant, passive and undemanding extremely demanding and aggressive anti-social, destructive behaviour low tolerance of frustration poor self-image unexplained mood swings

21. Indicators Emotional Abuse - Childís Behaviour parentified behaviour inappropriately infantile depressed, suicidal behaviour neurotic traits, eg. phobias, compulsion

22. Indicators Neglect - Childís behaviour begging for/stealing food gorging food when available inability to eat when hungry withdrawn, pale, thin, isolated engages in delinquent acts little positive interaction with the caregiver

23. Indicators Neglect - Childís behaviour appears miserable, irritated poor social skills poor evidence of bonding little anxiety about strangers indiscriminate with affection poor/irregular school attendance

24. History Taking Things to consider regarding parents intergenerational history of abuse poor self image poor impulse control/coping skills weak/non-existant boundaries external/chance events

25. History Taking Things to consider regarding parents lack of understanding about childrenís needs unrealistic expectations negative view of children firm beliefs in the value of punishment isolation/lack of supports

26. History Taking Things to consider regarding children pre-natal history that impacts on attachment ante natal problems - sleeping, feeding, settling, etc. child never met parentsí expectations

27. History Taking Things to consider regarding children difficulty with stages of development delays, temperament problems, etc. significant differences in child

28. Dynamics of Abuse Emotional Impact Skewed sense of normality/world view Self-blame/guilt Little trust in self/own feelings/others Denial of emotions/feelings Secrecy Boundaries blurred/shattered So letís look a bit more at the impact of abuse. Just note that this list is not necessarily and exhaustive one. At an emotional/psychological level experiences of abuse can play all sots of havoc for a person.First of all, the secrecy that surrounds abuse can create a psychological reality for children thatís pretty tenuous, scarey even. Part of their world is kept hidden from others, they are unable to share that - perhaps because they have been threatened of what will happen to them if they do. Perhaps because they know that what is happening is wrong and they know what happens when you do something wrong. Just being told to keep it a secret is enough to perhaps imply that itís wrong. Perhaps because they want to protect their parents, or even the perpetrator, or because theyíve tried to tell and no-oneís listened (or understood) and so why tell anyone else? Other effects involve the blurring of boundaries, whatís approprieate, where do I begin and end. Often a child can lose all sense of themselves as a person in her own right with her own valid feelings and needs. Rather she becomes an object of someone elseís gratification. And if her feelings are denied often enough, if she hears over and over how much she likes it, wants it, caused it, how can she learn to trust her own feelings, listen to her own feelings? Itís not a nice frame from which to view your world. So letís look a bit more at the impact of abuse. Just note that this list is not necessarily and exhaustive one. At an emotional/psychological level experiences of abuse can play all sots of havoc for a person.First of all, the secrecy that surrounds abuse can create a psychological reality for children thatís pretty tenuous, scarey even. Part of their world is kept hidden from others, they are unable to share that - perhaps because they have been threatened of what will happen to them if they do. Perhaps because they know that what is happening is wrong and they know what happens when you do something wrong. Just being told to keep it a secret is enough to perhaps imply that itís wrong. Perhaps because they want to protect their parents, or even the perpetrator, or because theyíve tried to tell and no-oneís listened (or understood) and so why tell anyone else? Other effects involve the blurring of boundaries, whatís approprieate, where do I begin and end. Often a child can lose all sense of themselves as a person in her own right with her own valid feelings and needs. Rather she becomes an object of someone elseís gratification. And if her feelings are denied often enough, if she hears over and over how much she likes it, wants it, caused it, how can she learn to trust her own feelings, listen to her own feelings? Itís not a nice frame from which to view your world.

29. Dynamics of Abuse Behavioural Impact Internalized behaviours low self esteem fears/anxiety/obsessiveness depression/withdrawal self abuse/mutilation suicidality Sometimes the impact is seen in behaviural symptoms. The research tells us that girls are more likely to display internalizing behaviours and boys display more externalizing behaviours.Sometimes the impact is seen in behaviural symptoms. The research tells us that girls are more likely to display internalizing behaviours and boys display more externalizing behaviours.

30. Dynamics of Abuse Behavioural Impact Externalized behaviours promiscuity aggression, acting out/risk taking sexualized behaviour offending behaviour poor concentration And as is often the case the children with externalizing behaviours often are the ones who end up in our rooms. They are the ones - aside from self mutilation and suicidality - that tend to grab peopleís attention. Often children are worried about developing these behaviours. Theyíve read something or heard about how if youíre abused youíll become an abuser. Yes itís a possibility, but itís a possibility without such a history and itís certainly not a certaintly. One adolescent boy with whom I woked was terrified that he was going to jump any girl he saw whom he found attractive, essentially because that was part of the manipulative line that the woman who abused him used. Other young people are fearful of becoming gay. Thereís no causal link that Iím aware of between abusive experiences and sexual preference. For that matter, many offenders target both boys and girls and may still carry on sexual relationships with adults. Promiscuity is often about seeing yourself as having no other role, but as a sexual object, or about having a level of control in a sexual relationship that was absent during the abuse. Offending behaviours can also reflect this need to identify with the aggressor and have control. Sexualized behaviurs are more than just ďyou show me yours, Iíll show you mineĒdoctors games between kids. Itís when children display behaviours that you would not reasonably expect them to know about, like oral sex or mutual masturbation. Sometimes itís a way children use to cope with anxiety or the way theyíve learnt to relate with others.And I mention poor concentration because itís often mistaken for bad behaviour, (and it can be pretty annoying) or ADD and in fact itís a childís hypervigilance. They are too busy looking out for threat and danger in their world to be a ble to concentrate on anything for more than a few minutes. And as is often the case the children with externalizing behaviours often are the ones who end up in our rooms. They are the ones - aside from self mutilation and suicidality - that tend to grab peopleís attention. Often children are worried about developing these behaviours. Theyíve read something or heard about how if youíre abused youíll become an abuser. Yes itís a possibility, but itís a possibility without such a history and itís certainly not a certaintly. One adolescent boy with whom I woked was terrified that he was going to jump any girl he saw whom he found attractive, essentially because that was part of the manipulative line that the woman who abused him used. Other young people are fearful of becoming gay. Thereís no causal link that Iím aware of between abusive experiences and sexual preference. For that matter, many offenders target both boys and girls and may still carry on sexual relationships with adults. Promiscuity is often about seeing yourself as having no other role, but as a sexual object, or about having a level of control in a sexual relationship that was absent during the abuse. Offending behaviours can also reflect this need to identify with the aggressor and have control. Sexualized behaviurs are more than just ďyou show me yours, Iíll show you mineĒdoctors games between kids. Itís when children display behaviours that you would not reasonably expect them to know about, like oral sex or mutual masturbation. Sometimes itís a way children use to cope with anxiety or the way theyíve learnt to relate with others.And I mention poor concentration because itís often mistaken for bad behaviour, (and it can be pretty annoying) or ADD and in fact itís a childís hypervigilance. They are too busy looking out for threat and danger in their world to be a ble to concentrate on anything for more than a few minutes.

31. Dynamics of Abuse Developmental Impact Attachment patterns/relationship templates Identity Ė sense of self, ďdifferentnessĒ Learning Ė opportunity & capacity to focus on learning Knowledge/experience of sexuality Abuse in all itís varieties also has an over-riding impact on a childís development. In terms of attachment, children who have been abused often display what Main and Solomon have labelled ďdisorganizedĒ attachment. These are kids who have no consistent pattern of response in relating with others. Their experience of care has probably been quite inconsistent as well. Perhaps theyíve had a parent whoís at least able to provide the basics of care for a few hours in the day, but once the alcohol haze has kicked in or after thereís been a highly physical screaming match between mun and dad or nice, attentive older brother has forced them into engaging in some sexual act, the reasonable stuff can get lost and leave a child quite confused. What they learn about relationships becomes very skewed. Perry and his colleagues also report the actual physiological changes that can occur in infanats brains when they have been exposed to chronic abuse and neglect. Cortisol levels tend to increase making a child more sensitive to threatening stimuli. They develop neural pathways that highlight this sensitivitiy and so they work at avoiding them.This in turn effects the patterns of relationships that they then form - who they trust (if anyone) how much of themselves they will share, how controlling they can be, their ability to relax at any timeÖÖ. Bessel van der kolk has done some research into abuse victimís inability to self regulate - to self soothe and relax. These things are very difficult to do if you canít identify or trust your own feelings. Such high levels of hyperarounsal and poort self regulation can also have long term effects on the immune system. Weíve covered identity somewhat already, but from a developmental perspective children who have been abused often miss out on opporytunities to develop a sense of themselves as competent or safe. These are critical elements in anyoneís development. Again, van der kolk suggests that without an experience of safety and competence in their history, children who have been abused are in major trouble. Inability to benefit from school because of poor concetration, anxiety etc. or obsessive perfectionaistic high achievers. Sexual knowledge out of sync with age - how they make sense of that, how it makes them different from peers, how it effects them when they engage in sexual relationships. Abuse in all itís varieties also has an over-riding impact on a childís development. In terms of attachment, children who have been abused often display what Main and Solomon have labelled ďdisorganizedĒ attachment. These are kids who have no consistent pattern of response in relating with others. Their experience of care has probably been quite inconsistent as well. Perhaps theyíve had a parent whoís at least able to provide the basics of care for a few hours in the day, but once the alcohol haze has kicked in or after thereís been a highly physical screaming match between mun and dad or nice, attentive older brother has forced them into engaging in some sexual act, the reasonable stuff can get lost and leave a child quite confused. What they learn about relationships becomes very skewed. Perry and his colleagues also report the actual physiological changes that can occur in infanats brains when they have been exposed to chronic abuse and neglect. Cortisol levels tend to increase making a child more sensitive to threatening stimuli. They develop neural pathways that highlight this sensitivitiy and so they work at avoiding them.This in turn effects the patterns of relationships that they then form - who they trust (if anyone) how much of themselves they will share, how controlling they can be, their ability to relax at any timeÖÖ. Bessel van der kolk has done some research into abuse victimís inability to self regulate - to self soothe and relax. These things are very difficult to do if you canít identify or trust your own feelings. Such high levels of hyperarounsal and poort self regulation can also have long term effects on the immune system. Weíve covered identity somewhat already, but from a developmental perspective children who have been abused often miss out on opporytunities to develop a sense of themselves as competent or safe. These are critical elements in anyoneís development. Again, van der kolk suggests that without an experience of safety and competence in their history, children who have been abused are in major trouble. Inability to benefit from school because of poor concetration, anxiety etc. or obsessive perfectionaistic high achievers. Sexual knowledge out of sync with age - how they make sense of that, how it makes them different from peers, how it effects them when they engage in sexual relationships.

32. Dynamics of Abuse Impact on Family Functioning grief/shock/anger rejection/blame/disbelief overprotection confusion life consumed by the events/revenge questioning ability to parent Then of course thereís the impact on the family and the secondary trauma that can sometimes visit on the child. In cases of physical abuse and neglect or inra-familial abuse there can be anger at the perpetrators, anger at the child, anger at the authorities. In cases of sexual abuse thereís the shock that something like that could have happened to a child, the grief, the disbelief. People blame themselves and others left right and centre. Some parents become over protective, anxious not to let their child be hurt again. Others become overindulgent, trying to make up for what has happened. Some families become consumed by their feelings, or by a need to exact revenge. Some parents worry that their child will turn out to be an abuser, or gay or psychotic, or that they are just damaged goods. These are all beliefs that impact negatively on the childís sense of self and on her path of resolution. (eg. Maria) For some parents their ability to parent is questioned. This is especially the case where sibling abuse has occurred.Then of course thereís the impact on the family and the secondary trauma that can sometimes visit on the child. In cases of physical abuse and neglect or inra-familial abuse there can be anger at the perpetrators, anger at the child, anger at the authorities. In cases of sexual abuse thereís the shock that something like that could have happened to a child, the grief, the disbelief. People blame themselves and others left right and centre. Some parents become over protective, anxious not to let their child be hurt again. Others become overindulgent, trying to make up for what has happened. Some families become consumed by their feelings, or by a need to exact revenge. Some parents worry that their child will turn out to be an abuser, or gay or psychotic, or that they are just damaged goods. These are all beliefs that impact negatively on the childís sense of self and on her path of resolution. (eg. Maria) For some parents their ability to parent is questioned. This is especially the case where sibling abuse has occurred.

33. Dynamics of Abuse Long Term Effects identity - living a life for others relationship difficulties repeated patterns mental health problems There has been lotís of research into the long term effects of abuse. Clearly one effect I have stressed is that on a personís identity. Children who have been abused could be described as developing an identity where they live their life for others. Their needs are subjugated, their importance is irrelevant. They donít expect to be listened to, complimented, valued and experiences like that can be really hard for them to handle and they will reject them. Iíve mentioned relationship difficulties in terms of patterns of attachment and capacity to trust and share. The ability to be intimate can be a major challenge for people who have been sexually abused. Some people find themselves in repeatedly abusive relationships. One woman I have seen in my private practice had relationships with a number of men who were at best distant, at worst flat out abusive. She hadnít seen me for some time but returned to therapy to tell me that she had met a wonderful, caring, committed man and she couldnít cope. She was desperately trying to fin something to hate about him, a way to push him away. She came in one day and said ďitís me, isnít it? I donít know how to let myself deserve something good.Ē Some people as Iívementioned develop repeated patterns by becoming offenders. And of course there are the myriad of mental health problems experienced by people who have been abused.There has been lotís of research into the long term effects of abuse. Clearly one effect I have stressed is that on a personís identity. Children who have been abused could be described as developing an identity where they live their life for others. Their needs are subjugated, their importance is irrelevant. They donít expect to be listened to, complimented, valued and experiences like that can be really hard for them to handle and they will reject them. Iíve mentioned relationship difficulties in terms of patterns of attachment and capacity to trust and share. The ability to be intimate can be a major challenge for people who have been sexually abused. Some people find themselves in repeatedly abusive relationships. One woman I have seen in my private practice had relationships with a number of men who were at best distant, at worst flat out abusive. She hadnít seen me for some time but returned to therapy to tell me that she had met a wonderful, caring, committed man and she couldnít cope. She was desperately trying to fin something to hate about him, a way to push him away. She came in one day and said ďitís me, isnít it? I donít know how to let myself deserve something good.Ē Some people as Iívementioned develop repeated patterns by becoming offenders. And of course there are the myriad of mental health problems experienced by people who have been abused.

34. Dynamics of Abuse Factors that contribute to the impact: Developmental stage Chronicity Severity Level of threat/danger Of course the impact of any abusive experience is mediated by a number of factors, as with any traumatic event, and it doesnít always have to be bad. Younger children are likely to be at greater risk of experiencing profound effects on their central nervous system and cognitive functions because these are developing at such a significant rate in the early years. The more chronic the abuse, the greater the impact. The more severe/extensive the abuse, the greater the impact. This is obvious in cases of physical abuse. Obviously where the child feels more threat or danger, the impact will be greater.Van der kolk and Terr have noted that perceived loss of control during a traumatic event, a sense of being immobilized or panicked does not bode well for a child.Of course the impact of any abusive experience is mediated by a number of factors, as with any traumatic event, and it doesnít always have to be bad. Younger children are likely to be at greater risk of experiencing profound effects on their central nervous system and cognitive functions because these are developing at such a significant rate in the early years. The more chronic the abuse, the greater the impact. The more severe/extensive the abuse, the greater the impact. This is obvious in cases of physical abuse. Obviously where the child feels more threat or danger, the impact will be greater.Van der kolk and Terr have noted that perceived loss of control during a traumatic event, a sense of being immobilized or panicked does not bode well for a child.

35. Dynamics of Abuse Factors that contribute to the impact: Specifics of the abuse Relationship to perpetrator Emotional health of the family Emotional health of the child In cases of sexual abuse the actual specifics of the abuse are important. Cases of penetration tend to have a greater impact than fondling for example. The closer the relationship to the perpetrator the more complicated the reaction can be. Itís easier for a family to unite against the perpetrator of a one off incident of abuse who is a stranger and for the child to place responsibility for the abuse on this ďmean personĒ than it is to take sides against a father or a favourite teacher. A family with good emotional health is also a buffering factor for a child. Perhaps because this child has been helped to develop healthy coping and relating mechanisms, but also the family is better placed to support the child. A lot of research suggest in regards to disclosures of sexual abuse, that the belief of a significant adult (most of the research has been on mothers) is critical to a childís healthy recovery. (Amanda) And of course the childís own mental health is important. Children who have experienced previous abuse, have existing diffiuclties are at greater risk of difficulties.In cases of sexual abuse the actual specifics of the abuse are important. Cases of penetration tend to have a greater impact than fondling for example. The closer the relationship to the perpetrator the more complicated the reaction can be. Itís easier for a family to unite against the perpetrator of a one off incident of abuse who is a stranger and for the child to place responsibility for the abuse on this ďmean personĒ than it is to take sides against a father or a favourite teacher. A family with good emotional health is also a buffering factor for a child. Perhaps because this child has been helped to develop healthy coping and relating mechanisms, but also the family is better placed to support the child. A lot of research suggest in regards to disclosures of sexual abuse, that the belief of a significant adult (most of the research has been on mothers) is critical to a childís healthy recovery. (Amanda) And of course the childís own mental health is important. Children who have experienced previous abuse, have existing diffiuclties are at greater risk of difficulties.

36. Dynamics of Abuse Resilience the childís personality the childís ability and opportunity to access support And then thereís resilience. Iím not sure we know exactly what this is or how it works, but it just seems that some children are more resilient than others. They have a stronger personality, perhaps itís about less neuroticism or lower levels of trait anxiety. Maybe itís about their ability to seek out and their opportunity to access supportive relationships, and ellicit positive regard Of course, I must point out, that if children can do this, itís a bonus. I donít believe that itís actually their responsibility to make their world safe and nurturing.And then thereís resilience. Iím not sure we know exactly what this is or how it works, but it just seems that some children are more resilient than others. They have a stronger personality, perhaps itís about less neuroticism or lower levels of trait anxiety. Maybe itís about their ability to seek out and their opportunity to access supportive relationships, and ellicit positive regard Of course, I must point out, that if children can do this, itís a bonus. I donít believe that itís actually their responsibility to make their world safe and nurturing.

37. Traumagenic States Finklehor & Browne (1980), James (1989) 4 states, expanded to 9 useful in treatment and planning Traumatic Sexualization Powerlessness Loss & Betrayal Stigmatization Now, Iím not going to say much about these. Itís just another way of describing much of what Iíve just been through. Finklehor and Browne in 1986, came up with these 4 ways in which sexual abuse impacts on and distorts a childís congitive and emotional orientation to the world. Traumatic sexualization refers to sexuality becoming the focus of a childís identity and the conditioning of negative emotions and memories with sexual activity. Ppowerlessness is about that sense of themselves as completely ineffectual, unable to stop the abuse or to make adults hear and believe. It is also about the invasion of their body and personal space.. Iíve not said much about loss and betrayal. The loss of trust, of a sense of safety. Betrayal by someone who should have care for and protected you. Sometimes that sense of betrayal is aimed at the non-offending parent. Children will frequently believe that their parents knew what was going on. Or they will have tried to tell them and the message didnít get across. They can feel quite betrayed as they perceive that they have been ignored/let down. Stigmatization is that identity stuff - damaged goods, a dirty girlÖ. Itís about self blame and blame by othersNow, Iím not going to say much about these. Itís just another way of describing much of what Iíve just been through. Finklehor and Browne in 1986, came up with these 4 ways in which sexual abuse impacts on and distorts a childís congitive and emotional orientation to the world. Traumatic sexualization refers to sexuality becoming the focus of a childís identity and the conditioning of negative emotions and memories with sexual activity. Ppowerlessness is about that sense of themselves as completely ineffectual, unable to stop the abuse or to make adults hear and believe. It is also about the invasion of their body and personal space.. Iíve not said much about loss and betrayal. The loss of trust, of a sense of safety. Betrayal by someone who should have care for and protected you. Sometimes that sense of betrayal is aimed at the non-offending parent. Children will frequently believe that their parents knew what was going on. Or they will have tried to tell them and the message didnít get across. They can feel quite betrayed as they perceive that they have been ignored/let down. Stigmatization is that identity stuff - damaged goods, a dirty girlÖ. Itís about self blame and blame by others

38. Traumagenic States Fragmentation of Bodily Experience Eroticization Destructiveness Self Blames Dissociative Disorder Attachment Disorder James, in 1989 expanded this model and argued its applicability to all sorts of childhood trauma. Fragmenentation of Bodily Experience refers to the tendency for traumatic memories to have been encoded through sensory and muscular memory as well as affective.Often these memories are not associated with a verbal script (van der kolk has done a lot of work in this area) or are not associated with a clear meaning. So when a particular touch or smell or sound triggers a distressing reaction the child doesnít understand why. Itís like thereís a dissociation between the body memory and the meaning. Itís worth noting in regards to this that rersearch shows that verbal functions in the brain tend to shut down during traumatic incidents because the focus is on the flight/fight system. Erotiicization is much like traumatic sexualization, but James adds that children may have had their early developmental needs met through sexual activity and in fact find somatic and psychic pleasure in the behaviour. Destructivenes refers to the child who engages in behaviours that push other people away or that result in them being disliked or punished. This may be their way of punishing themselves or of keeping themselves safe from potential abusers. Weíve already talked about self blame a bit and Dissociative and Attachment Disorder speak for theselves - or could take up a whole 1 1/2 lecture each. James, in 1989 expanded this model and argued its applicability to all sorts of childhood trauma. Fragmenentation of Bodily Experience refers to the tendency for traumatic memories to have been encoded through sensory and muscular memory as well as affective.Often these memories are not associated with a verbal script (van der kolk has done a lot of work in this area) or are not associated with a clear meaning. So when a particular touch or smell or sound triggers a distressing reaction the child doesnít understand why. Itís like thereís a dissociation between the body memory and the meaning. Itís worth noting in regards to this that rersearch shows that verbal functions in the brain tend to shut down during traumatic incidents because the focus is on the flight/fight system. Erotiicization is much like traumatic sexualization, but James adds that children may have had their early developmental needs met through sexual activity and in fact find somatic and psychic pleasure in the behaviour. Destructivenes refers to the child who engages in behaviours that push other people away or that result in them being disliked or punished. This may be their way of punishing themselves or of keeping themselves safe from potential abusers. Weíve already talked about self blame a bit and Dissociative and Attachment Disorder speak for theselves - or could take up a whole 1 1/2 lecture each.

39. Reporting Child Abuse Impediments to reporting Minimization Denial/resistance Inaction There are many factors that can impede people from reporting child abuse. Sometimes we might minimize concerns in order to protect ourselves from the consequences. It also allows us to maintain a belief that all parents love their children and could never hurt them or that there is some positive way we can reframe/explain what has happened. There is a resistance in all of us to explore and expose the possibility of child abuse. We canít be sure of what the outcome will be, how it will effect our role with the family, what our ongoing role in any possible investigation will be. We sometimes canít even be sure of what exactly is happening. And of course none of us want to discover child abuse, especially in families with whom we have established a good relationship. So we may not act and we rationalize our inaction if not by arguing that we donít know itís happening or that it will ruin our therapeutic relationship, then by saying it wonít help or someone else should do it.There are many factors that can impede people from reporting child abuse. Sometimes we might minimize concerns in order to protect ourselves from the consequences. It also allows us to maintain a belief that all parents love their children and could never hurt them or that there is some positive way we can reframe/explain what has happened. There is a resistance in all of us to explore and expose the possibility of child abuse. We canít be sure of what the outcome will be, how it will effect our role with the family, what our ongoing role in any possible investigation will be. We sometimes canít even be sure of what exactly is happening. And of course none of us want to discover child abuse, especially in families with whom we have established a good relationship. So we may not act and we rationalize our inaction if not by arguing that we donít know itís happening or that it will ruin our therapeutic relationship, then by saying it wonít help or someone else should do it.

40. Mandatory Reporting Child & Young Persons (Further Amendment) Act 1993 A mandated professional must notify the Department of Human Services if: In the course of carrying out the duties of his or her profession or carrying out the duties of his or her office, position or employment

41. Mandatory Reporting A mandated professional must notify the Department of Human Services if: S/he forms the belief on reasonable grounds that a child (a person under the age of 17) is in need of protection from sexual abuse or physical injury which results from abuse or neglect.

42. Mandatory Reporting Reasonable Grounds are: matters of which a person has become aware and any opinions based on those matters The notifier does not have to prove that the abuse actually occurred in order to report. The legislation requires reporting of suspected child abuse.

43. Mandatory Reporting Professional Groups mandated to report include: Medical practitioners, nurses, police (since November, 1993) Teachers (since July 1994) The penalty for not reporting is a $1000 fine. So as psychologists we are not mandated to report child abuse. However our code of ethics would not have us knowingly allow a client to remain at harm of hurt. Itís like saying ďIím not going to do something about my clientís expressed suicidal intentions because if she wants to kill herself I canít do anything to stop her.Ē Ultimately a decision not to report may place a child at serious, possibly life threatening risk. The main aim of protective servicesí investigations is to follow up with the family to make sure the child is safe and try to assist the family to resolve the problems that place the child at risk. So as psychologists we are not mandated to report child abuse. However our code of ethics would not have us knowingly allow a client to remain at harm of hurt. Itís like saying ďIím not going to do something about my clientís expressed suicidal intentions because if she wants to kill herself I canít do anything to stop her.Ē Ultimately a decision not to report may place a child at serious, possibly life threatening risk. The main aim of protective servicesí investigations is to follow up with the family to make sure the child is safe and try to assist the family to resolve the problems that place the child at risk.

44. Protection of Information 67(i) The giving of information to a protective intervener during the course of the investigation of the subject matter of a notification under Section 64(i): does not for any purpose constitute unprofessional conduct or a breach of professional ethics on the part of the person by whom it is given; and The legislation actually protects us from claims of breach of conduct. The legislation actually protects us from claims of breach of conduct.

45. Protection of Information if given in good faith, does not make the person by whom it is given subject to any liability in respect of it; and does not constitute a contravention of Section 141 of the Health Services Act. The notifierís name is NEVER released. On a slight tangent, I should also point out that Victorian law states that we cannot make files available to state courts in cases of child sexual abuse unless we have the consent of the client or their parent/guardian. This is a relatively recent change to the law - some of you might have seen it written up in an APS bulletin - and it places the responsibility on the lawyers to argue why a childís therapy file is relevant to a criminal hearing rather than on the childís or the therapistís legal representative to argue that it is not relevant. Our experience has often been that defence lawyers have wanted to go on fishing exercises to see what sort of dirt they could get on the child or the family to divert attention from the perpetrator, to muddy the waters with contextual factors that although they may have contributed to the childís vulnerability, do not excuse the actions of the perpetrator.On a slight tangent, I should also point out that Victorian law states that we cannot make files available to state courts in cases of child sexual abuse unless we have the consent of the client or their parent/guardian. This is a relatively recent change to the law - some of you might have seen it written up in an APS bulletin - and it places the responsibility on the lawyers to argue why a childís therapy file is relevant to a criminal hearing rather than on the childís or the therapistís legal representative to argue that it is not relevant. Our experience has often been that defence lawyers have wanted to go on fishing exercises to see what sort of dirt they could get on the child or the family to divert attention from the perpetrator, to muddy the waters with contextual factors that although they may have contributed to the childís vulnerability, do not excuse the actions of the perpetrator.

46. Myths Children are too young to understand what has happened to them Children will forget, get over it quickly or just grow out of it. Therapy only makes them remember and upsets them. A lack of observable behavioural or psychosomatic responses means a child has not been upset by events Letís look at some common myths about childrenís responses to child abuse.Letís look at some common myths about childrenís responses to child abuse.

47. Facts Children are sensitive to and aware of changes in their world One does not have to understand an event to be effected by it Ė in fact confusion can make it worse Any major event, happy or sad, becomes a part of the child and his/her life and thus has an impact A childís inner world may not be observable or recognized but still inhibit or constrain Children do not necessarily recover more quickly than adults (Gordon & Wraith, 1993) A lack of cognitive maturity does not necessarily buffer a child from the impact of abuse. As noted earlier, there are neurophysiological effects that potentially impact at a greater level on infants as they are passing through critical phases of neurological maturation. Even in older children, a lack of understanding can be a draw back rather than a help. Children will try and make sense of their experience - as any of us will. With their limited resources, with phenomenon like magical thinking and egocentrism, they can often come up with some quite bizarre and unhelpful explanations for what has happened to them. We cannot escape the fact that all things that happen to us have the potential to impact on who we are and how we make sense of our world. As children we may not be able to express that, we may not have the words to describe our experience, we may not even act it out in a way that others know what is going on. And there is nothing special about being a child that means things are easier to get over. Often a childís recovery is further effected by the responses of the adults around them. And it often the distress of the adults around them that leads to parents exclaiming that their child is distressed rather than helped by therapy. Itís important to point out to parents that sometimes symptoms will increase during therapy as the child begins to confront her fears/concerns and to equip parents with strategies to support their child and contain their own reactions.A lack of cognitive maturity does not necessarily buffer a child from the impact of abuse. As noted earlier, there are neurophysiological effects that potentially impact at a greater level on infants as they are passing through critical phases of neurological maturation. Even in older children, a lack of understanding can be a draw back rather than a help. Children will try and make sense of their experience - as any of us will. With their limited resources, with phenomenon like magical thinking and egocentrism, they can often come up with some quite bizarre and unhelpful explanations for what has happened to them. We cannot escape the fact that all things that happen to us have the potential to impact on who we are and how we make sense of our world. As children we may not be able to express that, we may not have the words to describe our experience, we may not even act it out in a way that others know what is going on. And there is nothing special about being a child that means things are easier to get over. Often a childís recovery is further effected by the responses of the adults around them. And it often the distress of the adults around them that leads to parents exclaiming that their child is distressed rather than helped by therapy. Itís important to point out to parents that sometimes symptoms will increase during therapy as the child begins to confront her fears/concerns and to equip parents with strategies to support their child and contain their own reactions.

48. Some Research Goodman: child memory & suggestibility 4-5yr olds are no more suggestible than adults memories are inaccurate by omission rather than addition/exaggeration Myers-Williams: false memory 38% of adults taken to hospital as children for sexual abuse did not recall that abuse Here are some interesting points from the research into child abuse. You may want to follow them up further. In regards to false Memory Syndrome, I should point out that itís not a syndrome by definition. Thereís not any cluster of indicators/symptoms that a person might display to earn such a diagnosis. Much of the research is confounded by small or unrepresentative samples. Here are some interesting points from the research into child abuse. You may want to follow them up further. In regards to false Memory Syndrome, I should point out that itís not a syndrome by definition. Thereís not any cluster of indicators/symptoms that a person might display to earn such a diagnosis. Much of the research is confounded by small or unrepresentative samples.

49. Some Research Sorenson & Snow: of 186 children with medical evidence of abuse, 80% initially denied the abuse Rosenbloom: 80% of children touched parentsí genitals Ė not an indicator of abuse ON ITS OWN Friedrich: Coercive, powerful, humiliating acts of sexualized behaviour by children are most concerning indicators of potential perpetrator behaviour Perhaps what some of this research alerts us to is that child abuse is not a simple thing that children easily talk about or disclose, even in the face of incontrevertible evidence. They have parents to protect, punishments and threats to avoid. They may need to idealized their abuser and locate the cause in themselves otherwise they must contemplate that they have been hurt because they are unlovable, because a parent could never hurt a child they love. In regards to sexualized behaviour we need to remember that such behaviour occurs along a continuum and that some such behaviour is quite normal.Perhaps what some of this research alerts us to is that child abuse is not a simple thing that children easily talk about or disclose, even in the face of incontrevertible evidence. They have parents to protect, punishments and threats to avoid. They may need to idealized their abuser and locate the cause in themselves otherwise they must contemplate that they have been hurt because they are unlovable, because a parent could never hurt a child they love. In regards to sexualized behaviour we need to remember that such behaviour occurs along a continuum and that some such behaviour is quite normal.

50. Assessment & Treatment Assessment Goals Gauge the impact of the experience Determine the childís needs Plan treatment Ok, so what do we do when a child who has been abuse comes into our rooms? Obviously we start with an assessment. Iím looking to get some idea of how the child has been effected and therefore what needs this child may have so that I can plan for treatment.Ok, so what do we do when a child who has been abuse comes into our rooms? Obviously we start with an assessment. Iím looking to get some idea of how the child has been effected and therefore what needs this child may have so that I can plan for treatment.

51. Assessment Goals Engage the child and family/carers How the child experiences/sees her world & herself How the child is coping with the memory of the abuse. Of course itís important to engage the child and to get a window into her world. These children can be overly affectionate, desperate to please, prickly and defensive, cold and distant, rude and aggressiveÖ.. What ever it is that has worked as a coping strategy for them is what you are likely to see. So you need to take some time to learn about them and give them time to learn about you. Then you can hope to get some sense of their world and how they are dealing with what has happened to them.Of course itís important to engage the child and to get a window into her world. These children can be overly affectionate, desperate to please, prickly and defensive, cold and distant, rude and aggressiveÖ.. What ever it is that has worked as a coping strategy for them is what you are likely to see. So you need to take some time to learn about them and give them time to learn about you. Then you can hope to get some sense of their world and how they are dealing with what has happened to them.

52. Assessment Things to consider Developmental stage Attachments/way of relating Family context, responses, coping, supports Understanding of concepts: feelings, touch, good/bad Physical & mental state Things you need to consider or get a feel for during your assessment include where the child is at developmentally. Obviously this will impact on how you communicate with them, what they understand and how they make sense of things. For littlies you need to get some sense of their understanding of feelings - many kids have no words for feelings either such concepts have not existed in their world or their own have been denied for so long that they donít mean anything to them. Itís good to get a sense of what prepositions the child understands (on, under over, in), what ďtouchĒ words they use. What family means to them can also be interesting (Scott, Brodie) The way a child separates from their carer/parent, the way they relate with you and them are all important indicators of what sort of attachment template they may have developed and will influence how you relate with them. And of course their physical and mental state in general will guide what action you take. Things you need to consider or get a feel for during your assessment include where the child is at developmentally. Obviously this will impact on how you communicate with them, what they understand and how they make sense of things. For littlies you need to get some sense of their understanding of feelings - many kids have no words for feelings either such concepts have not existed in their world or their own have been denied for so long that they donít mean anything to them. Itís good to get a sense of what prepositions the child understands (on, under over, in), what ďtouchĒ words they use. What family means to them can also be interesting (Scott, Brodie) The way a child separates from their carer/parent, the way they relate with you and them are all important indicators of what sort of attachment template they may have developed and will influence how you relate with them. And of course their physical and mental state in general will guide what action you take.

53. Assessment Things to consider Attention span/impulse control Coping skills Non-verbals Likes/dislikes, strengths/weaknesses Other things that will give you information about how to relate with this child and where to go with them are their attention span, their coping skills, the non-verbal messages they give you, the things they say they like/dislike and the strengths/weaknesses you can determine.Other things that will give you information about how to relate with this child and where to go with them are their attention span, their coping skills, the non-verbal messages they give you, the things they say they like/dislike and the strengths/weaknesses you can determine.

54. Assessment Point of Time Prior to clear disclosure Immediately after disclosure Some time after the disclosure In regards to sexual abuse, itís important to know at which point of time you have the child in your room: Prior to, soon after or a long time after the disclosure. Clearly this will impact on how you proceed as the presentation is likely to be different. Children who have not disclosed may looking to find a safe place where they can do so, and you need to be clear whether your role is to look for a disclosure or make a general assessment of where this kid is at. Soon after a disclosure everything could be in chaos. The child could be taking it all back because sheís seen what turmoil her disclosure has created. With the relief of the disclosure she could fly into all sorts of symptomatic behaviour as she no longer has to hide anything, or symptoms could dissipate. If itís some time after the disclosure itís important to find out what has prompted the call for treatment (as it is at any time). Their could be something triggering off old symptoms again, the child may be being abuse again and not disclosed, their may be developmental tasks that have triggered off something for the child. A common example of this is when adolescents begin to contemplate relationships with boys.In regards to sexual abuse, itís important to know at which point of time you have the child in your room: Prior to, soon after or a long time after the disclosure. Clearly this will impact on how you proceed as the presentation is likely to be different. Children who have not disclosed may looking to find a safe place where they can do so, and you need to be clear whether your role is to look for a disclosure or make a general assessment of where this kid is at. Soon after a disclosure everything could be in chaos. The child could be taking it all back because sheís seen what turmoil her disclosure has created. With the relief of the disclosure she could fly into all sorts of symptomatic behaviour as she no longer has to hide anything, or symptoms could dissipate. If itís some time after the disclosure itís important to find out what has prompted the call for treatment (as it is at any time). Their could be something triggering off old symptoms again, the child may be being abuse again and not disclosed, their may be developmental tasks that have triggered off something for the child. A common example of this is when adolescents begin to contemplate relationships with boys.

55. Types of Disclosure Accidental Observed by third party Suspicious physical injury Behavioural indicators Psychosomatic complaints It is helpful to know how a childís disclosure came about. Was it accidental or deliberate. The child whose abuse is discovered accidentally may have been trying to disclose, may have thought they told someone, may be terrified of the consequences because they have been threatened with who knows what about keeping the secret.It is helpful to know how a childís disclosure came about. Was it accidental or deliberate. The child whose abuse is discovered accidentally may have been trying to disclose, may have thought they told someone, may be terrified of the consequences because they have been threatened with who knows what about keeping the secret.

56. Types of Disclosure Purposeful sharing a secret an attempt to get adults to stop the abuse fear of pregnancy The child who makes a purposeful disclosure, and gets a supportive reaction perhaps has created an opportunity of control for herself. Itís also possible though that she will feel enormously guilty for ďdobbingĒ in her abuser and ruining everybody elseís lives or for not having said something earlier on.The child who makes a purposeful disclosure, and gets a supportive reaction perhaps has created an opportunity of control for herself. Itís also possible though that she will feel enormously guilty for ďdobbingĒ in her abuser and ruining everybody elseís lives or for not having said something earlier on.

57. Disclosure Disclosure can occur over time Not often immediate Often fragmented The worst parts are often disclosed later It should be remembered that disclosures more often than not do not occur immediately. Younger children who havenít been significantly threatened are more likely to say something soon. Often they are more likely to say they donít want to see their abuser or donít want to go somewhere theyíve always liked than to be specific. Disclosures often come in pieces with the worst stuff being left for later. They test us all out for our reactions before they spill everything.It should be remembered that disclosures more often than not do not occur immediately. Younger children who havenít been significantly threatened are more likely to say something soon. Often they are more likely to say they donít want to see their abuser or donít want to go somewhere theyíve always liked than to be specific. Disclosures often come in pieces with the worst stuff being left for later. They test us all out for our reactions before they spill everything.

58. Disclosure Children test the water Your reaction Your persistence Can you be trusted? Will we be angry, disgusted, blaming? Will we make them talk about things they donít want to talk about - take away their control again. Or will we let them know that there may be more to say, but we can wait if theyíre not ready? Can they trust us? Of course itís as important in this sort of work as in any to explain to kids where you stand with notifying authorities and talking to parents.Will we be angry, disgusted, blaming? Will we make them talk about things they donít want to talk about - take away their control again. Or will we let them know that there may be more to say, but we can wait if theyíre not ready? Can they trust us? Of course itís as important in this sort of work as in any to explain to kids where you stand with notifying authorities and talking to parents.

59. Disclosure What to do? Listen and Validate Acknowledge that telling can be difficult. Express your belief in him/her and that you know that this happens to other children/young people too. If you get a disclosure from a child during your work with them itís of course critical to listen and validate their experience. To acknowledge the difficulty and the importance of what they have just done and to assure them that you know this sort of stuff happens. I tell kids that all the children who come to see me do so because someone has abused them. I modify my language according to how old the child is and whether or not they have made a disclosure yet.If you get a disclosure from a child during your work with them itís of course critical to listen and validate their experience. To acknowledge the difficulty and the importance of what they have just done and to assure them that you know this sort of stuff happens. I tell kids that all the children who come to see me do so because someone has abused them. I modify my language according to how old the child is and whether or not they have made a disclosure yet.

60. Disclosure What to do? Be clear/up front about what you can/must do next. Get support from/consult with colleagues, your supervisor, other professionals. Report the disclosure to the appropriate authority. Itís critical to be up front with kids about what has to happen next. Keeping them a part of the process, particularly adolescents, can help them feel some sense of control. Not all kids want this though. Obviously you need to report the disclosure, but itís also important to consult with and get support from your colleagues. Itís critical to be up front with kids about what has to happen next. Keeping them a part of the process, particularly adolescents, can help them feel some sense of control. Not all kids want this though. Obviously you need to report the disclosure, but itís also important to consult with and get support from your colleagues.

61. Assessment Process cognitive vs emotional levels roles, rules, responsibilities, expectations play drawing projective and objective techniques telephones games, crafts Itís important when you conduct your assessment to create a safe space to get into the emotions. Earlier sessions are often more cognitive than emotional. I talk to kids about what a safe place is for them, how we can make my room a safe place for them, give them permission to have a say in the process. You need to explain yur role, ascertain the childís understanding of whatís going on - ďI donít knowĒ may mean, ďIím not feeling safe enough to sayĒ Play is brilliant! Dolls houses can tell you heaps about family relationships, the way a child plays with a baby doll or uses puppets gives you so much. Dolls and puppets can represent them and others quite deliberately, or subconsciously. They can say things that the child canít say. Telephones can also be good for talking - itís like the phone givens them a barrier of safety, or maybe they feel in control because they can give up. Play doh is also great. Drawings - free, dreams, family, feelings, the offender, safe place, self 3 wishes is a great assessment tool. Most kids nowadays ask for millions of dollars, but have everything from ďmummy to be happyĒ to ďworld dominationĒ. Sometimes when 3 wishes results in nothing but materialistic stuff 3 wishes for things to be different can work. The sad ones are the ones who say ďnothingĒ ďwishes arenít trueĒ And for the really resistant kids, sometimes crafts or games can serve as distractions that then make it easier to talk or can also give you information about the way they see their world by how they play the game.Itís important when you conduct your assessment to create a safe space to get into the emotions. Earlier sessions are often more cognitive than emotional. I talk to kids about what a safe place is for them, how we can make my room a safe place for them, give them permission to have a say in the process. You need to explain yur role, ascertain the childís understanding of whatís going on - ďI donít knowĒ may mean, ďIím not feeling safe enough to sayĒ Play is brilliant! Dolls houses can tell you heaps about family relationships, the way a child plays with a baby doll or uses puppets gives you so much. Dolls and puppets can represent them and others quite deliberately, or subconsciously. They can say things that the child canít say. Telephones can also be good for talking - itís like the phone givens them a barrier of safety, or maybe they feel in control because they can give up. Play doh is also great. Drawings - free, dreams, family, feelings, the offender, safe place, self 3 wishes is a great assessment tool. Most kids nowadays ask for millions of dollars, but have everything from ďmummy to be happyĒ to ďworld dominationĒ. Sometimes when 3 wishes results in nothing but materialistic stuff 3 wishes for things to be different can work. The sad ones are the ones who say ďnothingĒ ďwishes arenít trueĒ And for the really resistant kids, sometimes crafts or games can serve as distractions that then make it easier to talk or can also give you information about the way they see their world by how they play the game.

62. Assessment Parental and Family Interviews Developmental history Disclosure/abuse history Family and marital history Relationships/boundaries/communication Of course, assessment also includes the parents/carers and other significant family members. The child does not exist in a vacuum. As in any assessment you want a developmental and family history to help place this child in context. You want to know how this family relates and communicates. Are you going to need to incorporate some work with the parents/family on boundaries and communication? Are you dealing with parents who have their own abuse history and may need some therapy of their own? Is the family supportive, ambivalent, divided and how does all of that impact on the child?Of course, assessment also includes the parents/carers and other significant family members. The child does not exist in a vacuum. As in any assessment you want a developmental and family history to help place this child in context. You want to know how this family relates and communicates. Are you going to need to incorporate some work with the parents/family on boundaries and communication? Are you dealing with parents who have their own abuse history and may need some therapy of their own? Is the family supportive, ambivalent, divided and how does all of that impact on the child?

63. Assessment Parental and Family Interviews Problem solving/coping skills Symptoms/current concerns Discipline issues School issues What can the parents/carers tell you about this childís coping skills and problem solving abilities? What is their perspective of the symptoms (children will often deny them or may not be bothered by them - e.g. Christine and toilets). There may be discipline and school issues that are now put in context with the disclosure or that need attention. The whole issue of missing school to come to therapy can be a problem too and needs to be watched for.What can the parents/carers tell you about this childís coping skills and problem solving abilities? What is their perspective of the symptoms (children will often deny them or may not be bothered by them - e.g. Christine and toilets). There may be discipline and school issues that are now put in context with the disclosure or that need attention. The whole issue of missing school to come to therapy can be a problem too and needs to be watched for.

64. Assessment Parental and Family Interviews Parental fears/expectations of therapy Resources/supports Shared and different perspectives What expectations do parents have of therapy? Are they realistic or obstructive? Parents need to be warned that sometimes their child may be upset or play up after therapy. They need to know how you will keep them informed and how they will be involved. Many parents fear that their child will be forced to remember things they donít want to or that if they donít talk about it all they will grow up to be psychotic, suicidal, homicidal, homosexual, anorexicÖÖ Itís important to warn parents that symptoms may escalate now that they child may feel safe to display them, may be expressing their anger at themselves or everyone else, may be testing who still loves them. Itís equally important to explore the supports and resources within the family. Are they there or do you have to help develop them? Itís important to help the family explore their reactions and bring their feelings out so you can use that to plan how they support the child and avoid secondary trauma.What expectations do parents have of therapy? Are they realistic or obstructive? Parents need to be warned that sometimes their child may be upset or play up after therapy. They need to know how you will keep them informed and how they will be involved. Many parents fear that their child will be forced to remember things they donít want to or that if they donít talk about it all they will grow up to be psychotic, suicidal, homicidal, homosexual, anorexicÖÖ Itís important to warn parents that symptoms may escalate now that they child may feel safe to display them, may be expressing their anger at themselves or everyone else, may be testing who still loves them. Itís equally important to explore the supports and resources within the family. Are they there or do you have to help develop them? Itís important to help the family explore their reactions and bring their feelings out so you can use that to plan how they support the child and avoid secondary trauma.

65. Assessment Questionnaires, Self Reports, Cognitive Specific Abilities Tests, Projective Tests General behaviour check lists (eg. BASC) Parental Stress Inventory Trauma Symptom Checklist Other self reports (eg Beck Youth Scales, Self esteem inventories) Cognitive assessments CAT, TAT, Sentence Completion Now I donít use formal or standardized assessment tools all the time. Sometimes I use them and think theyíre not telling me something I donít already know or couldnít get from a thorough interview. Sometimes Iím glad I did use them. This is not an exhaustive list of what can be used, but some of the ones I might use more commonly. Checklists for parents to complete can give them something to do in the waiting room as well as help them to focus on the information you want to get from them. I found the PSI useful recently with a mother of a child who was being seen by one of my colleagues. My colleague felt the child was ready for termination, but the mother was not. Once she completed the PSI, however, she reported that she didnít realize how much better things had become for her child. Termination became a much simpler process after that. Trauma, anxiety, depression, self esteem, dissociation or PTSD scales can be useful pre and post measures or for kids who prefer not to talk about whatís going on. Sometimes they give you fuel for therapy - like the kid who reports super amazing self esteem when their presentation surely suggests elsewise. The patterns of performance in cognitive tests can be interesting. Like kids who can get almost perfect PC and OA, but canít figure PA or Comp. Projective tests can also be good for kids that donít like talking about their own stuff, but are happy to write or able to project onto pictures that seem completely unrelated.Now I donít use formal or standardized assessment tools all the time. Sometimes I use them and think theyíre not telling me something I donít already know or couldnít get from a thorough interview. Sometimes Iím glad I did use them. This is not an exhaustive list of what can be used, but some of the ones I might use more commonly. Checklists for parents to complete can give them something to do in the waiting room as well as help them to focus on the information you want to get from them. I found the PSI useful recently with a mother of a child who was being seen by one of my colleagues. My colleague felt the child was ready for termination, but the mother was not. Once she completed the PSI, however, she reported that she didnít realize how much better things had become for her child. Termination became a much simpler process after that. Trauma, anxiety, depression, self esteem, dissociation or PTSD scales can be useful pre and post measures or for kids who prefer not to talk about whatís going on. Sometimes they give you fuel for therapy - like the kid who reports super amazing self esteem when their presentation surely suggests elsewise. The patterns of performance in cognitive tests can be interesting. Like kids who can get almost perfect PC and OA, but canít figure PA or Comp. Projective tests can also be good for kids that donít like talking about their own stuff, but are happy to write or able to project onto pictures that seem completely unrelated.

66. Treatment Whatís needed? Individual, family, group therapy Therapy/support for parents Short term Long term Assessments can take up to about 6 sessions. You then need to take this information and make some decisions about treatment. Not all children who have been abused need treatment. It depends on the level of impact. Sometimes the issues that require treatment are not a function of the abuse. Sometimes the work that is needed to be done is with the parents - either because of their own abuse history, to help them deal with the impact of the disclosure or to assist them with parenting based issues. Sometime the work is clearly focused on specific symptoms and once they remit itís all over. Sometimes, often commensurate with the more chronic cases of abuse, the work is long term. Especially where thereís attachment issues or self destructive behaviour.Assessments can take up to about 6 sessions. You then need to take this information and make some decisions about treatment. Not all children who have been abused need treatment. It depends on the level of impact. Sometimes the issues that require treatment are not a function of the abuse. Sometimes the work that is needed to be done is with the parents - either because of their own abuse history, to help them deal with the impact of the disclosure or to assist them with parenting based issues. Sometime the work is clearly focused on specific symptoms and once they remit itís all over. Sometimes, often commensurate with the more chronic cases of abuse, the work is long term. Especially where thereís attachment issues or self destructive behaviour.

67. Treatment Aims help the child make sense of her experience empower work on identity reconnect with the world develop adaptive coping skills Therapy is not going to take the experience away. It wonít remove the memories. What it can do is help the child make sense of what happened, how she reacted then, how she responds now, how and why others reacted and react the way they do. It can give the child back a sense of control, it can give her a life that is not overwhelmed by intrusive thoughts, depressive moods and flashbacks. It can help her to recreate her sense of who she is. Not damaged goods. Not that kid that got abused. It can help her to reconnect with a world that doesnít require them to be a victim. It can help them to learn new skills that keep her safe, give her permission to ask for help and allow her to get on with her life. It is not written in concrete that you have to go over every incident, every feeling, every moment. Not everybody has to be forgiven or cut out of their lives. Some times you work on something for a while and they might come back at a later date for more work. Some aspects of their trauma may not be integrated - ever. Therapy is not going to take the experience away. It wonít remove the memories. What it can do is help the child make sense of what happened, how she reacted then, how she responds now, how and why others reacted and react the way they do. It can give the child back a sense of control, it can give her a life that is not overwhelmed by intrusive thoughts, depressive moods and flashbacks. It can help her to recreate her sense of who she is. Not damaged goods. Not that kid that got abused. It can help her to reconnect with a world that doesnít require them to be a victim. It can help them to learn new skills that keep her safe, give her permission to ask for help and allow her to get on with her life. It is not written in concrete that you have to go over every incident, every feeling, every moment. Not everybody has to be forgiven or cut out of their lives. Some times you work on something for a while and they might come back at a later date for more work. Some aspects of their trauma may not be integrated - ever.

68. Vicarious Trauma What is it? An understandable response Not burnout Works on our vulnerabilities Now as I said right at the beginning, in this work you hear some sad and some horrible stuff. Sometimes you see it too. Hear and see enough of it and you canít help but feel some impact. When you start to experience the same symptoms as your clients, when you notice yourself losing interest in things you loved before, cutting yourself off from family/friends/colleagues, experiencing intrusive thoughts or images that should belong to your clients, begin wondering why youíre doing this work/if you can do anyone any good or any other depressive/anxiety/PTSD type symptomology, then itís time to take careful stock. Itís not burnout. Thereís a sense of finality to the term burnout. Vicarious trauma is a secondary traumatization created by our repeated exposure to the trauma of others. Itís about our sense of meaning and faith being constantly assaulted and the erosion of how we make sense of ourselves and our world. Itís not much fun, but it can be ameliorated and turned around. VT latches on to our vulnerable spots. The issues that press our buttons are the issues around which VT will latch on. Now as I said right at the beginning, in this work you hear some sad and some horrible stuff. Sometimes you see it too. Hear and see enough of it and you canít help but feel some impact. When you start to experience the same symptoms as your clients, when you notice yourself losing interest in things you loved before, cutting yourself off from family/friends/colleagues, experiencing intrusive thoughts or images that should belong to your clients, begin wondering why youíre doing this work/if you can do anyone any good or any other depressive/anxiety/PTSD type symptomology, then itís time to take careful stock. Itís not burnout. Thereís a sense of finality to the term burnout. Vicarious trauma is a secondary traumatization created by our repeated exposure to the trauma of others. Itís about our sense of meaning and faith being constantly assaulted and the erosion of how we make sense of ourselves and our world. Itís not much fun, but it can be ameliorated and turned around. VT latches on to our vulnerable spots. The issues that press our buttons are the issues around which VT will latch on.

69. Vicarious Trauma What can you do? Supervision Be aware of your vulnerabilities Therapy Cultivate other skills Have faith Have fun Never underestimate the importance of supervision when youíre working with other peopleís trauma - perhaps even more so when itís children. Supervision is a place to get support and ideas, but also to check out your reactions and responses to what you are witnessing. Being aware of what pushes your buttons is critical. I know the thing that riles me is when someone manipulates, violates and just flat out disregards someone who is essentially powerless to stop them. As you can imagine, that happens a lot in child abuse. And when that sense of powerlessness gets hooked up with a sense of worthlessness then I have to watch my responses. I keep an eye on my levels of anxiety and look out for those ďIím no good at this job, I should have been an air hostessĒ thoughts. Iím a strong advocate for therapists getting their own therapy. Not least because itís a wonderful experience to sit in that other chair and feel what your clients might be feeling. Itís also important to develop competency in other areas, especially not related to your work. Garden, sew, cook. Do things that are achievable, concrete, and offer fairly quick reward. The more your sense of identity is tied into being a psychologist and the work you do as such, the more vulnerable you are to the effects of VT. Have faith. In something. It might be religion, it might be humanityÖ... And above all have fun. The things that make us good psychologists, our empathy our willingness to walk with people through their darkness often means we forget to lighten up. We can take life too seriously. Never underestimate the importance of supervision when youíre working with other peopleís trauma - perhaps even more so when itís children. Supervision is a place to get support and ideas, but also to check out your reactions and responses to what you are witnessing. Being aware of what pushes your buttons is critical. I know the thing that riles me is when someone manipulates, violates and just flat out disregards someone who is essentially powerless to stop them. As you can imagine, that happens a lot in child abuse. And when that sense of powerlessness gets hooked up with a sense of worthlessness then I have to watch my responses. I keep an eye on my levels of anxiety and look out for those ďIím no good at this job, I should have been an air hostessĒ thoughts. Iím a strong advocate for therapists getting their own therapy. Not least because itís a wonderful experience to sit in that other chair and feel what your clients might be feeling. Itís also important to develop competency in other areas, especially not related to your work. Garden, sew, cook. Do things that are achievable, concrete, and offer fairly quick reward. The more your sense of identity is tied into being a psychologist and the work you do as such, the more vulnerable you are to the effects of VT. Have faith. In something. It might be religion, it might be humanityÖ... And above all have fun. The things that make us good psychologists, our empathy our willingness to walk with people through their darkness often means we forget to lighten up. We can take life too seriously.

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