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Article Excerpt
A child awakens in the middle of the night, the nightmare still fresh in her mind of "him" on top of her. Her breath comes in short, quick gasps as she struggles to determine whether what she has just experienced was real or only a dream. She strains to hear if the footsteps coming down the hall are real or imagined. She pushes the thoughts out of her head. Perhaps if she sleeps under the bed, he will not find her. She wishes her mother would come in and comfort her, but she feels disconnected from her family, as if she is a stranger living in her own house. No one understands. No one cares. She prays for the morning to come so the dreams will stop, but she knows that the morning brings nightmares of its own: the looks from her sister, the speeches from her teacher about her lack of concentration in class. Her day is spent alternately trying to recall what happened and trying to forget. She finds no pleasure in the activities that she once loved. The night comes again, and the cycle continues. The monster that was once in her bed has now been replaced by monsters in her head.
There has been a growing body of literature on the subject of posttraumatic stress disorder (PTSD) in children. The literature consistently points to children's vulnerability to the development of PTSD aider severe trauma, particularly child sexual victimization. (Note. In this article, both the terms child sexual victimization and child sexual abuse are used. Child sexual victimization refers to the symptomatology experienced by the person being victimized. This term assumes the perspective of the victim. Child sexual abuse refers to the overall experience and nature of sexual abuse, including the criminal component.) When children's bodies are used to meet adult needs, there is enormous potential for physical and psychological trauma (Monahon, 1993). Many clinicians differ on the applicability of a diagnosis of PTSD for children who have been sexually victimized. Although many authors believe that PTSD is a logical outcome following child sexual victimization, others (e.g., Finkelhor, 1990) object to using the diagnosis of PTSD as a way of always conceptualizing the sequence of events and symptoms that children who are sexually abused often face after the trauma. This article does not seek to resolve this debate, but rather seeks to shed light on the controversy. This article examines the nature and scope of the problem, proper assessment and diagnosis of PTSD in children, treatment strategies known to be effective, and implications for counselors treating this population. In the interest of time and space, this article only addresses PTSD as it specifically relates to child and adolescent survivors of child sexual victimization, while acknowledging that adult survivors of child sexual abuse may also experience the effects of PTSD.
* Nature and Scope of the Problem
PTSD has long been associated with the aftereffects of war and natural disasters. This disorder was brought to mainstream attention with the return of soldiers from the Vietnam War. Many of these returning soldiers experienced recurrent nightmares, suddenly feeling or acting as if the event were recurring, restricted range of affect, and hypervigilance (Davidson & Foa, 1993). It is now recognized that PTSD is not limited to wartime but may arise from a variety of traumatic events that can occur throughout the life cycle of men, women, and children. It is estimated that 4 out of 10 Americans have experienced major trauma, and the disorder may be present in 9% of the U.S. population (Breslau & Davis, 1987). A growing number of Americans with PTSD are children who have been sexually abused. According to the U.S. Department of Health and Human Services (2000), 11.5% of the 903,000 children who were victimized in 1998 were victims of sexual abuse. According to Browne and Finkelhor (1986), it is estimated that between 46% and 66% of children who are sexually abused exhibit significant psychological impairment. McLeer, Deblinger, Atkins, Foa, and Ralphe (1988) studied the prevalence of PTSD in 31 children who were sexually abused and found that in 48% of their sample, a diagnosis of PTSD was warranted. Many children who did not meet PTSD criteria nevertheless experienced PTSD symptoms.
Another study by Briere, Cotman, Harris, and Smiljanich (as cited in Briere, 1992) found that "both clinical and non clinical groups of sexual abuse survivors report intrusive, avoidant, and arousal symptoms of PTSD" (p. 20). According to Briere, survivors of sexual abuse are prone to displaying PTSD-related intrusive symptoms. Other symptoms survivors of sexual abuse may experience include mood disorders, somatization, sexual difficulties, anger and frustration, self-injurious behaviors, and a pervasive distrust of others (Naugle, Bell, & Polusny, 2003). These symptoms often manifest themselves in the form of flashbacks, when the survivor is flooded with intrusive sensory memories that may include visual, auditory, tactile, or olfactory sensations (Briere, 1992). Many of these flashbacks may be triggered by abuse-related stimuli or interactions.
I worked with a young girl who became physically ill when she encountered the smell of chlorine, particularly prevalent around swimming pools. During the course of therapy, it was discovered that the client had been repeatedly sexually assaulted one summer by one of her older brother's friends at a local swimming pool. The perpetrator would take the client behind the pool's storage shed and repeatedly assault her. The smell of the chlorine would inevitably return her to that place, and she would "feel" his hands on her. Often, disclosing the abuse experience can be the only stimulus needed to trigger flashbacks.
In a survey of six separate studies by McNally (1993), which involved the application of PTSD criteria to cases of child sexual abuse, four of these studies reported no cases of PTSD, whereas the other two studies reported rates of 48% and 90%, respectively. As McNally noted, "Clearly, there is no uniform outcome associated with child sexual abuse" (p. 69). The clinician working with this population should consider a diagnosis of PTSD as a possible outcome of child sexual abuse but recognize that such a diagnosis is not always a given in cases in which child sexual abuse has been reported.
* Symptomatology
It is important for the clinician dealing with survivors of child sexual victimization to be aware of how these clients will present upon entering counseling. The clinician who suspects that a child is experiencing PTSD should be cognizant of the signs and symptoms that are possible indicators of PTSD. Frequently, fearfulness and anxiety-related symptoms have been described as sequelae of sexual abuse. Green (1985) described anxiety states, sleep disturbances, nightmares, and psychosomatic complaints in children who were sexually assaulted. Sgroi (1982) observed fear reactions in children who had been sexually abused extending to a phobic avoidance of all males (when the perpetrator is male). Kiser et al. (1988) documented PTSD in 9 out of 10 children between the ages of 2 and 6 years who were molested in a day-care setting. The most frequently observed symptoms were acting as if the traumatic event were reoccurring, avoiding activities reminiscent of the traumatic event, and intensification of symptoms on exposure to events resembling the molestation, all of which satisfied criteria for a diagnosis of PTSD.
According to Koverola and Foy (1993), one of the ongoing controversies in the diagnosis of PTSD in children who have been sexually victimized lies in the issue of whether children manifest PTSD symptoms in the same way that adults do. As Koverola and Foy noted, "One way in which PTSD in children may differ from PTSD in adults is in the nature of the traumatic reexperiencing" (p. 120). It is argued that children are more likely to experience nightmares as opposed to the dissociative flashbacks that adults experience (Koverola & Foy, 1993). These nightmares can be classified into two types of PTSD according to Terr (1989). Type I can be classified as a graphic representation of the original trauma and that results from a single incident. Type II can be classified as more symbolic representation of the event and is often classified by denial, dissociation, and numbing. Type I...
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