Childhood sexual abuse: what rehabilitation counselors need to know.

Individuals with disabilities are at greater risk of sexual abuse. This includes both people who have congenital disabilities and those with acquired disabilities. Contrary to popular belief that young people with disabilities are protected from abuse and exploitation, there is evidence that they are, in fact, at increased risk for sexual abuse and maltreatment. In a British Columbia (Canada) survey of 16,000 high school students, 38% of those students with disabilities reported having been sexually abused or assaulted, compared with 17% of those without disabilities (Murphy, 1995). The fact that youth who have disabilities are at a higher risk for sexual abuse indicates that this area needs exploration by the rehabilitation counseling profession.

Definition of Sexual Abuse

Sexual abuse is defined as being forced, threatened, or deceived into sexual activities ranging from looking or touching to intercourse or rape. Child abuse has been defined in the literature to include any act of commission or omission that endangers or impairs a child's physical or emotional health and development. It may be evident by an injury or series of injuries appearing to be non-accidental in nature and which cannot reasonably be explained. The most frequent forms of child abuse are physical abuse, emotional abuse or deprivation, and sexual abuse.

Sexual abuse of children involves someone too young to give informed consent but who has been involved in a sexual act. Exploitation of an individual who lacks adequate information to recognize such a situation or who is unable to understand or communicate (i.e., the child with a mental or physical disability) is also considered sexual abuse. This kind of abuse is a violation of the whole person and is not restricted to only a sexual act. It results in indignation and an overwhelming sense of violation and invasion that can affect the victim in physical, psychological, and social ways. Frequently, the aftermath of the assault or abuse is more severe than the actual event. This is particularly true of people with disabilities who cannot (or do not) access support systems and services that may otherwise be available. There is sexual abuse without touch, as when someone exposes his or her genitals or forces or tricks an individual to exposing his or her own genitals. Another type of sexual abuse without touch involves obscene telephone calls, as when an individual calls and talks about sex (e.g., ways they would like to touch a person's body or be touched).

Primary affects of these crimes may be short-term but in many cases there is irreparable psychological harm done to the victim that can continue into adulthood. The nature of the sexual abuse also makes it difficult to observe and therefore more threatening to report. Professionals who work with people with disabilities need to be able to recognize signs and symptoms of sexual abuse. These symptoms include behaviors, attitudes, psychosocial aspects, and physical manifestations.

Scope of the Problem

It is difficult to estimate rates of sexual abuse among children with disabilities. One reason is that states do not collect data about abused children in the same way. A second reason is that researchers identify disability among maltreated children in different ways. Additionally, many cases of sexual abuse go unreported because these children do not inform anyone, especially when other family members are involved; parents often fear repercussions if the authorities become involved.

Nonetheless, available research has found that children with disabilities are more vulnerable to sexual abuse than children without disabilities. A national study (Crosse, Kaye, & Ratnofsky, 2001) found that children with disabilities were 1.7 times more likely to be abused than children without disabilities.

It is estimated that between 9% and 15% of all children in the United States have a disability; approximately 175,000 to 300,000 children with disabilities in this country are maltreated each year. Crosse et al. (2001) acknowledged that their study might have underestimated the incidence of maltreatment of children with disabilities. A study conducted in Omaha, Nebraska, in 1997 found that children with disabilities were 3.4 times more likely to be maltreated than were children without disabilities (Sullivan & Knutson, 2003). Although the Omaha study did not use a national sample, its findings underscored a need for more research on the scope of this problem.

Why Childhood Sexual Abuse is Important to Rehabilitation Counselors

As noted by Deaton and Hetica (2001), learned helplessness is a common result of being a survivor of abuse. The perception of powerlessness may become paramount in a person's thoughts and behaviors. Individuals often suffer from depression, dissociation, heightened anxiety, sleep disturbances, and low self-esteem. If the rehabilitation counselor does not attempt to help the person resolve the issues that remain, the likelihood is great that rehabilitation services will be significantly impeded.

The rehabilitation counseling profession reflects the value society places on employment. A core belief is that everyone should work, if possible. In our capitalist society, work is a right; rehabilitation services have also become an established right for individuals with disabilities. As counselors, we must become aware of the long term impact childhood sexual abuse can have on clients for whom we provide services. There have been numerous studies (Sobsey, 1994; Mullen, Martin, Anderson, Romans, & Herbison, 1996; Sullivan & Knutson, 2003) examining the association between the history of child sexual abuse and mental health problems in adult life that impede psychological, social, educational, vocational, and interpersonal development. Results indicated that child sexual abuse impacts the total personality and functioning of the person.

Socioeconomic Status 

The possible influence of childhood sexual abuse on adult social and financial functioning and the provision of vocational rehabilitation have not received the attention deserved in the rehabilitation counseling literature. It is well documented that sexually abused children experience difficulties in school with academic performance and general behavior (Tomison, 1996; Fergusson & Lynskey, 1997; Orelove, Hollahan, & Myles, 2000). This can have a negative influence on educational attainment, and impair the development of the skills and discipline necessary to sustain effective work roles.

Mullen et al. (1996) noted that those individuals who have histories of child sexual abuse tended to have lower socioeconomic status. They were also likely to have partners whose occupations were in lower paying, less skilled jobs. This lower socioeconomic status could not be accounted for by simple educational failure, nor could it be explained by reduced participation in the workforce, or preference for part-time employment. The explanation for women who were sexually abused (more so than men) being in less well paid, less prestigious jobs could be that they underestimated their value and sought occupations below their capacities, or they were less adept at translating training and opportunity into effective functioning in the work atmosphere (Siu, 2005b). Rehabilitation counselors need to take this into account when providing vocational rehabilitation to ensure that they provide fair and equitable services.

This greater likelihood of lower socioeconomic status relative to family of origin is a crude measure of social and economic failure, and suggests a wide ranging disruption of function that is particularly marked in those reporting the more severe abuse experiences. As counselors see clients with abuse issues, especially when the abuse occurred in childhood or youth, they need an understanding of the ways in which successful vocational rehabilitation may be impeded.

Why Children with Disabilities are at Higher Risk for Maltreatment

Researchers who specialize in child abuse have compared the characteristics of sexual abuse and maltreated children with and without disabilities. Studies also have looked at characteristics of adults who sexually abuse and maltreat children with disabilities. Jones, Peterson, Goldberg, Goldberg, and Smith (1995) indicated that a quarter of all abuse occurs to individuals before the age of seven; over a third of all those who suffer sexual abuse are victimized before the age of nine.

Most abuse is perpetuated by people who know the victim, such as family members, acquaintances, residential care staff, personal care attendants, and transportation providers. Research (Crosse et al., 2001; Sullivan & Knutson, 2003) suggested that up to 95% of abusers are known and trusted by their victims. To comprehend why abuse occurs more frequently in children with disabilities, rehabilitation professionals need to look at risk factors for this population.

Researchers have identified a number of factors related to parents, children, families, service systems, and society at large which increase the potential for maltreatment of children with disabilities (Mitchell & Buchele-Ash, 2000; Siu, Brodwin, & Orange, 2005; Steinberg & Hylton, 1998). Yet, there is disagreement among researchers regarding the legitimacy of certain risk factors. This section describes major findings in this area.

There is general acceptance that no single factor places a child at risk for abuse and neglect. Rather, it is the interaction of factors that seems to be critical. Sobsey (1994) proposed an integrated ecological model of abuse to explain the interaction of factors that may lead to abuse or neglect. Sobsey's model (which is based on Bronfenbrenner's ecological model of child development) takes into account cultural and environmental factors, as well as characteristics of the parents and the child and their interactions. When using this model for abuse prevention, Sobsey focused particularly on power inequities between the potential offender and potential victim. Some factors that place children with disabilities at risk for abuse are those that place all children at risk (Ammerman & Patz, 1996; Orange & Brodwin, 2005).

It is well recognized that shame and guilt (either one or both) are the primary psychological injuries. Both of these devastating repercussions are the result of internalization of the offense, increasing the risk for future abuse. Victimized children frequently view themselves as the cause, being responsible for the event, and perhaps ultimately being a 'bad' person.

Shame is the emotion most individuals experience involving feelings of defeat and weakness in these highly traumatic and emotionally defeating situations (Santrock, 2004). There is a sense of loss of self-control with accompanying damage to self-esteem and a diminished concept of self (Hassouneh-Philips & Curry, 2002). This emotional damage makes the person more vulnerable and at greater risk for future events. Victims may be pressured, forced, or tricked and still believe they are partially to blame for the sexual abuse, even though they do not truly consent and perhaps do not fully understand. The abuser can completely dominate and manipulate the victim. The shame resulting from the abuse often becomes incorporated within the child's personality (Tomison, 1996).

The negative emotions related to the abuse experience affect the total personality of the child and, unless appropriately treated, carry into adult life. These emotions often intensify an already diminished view of self related to having a disability. Rehabilitation counselors will serve some of these individuals in adulthood when providing rehabilitation services. Counselors may also see these persons when providing services in agencies which serve families who have children with disabilities.

Risk Factors

Parental Risk Factors

Certain factors related to parents are associated with increased risk of maltreatment for all children. Parental substance abuse is a risk factor identified by many researchers (Crosse et al., 2001; Steinberg & Hylton, 1998; Struck, 1999). Other parent-related risk factors are poor coping skills, diminished impulse control, and a history of violence (Ammerman & Baladerian, 1993). Parents with low self-esteem or those diagnosed with chronic depression may be at greater risk for abusing their children (Mitchell & Buchele-Ash, 2000; Nosek, Howland, & Young, 1998). Many of these parents were themselves victims of child maltreatment. Parents who have disabilities may be at a higher risk for abusing their children, especially if they were raised in group care and lacked positive parenting models.

Societal Risk Factors

Researchers in rehabilitation counseling and related fields (Crosse et al., 2001; Orange, 2002; Orelove et al., 2000; Rogow & Hass, 1999) reported that societal attitudes and beliefs play a significant role in placing children with disabilities at risk for abuse. Children with disabilities may internalize societal attitudes and feel shame or believe themselves less worthy of being treated respectfully (National Resource Center on Child Sexual Abuse, 1994). As is familiar to rehabilitation counselors, segregating children with disabilities tends to increase the perception of differences and suggests that, "group membership and social distance influence our attitudes about the acceptability of violence. Attitudes about individuals or groups that tend to depersonalize, dehumanize, or distance them appear to make violence against them more acceptable" (Sobsey, 1994, p. 307).

Societal myths associated with children with disabilities increase risk. Sobsey (1994) and Brodwin, Orange, and Chen (2004) discussed the myth held by many that children with disabilities are not vulnerable to abuse; belief in this can result in a lack of awareness and attention to the problem. Baladerian (1994) and Steinberg and Hylton (1998) discussed the myths that rehabilitation counselors should be aware of, including:

* Children with disabilities are asexual and therefore do not need sex education (denying them information that may help prevent abuse).

* Some children with disabilities are unable to manage their own behavior (resulting in caretakers exerting unnecessary control).

* Some children with disabilities do not feel pain (resulting in aversive therapies being used).

* All caretakers are special and good (resulting in a lack of awareness and attention to signs of abuse and neglect).

Child-related Risk Factors

Numerous risk factors related to children with disabilities have been identified. In actuality, many of the factors discussed here are considered 'socially mediated effects of disability'. This refers to people's response to children with disabilities, rather than to the specific child or the disability itself. Although some feel that viewing child-related characteristics as risk factors is 'victim blaming' (Tomison, 1996), it is important to note these characteristics, especially in conjunction with other risk factors.

Because the care required by some children with disabilities is critical to their survival, many have been taught to obey those in authority and comply with their caretakers' requests or demands (National Resource Center on Child Sexual Abuse, 1994; Steinberg & Hylton, 1998). Some children with disabilities may feel that their bodies do not belong to them. If a caretaker behaves inappropriately, a child may not complain or resist because he or she believes the caretaker knows what is best (Sobsey, 1994).

Many researchers in the field of rehabilitation counseling have found that some children with disabilities lack the knowledge or understanding to know when behavior is wrong or inappropriate (Ammerman, 1997; Crosse et al., 2001; Steinberg & Hylton, 1998). Even if they do recognize behaviors as wrong, children with disabilities may not attempt to stop the abuse or neglect because they fear losing the relationship and they are emotionally and physically dependent on their caretakers (National Resource Center on Child Sexual Abuse, 1994). In some cases, their disabilities may prevent them from being able to defend themselves or escape from the situation. Children who have difficulty communicating are at higher risk for maltreatment because potential perpetrators may believe they can 'get away with it', thinking that the child will not be able to report the behavior. Children with disabilities may be perceived as being relatively 'safe victims' (Ammerman & Patz, 1996; Orange & Brodwin, 2004).

Association of Sexual Abuse in Young Adults and in Adult Life

Rehabilitation counselors need an awareness of the wide range of potential adverse adult outcomes associated with childhood sexual abuse in order to effectively serve these individuals. However, there is no unique pattern for these long-term effects. This would suggest that child sexual abuse is best viewed as a risk factor for a wide range of subsequent problems. Sexual abuse of children occurs during a period in life where complex changes are occurring in the child's physical, psychological, and social being (Santrock, 2004). Additionally, instability within the family leaves the child vulnerable to sustaining emotional damage that remains untreated and may prevent the normal developmental process, hindering successful assimilation into adulthood.

The impact of abuse is likely to be modified by the developmental stage at which it occurs. It will also vary according to how resilient the child is in terms of psychological and social development (Santrock, 2004). A child, who has already had to cope with a problematic family background or prior emotional abuse, is more vulnerable to the additional effects of sexual abuse. The child from a more secure and privileged background may well be equally distressed at the time by the abuse, but is likely to sustain less long-term developmental damage.

The long-term effects of child sexual abuse also will be modified by the individual's experience subsequent to the abuse. Romans, Martin, and Mullen (1997), demonstrated that long-term problems following child sexual abuse were significantly lower in those who had supportive and confiding relationships with their mothers. Also, success at school and nurturing relationships with peers were determining factors in strengthening self-esteem and enhancing opportunities for effective social interaction.

Childhood sexual abuse interacts with family background to produce disruption of the child's developing self-esteem and sense of mastery of the world. It is these deficits that increase the likelihood of psychological problems later in life. Rehabilitation counselors need an understanding of the association between these developmental deficits leading to social and personal vulnerabilities in adult life, which in turn create increased risk of mental health problems, potentially impeding the successful provision of vocational rehabilitation.

Warning Signs of Sexual Abuse

Rehabilitation counselors need to be effective in recognizing their adult clients who may have been sexually abused as children, as the effects of early sexual abuse last well into adulthood, effecting relationships, work, family, and the provision of vocational rehabilitation services. According to Mullen et al. (1996) and Romans et al. (1997), individual symptomatology tends to fall into four areas:

1. Damaged goods: Low self-esteem, depression, self-destructiveness (suicide and self-mutilation), guilt, shame, self-blame, constant search for approval, and nurturance.

2. Betrayal: Impaired ability to trust, blurred boundaries and role confusion, rage and grief, difficulty forming relationships.

3. Helplessness: Anxiety, fear, tendency toward re-victimization, panic attacks.

4. Isolation: Sense of being different, stigmatized, lack of support, poor peer relations.

Adult survivors of childhood sexual abuse may demonstrate some of the following symptoms (Mitchell & Buchele-Ash, 2000; Mullen et al., 1996):

* Fear of the dark, fear of sleeping alone, nightmares, night terrors 

* Difficulty with swallowing, gagging 

* Poor body image, poor self-image in general

* Wearing excessive clothing

* Addictions, compulsive behaviors, obsessions

* Self-abuse

* Suicidal ideation 

* Phobias, anxiety disorder, panic attacks, startle response 

* Difficulties with anger, hostility, rage

* Issues with trust, intimacy, relationships

* Issues of boundaries, control, abandonment

* Blocking out memories especially between 1 and 12 years of age

* Denial, flashbacks

* Multiple personalities

* Signs of posttraumatic stress disorder 

Through awareness of these various signs and symptoms of child sexual abuse, rehabilitation counselors may be able to more readily identify clients who have related unresolved problems. With appropriate treatment of these issues, counselors are more likely to be able to provide vocational rehabilitation services that result in success and are more meaningful for their clients. At the same time, these signs and symptoms occur with many other conditions and one must not assume they are due to sexual abuse without first seeking further information from the client. Some clients will decline to reveal or discuss these highly, personal issues; counselors need sensitivity to their clients' preferences in this area.

Prevention of Abuse

As Ammerman and Baladerian (1993) stated, "the physical, emotional, and financial costs of abuse and neglect are so great as to make prevention the number one priority in the effort to eliminate maltreatment of children" (p. 9). If abuse or neglect does occur, it is paramount to investigate, possibly report, and treat the problem. It is equally relevant to address efforts to prevent abuse and neglect. Prevention may be aimed at the general public (known as primary prevention) or targeted specifically to families considered at risk of child abuse (known as secondary prevention). A third form of prevention, not covered in this document, is known as tertiary prevention and is designed to prevent the reoccurrence of abuse.

Because different interrelated factors can contribute to child sexual abuse, a variety of coordinated prevention strategies are needed. A multifaceted approach is the most effective. Strategies may be parallel, in which separate programs are implemented for children with disabilities, or integrated, in which the needs of children with disabilities are accommodated in generic programs serving all children.

Prevention at the Societal Level

For rehabilitation professionals, one of the first steps in prevention of abuse among children with disabilities is a heightened awareness of the problem (Orange & Brodwin, 2005). Heightened awareness on a societal level can lead to more funding for research and prevention programs and improved programming to combat the problem.

Most experts in the field of abuse recommend coordination among relevant parties to ensure that prevention efforts are comprehensive. Governments, service providers, and local communities can work together to support families that have children with disabilities, while rehabilitation counselors and professionals from related fields collaborate (Rogow & Hass, 1999). Educators and health care professionals who are often in contact with children with disabilities can be trained to understand the problem and their roles in prevention. Rehabilitation researchers (Nosek et al., 1998; Orelove et al, 2000; Siu, 2005a, 2005b) found that the majority of special educators, rehabilitation education students, and rehabilitation counselors surveyed were willing to attend specialized training on abuse prevention if it were made available.

At the societal level, prevention efforts often focus on changing social attitudes about children with disabilities. The National Symposium on Abuse and Neglect of Children with Disabilities (1995) and Sobsey (1994) recommended promoting inclusion of children with disabilities into everyday life. Steinberg and Hylton (1998) added suggestions that included encouraging valuing children with disabilities, seeing each of them as individuals, and sharing responsibility for their well being. Sobsey recommended that rehabilitation counselors advocate and educate others specifically about people with disabilities, challenging negative attitudes and behaviors, and personalizing interactions.

Mitchell and Buchele-Ash (2000) advocated enacting legislation that supports prevention and protection of children with disabilities. The Child Abuse Prevention, Adoption, and Family Services Act of 1998 was passed to increase awareness of crimes committed against youth who have disabilities, collect data, and develop strategies to address the needs of this population.

Child-focused Prevention Efforts

Child maltreatment prevention programs are rarely made available or accessible to children with disabilities, often due to a lack of funding or a mistaken belief that this population does not need prevention information (Baladerian, 1994). In actuality, "withholding knowledge from individuals with disabilities concerning self-protection increases their vulnerability to abuse and neglect" (Mitchell & Buchele-Ash, 2000, p. 235). Ammerman and Baladerian (1993) noted that child-focused prevention programs for children with disabilities should include sharing information about abuse (how to identify it, how to respond, how to tell others) and talking about feelings that may occur if abuse is attempted. Additionally, parental involvement throughout the program is crucial to ensure that all family members are aware of and support the instruction and philosophy of the program. Rehabilitation counselors can serve as team leaders in developing a group of professionals to treat and provide support for these individuals.

A number of researchers have discussed the need for more appropriate and accessible programming for children with disabilities (Fergusson & Lunskey, 1997; Mullen et al., 1996; Struck, 1999). Programs need to be inclusive and sensitive to ability levels, culture, and gender. Steinberg and Hylton (1998) suggested the use of developmentally appropriate concepts, concrete activities, and audiovisual aids. They also recommended, as does the National Symposium on Abuse and Neglect of Children with Disabilities (1995), that prevention programs for children with disabilities be ongoing rather than a one-time effort; children with certain disabilities (i.e., cognitive) may need lessons repeated frequently.

Many programs provide specific information about abuse-what it is, how to recognize it, and what rights children have (Mullen et al., 1996; Romans et al., 1997). In addition to education, teaching assertiveness skills to children is often mentioned as a component of prevention (Brodwin et al., 2004). Yet, Baladerian (1994) cautioned that simply telling children with disabilities to say 'no' to an adult is often not useful because they are taught to highly respect and comply with adults in authority. Finally, many abuse prevention programs teach safety and self-defense skills (Crosse et al., 2001). Sobsey (1994) noted, "... it is important to recognize that many abused people with disabilities, as with other victims of abuse, face extreme power inequities that no amount of individual training can overcome" (p. 178).

Families can play a role in preventing abuse and neglect by other caregivers. A parent getting to know and being involved with a child's caretakers can serve as a deterrent. Parents should tell providers who care for and interact with their child that he or she has been trained in abuse prevention techniques and, further, they should discuss abuse awareness with their child. Rehabilitation professionals can help raise the awareness of this issue when they work with parents who have children with disabilities.

Recommendations for Rehabilitation Counselors

It is suggested that rehabilitation counselors utilize some of the suggestions identified below in order to work more effectively with clients who have been abused as children (Deaton & Hetica, 2001; Gordon, 1998; Kapala & Keitel, 2003).

1. Stay focused. Discussion of child abuse issues causes negative emotions in most counselors. To manage counseling sessions and support the person effectively, a counselor must withdraw personal feelings from the discussion. A counselor needs a balance of empathy and objectivity. At the same time, excessive story telling by the client can be counterproductive.

2. Concentrate efforts on the well being and emotional health of the client.

3. Be cautious, sensitive, and use good judgment when helping persons who have child abuse issues.

4. Focus on the needs and desires of the client. If the person does not want to discuss child abuse issues, respect and abide by this desire.

5. Empower the client. If childhood abuse is an issue, recommend agencies and organizations within the community that can help by providing treatment.

6. A client's self-concept and self-esteem may be impaired. Provide support for the individual and/or referral to a professional experienced in sexual abuse issues.

7. Assist the client in developing a network of support to help deal with essential needs.

8. Attend or facilitate workshops within the community on child sexual abuse.

9. Help the client practice responding to potentially negative reactions through the use of role playing and practice interviews.

10. Utilize group therapy. Being part of a group may help the person move from isolation and shame to growth-fostering connections.

11. Establish and build a database of community resources and agencies.

Conclusion

Children with disabilities are at greater risk for sexual abuse than children who do not have disabilities. Factors that place these children at higher risk include those that place all children at risk for sexual abuse and maltreatment, in addition to other risk factors that are more directly related to disability. These include:

* Societal attitudes about disabilities.

* People's reactions to, and interactions with, children with disabilities (including family members and non-family caregivers).

* Factors that relate to the disability itself.

* Program policies and procedures governing the care of children with disabilities by others.

Rehabilitation counselors who work with families can help prevent or lessen the opportunities for sexual abuse of children with disabilities through encouraging parents to increase their children's awareness and coping skills regarding abuse. To not alarm their children, parents can provide this information in a routine, matter-of-fact manner along with discussions of other safety information. Although even the most informed child cannot always avoid sexual abuse, children with disabilities who are prepared have a greater chance to avoid possible abusive situations or inform parents if abuse has occurred. Letting the child know he or she is loved and did nothing wrong helps the child maintain sell-esteem and face the situation realistically. Unconditional love and understanding are key characteristics in maintaining self-worth and self-esteem. In discussing abuse and violence against people with disabilities, Sobsey (1994) stated, "Before this problem can be successfully managed, society must adopt attitudes that allow all of its members to see the problem, recognize that it must be addressed, and believe that meaningful change is possible" (p. 304).

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Leo M. Orange

Oxnard College 

Martin G. Brodwin

California State University 

Martin G Brodwin, California State University, Division of Special Education and Counseling, King Hall C-1064, 5151 State University Drive, Los Angeles, CA 90032