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Traumatic symptoms in sexually abused children: implications for school counselors.

School counselors have a duty to formulate strategies that aid in the detection and prevention of child sexual abuse (American School Counselor Association, 2003). School counselors are charged with helping sexually abused children by recognizing sexual abuse indicators based on a child's symptomotology and/or behavior, and understanding how this trauma may affect children in the school setting. Mandated reporting issues, talking with children and adolescents about sexual abuse suspicions, and understanding trauma symptoms and their contribution to the difficulties that sexually abused children have in school are highlighted. In addition, how school counselors can collaborate with clinicians treating sexually abused children through role-appropriate advocacy, intervention, and aftercare strategies is described.

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School counselors will be better prepared to recognize and identify cognitive, affective, and behavioral patterns of sexually abused children by understanding the outcomes of trauma and how symptoms manifest in sexually abused children, especially in the school environment. Traumatic events give rise to various symptoms and consequences that differ among affected children (Downs, 1993; Saywitz, Mannarino, Berliner, & Cohen, 2000; Webster, 2001). Children who experience the trauma of sexual abuse are no exception, as they exhibit a highly heterogeneous symptomotology (Valle & Silovsky, 2002). Trauma produces profound and prolonged changes in physiological arousal, emotion, cognition, and memory that "may sever these normally integrated functions from one another" (Herman, 1997, p. 34). These changes would necessarily affect school functioning.

Research has shown that traumatic symptoms that arise from sexual abuse may be exacerbated by the number of perpetrators; the duration, frequency, and severity of abuse; the age of the victim and of the perpetrator at onset; and the victim's feelings of responsibility, powerlessness, betrayal, or stigma at the time of the abuse (Briere, 1992a). By understanding the ramifications of sexual abuse, school counselors will be able to adjust their comprehensive guidance and counseling programs to include more appropriate intervention, aftercare, and advocacy strategies on behalf of this vulnerable population of children and adolescents.

THE SCHOOL COUNSELOR'S ROLE IN PREVENTING CHILD SEXUAL ABUSE

The American School Counselor Association's (ASCA, 2003) position statement regarding the school counselor's role in child abuse and neglect prevention reflects ASCA's assertion that school counselors are legally, ethically, and morally responsible for reporting suspected cases of child abuse to the proper authorities. Furthermore, ASCA suggested that counselors should demonstrate an understanding of child abuse problems, recognize and detect indicators of abuse, and provide strategies for preventing and combating the cycle of child abuse. Clearly, school counselors may be integrally involved in prevention and intervention efforts to support sexually abused children and adolescents in the school setting.

Programs aimed at preventing child abuse may target different levels of prevention (i.e., primary, secondary, or tertiary) and different populations of people in positions to help sexually abused children (e.g., school personnel, students, parents/guardians, and community members). Primary prevention efforts are those aimed at a broader audience that address underlying societal causes of maltreatment (Geeraert, Van den Noortgate, Grietens, & Onghena, 2004). They may include advocating for a ban on corporal punishment in schools (ASCA, 2003; Geeraert et al.). Secondary prevention efforts are those aimed at specific groups at risk for maltreatment, such as students, that attempt to decrease the risk factors (Geeraert et al.). They may include providing classroom guidance lessons to all students about personal safety and sexual abuse prevention (Hollander, 1992; Schmidt, 2004); psychoeducational presentations to parents explaining how to talk in developmentally appropriate ways to children about protecting their bodies or how to recognize the signs of potential perpetrators in the community (Finkelhor, Asdigian, & Dziuba-Leatherman, 1995; Stop It Now! Georgia, n.d.); or coordinating efforts for other professionals to educate children about sexual abuse prevention (e.g., Hayward & Pehrsson, 2000; Sloan & Porter, 1984).

Tertiary prevention efforts are those aimed at specific groups for whom maltreatment has already occurred (Geeraert et al., 2004). These may include providing training to school personnel that focuses on recognition of abuse indicators and reporting procedures, referring suspected abuse cases to the proper child protection authorities, and collaborating with outside child protection and other treatment agencies to coordinate successful intervention and aftercare for the child and support for the family in the school setting (ASCA, 2003; Hollander, 1992; Schmidt, 2004; Webster, 2001). Because these tertiary prevention efforts are dependent on recognizing indicators of sexual abuse, it is pertinent to discuss what these indicators are in observable terms (i.e., physical and behavioral signs of abuse) so that school counselors can help other school personnel recognize these indicators and so school counselors may best proceed in gathering information that will be helpful in making a report to the proper authorities.

RECOGNIZING ABUSE INDICATORS

ASCA (2003) emphasized the crucial role that school counselors play in the early detection of abuse and in breaking the cycle of child abuse. During 2004, an estimated 477,755 children were found to be victims of maltreatment, with 9.7% of those (or approximately 46,343 children) being sexually abused (U.S. Department of Health and Human Services [USDHHS], 2006). As mandated reporters of child abuse in all 50 states, school counselors and other educators are responsible for reporting suspicions of child abuse or neglect to the appropriate local authorities. Of all professionally reported cases of child abuse in the United States in 2004, educators filed the highest average number of mandated reports (16.5%), though law enforcement professionals filed the highest average number of sexual abuse reports (26.5%; USDHHS).

Although it is beyond the scope of the school counselor to conduct a formal interview about the abuse or clinically treat substantiated cases of abuse, as these activities require specialized skills and training (Cole, 1995), school counselors can be helpful in gathering pertinent information that aids in child protection or therapy services being rendered. This information may include demographic information, such as names and ages of people (and especially other children) actually living in the home, which may differ from official school records, brief details about any signs or symptoms reported to the counselor (e.g., bruises, asking to use the restroom frequently), and how the child feels about the situation (i.e., afraid to go home or to see a particular person). Briere and Scott (2006) noted that much data may be gathered when speaking informally or in an unstructured context with a client. School counselors have the opportunities to observe students' interactions with teachers, peers, and others, as well as when students meet with them individually, in groups, or during classroom guidance sessions. Different signs of abuse may be evident and noted during these interactions or reported to the school counselor by teachers or other school staff members, such as the school nurse. It is particularly important to attend to any signs or suspicions of abuse early on, as untreated abuse-related distress and abuse-specific coping mechanisms generalize and exacerbate over time (Briere, 1992a) and may manifest in different school-related troubles.

Physical Indicators of Abuse

Although signs of physical abuse are often easier to see than signs of sexual or emotional abuse or neglect, there are different physical and behavioral indicators that, when noticed by teachers, school nurses, or school counselors themselves, should raise suspicion of an at-risk situation and possibly of sexual abuse. These indicators may include but not be limited to difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching in the genital area; frequent urinary or yeast infections; bruises, bleeding, or lacerations in the external genitalia area; or presence of a sexually transmitted disease (Cobb County Department of Family and Children's Services: Child Protective Services [Cobb County CPS], 2005).

Teachers, because of the large amount of time they spend with students, and nurses to whom children may report physical problems, may be the first to become aware of physical indicators of sexual abuse. Children often may ask to go to the bathroom or to see the school nurse due to the nature of the itching, swelling, or other sensations they may experience. School counselors can ask teachers and school nurses to alert them to these symptoms should they occur frequently. In this way, school counselors may be able to talk with the child to better understand the circumstances surrounding the symptoms or behaviors and refer him or her for further medical follow-up.

Behavioral Indicators of Abuse

Behavioral indicators of abuse may include but not be limited to inappropriate sex play or advanced sexual knowledge or promiscuity; lack of emotional control; sudden school difficulties; withdrawal or depression; excessive worry about siblings; difficult peer relationships or resisting involvement with peers; self-imposed social isolation; avoidance of physical contact or closeness; or sudden massive weight change, be it loss or gain (Cobb County CPS, 2005). Sexualized behavior in the form of age-inappropriate sexual knowledge, excessive masturbation, seductive behaviors, and sexualized play behaviors is often considered the hallmark symptom of sexual abuse and is most often studied in comparisons between sexually abused children and their nonabused peers (Friedrich, 1993; Kendall-Tackett, Williams, & Finkelhor, 1993). Homeyer (2001) stated that children use their behavior to communicate, and it is the responsibility of the adults around them to try to understand what they are trying to say. Because "toys are used like words by children, and play is their language" (Landreth, 2002, p. 16), a child's play behaviors also may raise suspicions of sexual abuse that warrant further follow-up by the school counselor.

PLAY BEHAVIORS AS INDICATORS OF ABUSE

Children and adults, alike, often reenact the traumas they have experienced in an attempt, most theorists believe, to heal from the experiences (Herman, 1997). Terr (as cited in Herman) found that children's play often revealed evidence of traumatic memory, as children are often not able to verbalize the nature of their traumas. These behaviors may be noted in play therapy or counseling sessions, where the child feels more comfortable and safe expressing himself or herself, but also in other play contexts, such as during physical education or recess, or other non-instructional times, such as lunchtime.

Ater (2001) categorized sexually abused children's play during play therapy sessions in several different ways, such as abreactive, aggressive, dissociative, nurturing, perseveration, regressive, and sexualized. Each of these is discussed in turn to illuminate the behaviors and how they may be indicative of abuse history. It is also prudent to note that the presence or absence of any of these behaviors does not, in and of itself, indicate that sexual abuse occurred. However, children who have disclosed sexual abuse frequently exhibit these play behaviors during play rimes. Additionally, a one-rime observation of these behaviors may not warrant suspicion of sexual abuse; notwithstanding, consistent and repeated observations of these behaviors over time and other behaviors that are not characteristic for the child should raise suspicion that warrants further follow-up.

Abreactive Play Behaviors

Abreactive play behaviors are reenactments of the trauma repeated again and again, and they may literally represent the abuse that occurred (Ater, 2001). Sexually abused children and adults often feel a need to re-create their traumas (Ater; Herman, 1997) in order to integrate the experiences into their life stories (Findling, Bratton, & Henson, 2006; Herman). Some children and adolescents may draw pictures of the abusive acts that happened, tell stories about it, or use dolls, puppets, or other types of stuffed animals to show the things that happened to them. These reenactments may be more literal, in showing exactly what the child reported, or they may be more figurative in nature, where monsters are drawn or aggressive puppets, such as alligators, are used in order to re-create abusive acts.

Aggressive Play Behaviors

Aggressive play may be related to the sexual abuse experiences or may reflect the child's overidentification with his or her abuser (Ater, 2001). Some children may hit a Bobo doll; punch or kick a punching bag; or use other toys, such as plastic guns, knives, handcuffs, or belts, to act out aggressively on dolls or puppets. In addition, these children or adolescents may yell, express anger, or make threats while in the playroom or outside of it to imitate their abuser's actions.

Dissociative Play Behaviors

Playing without being connected to the play theme (i.e., being emotionally and cognitively distant from what he or she is doing), becoming quiet, and appearing to stare into space are examples of dissociative play (Ater, 2001). Dissociation is a common trauma-related symptom (Herman, 1997). One 10-year-old boy often scooped sand with his hand or with a shovel, held a funnel over the sand tray, and poured the dry sand into a small pile during nondirective play therapy. Although the play therapist tracked his play, he remained quiet and stared at the sand. Water is another material often used in dissociative play (Ater).

Nurturing Play Behaviors

Sexually abused children often will use nurturing play to express the lack of nurturing they have experienced and their need to be nurtured (Ater, 2001). Children may take care of dolls or cook food and feed the counselor or dolls (Ater). In addition, other nurturing actions may involve using a medical kit and placing bandages on dolls, the counselor, or himself or herself; listening to his or her heart or to the counselor's; or giving immunizations with a play syringe. Older children may give compliments or attend to their appearance, hair, or makeup, or that of others.

Perseverant Play Behaviors

Ater (2001) described perseverance play as "a constant, monotonous, ritualized reenactment of the trauma" (p. 122) that "differs from abreactive play in that the children are not able to 'change' the ending to create hope for themselves" (p. 122). This reenactment, again, may be literal or figurative, and it may be repeated across several sessions. What differentiates perseverance play, however, is that the ending is usually the same and is desperate. For example, one 9-year-old boy always set up different army men in the sand tray to do battle with a small group of monsters. In the same manner each time, each line of the regiment was killed by a monster-type figure and eaten by one bigger monster. This child not only had been orally and anally sodomized by an adult male but also by other boys his age at the direction of this abuser. His play theme in the sand was not a literal representation of his abuse, but the ending was repetitive and never changed for the better.

Regressive Play Behaviors

Within regressive play, sexually abused children often will use regressive behaviors to escape from thoughts of abusive experiences (Ater, 2001). Some of these other behaviors may include thumb sucking, using a pacifier, or using baby talk or a high-pitched or baby-like voice. The use of a pacifier also has been noted in older, middle and high school aged, children. Other children may hide under tables or in other play structures, such as a tent, tube, or tunnel, to avoid or escape addressing abusive experiences.

Sexualized Play Behaviors

Ater (2001) described three different kinds of sexualized play that sexually abused children use, to (a) reenact their abuse (abuse-reactive play) in which the child may display oversexualized behaviors indicative of the way he or she was abused, (b) express their own emotional reactions to the abuse (reenactment play), and (c) gain understanding and acceptance of the fact that they were abused (symbolic play). Findling et al. (2006) also found that a particular cluster of play behaviors, when taken together, was successful in discriminating traumatized from nontraumatized children. Traumatized children had more intense play, play disruptions, repetitive play, avoidant play behavior, and negative affect. These authors stated that these play behaviors, all together, may denote posttraumatic responses in children (see Findling et al. for further discussion).

When school counselors observe some or all of these play behaviors, they should not automatically assume that sexual abuse has occurred. Other factors, such as parents' separation or divorce, birth of a sibling, death of a significant person, or normal reactions to developmental changes, also may be at the root of these play behaviors (Homeyer, 2001). Verbally acknowledging these behaviors, when noticed, may help the counselor to better understand their origins. By saying to a child, "I notice that you don't seem interested in playing today--you have also been very quiet," the counselor invites the child to comment further without requiring it. Even if the child does not verbally respond, the counselor can note the child's reaction to the comment (e.g., surprised, affirmation via head nod or smile, or no facial reaction).

Although many sexually abused children exhibit the play behaviors described above, Homeyer (2001) cautioned that sexually abused children's behavior may differ in and outside of the playroom and stated that effects of sexual abuse are more likely to be seen outside of the playroom. There are other problems that known sexual abuse survivors may have in school that also may raise suspicion of abuse or be related to other issues.

PROBLEMS SEXUAL ABUSE SURVIVORS HAVE IN SCHOOL

Soloman and Heide (2005) asserted that the publication of both human and animal studies has shown that the brains of victims of traumatic stress differ from those of subjects who had not experienced trauma. These authors also stated that changes in brain structure and physiology related to traumatic experiences are "thought to affect memory, learning, ability to regulate affect, social development, and even moral development" (p. 53). These effects of sexual abuse can clearly affect learning potential and classroom performance.

In school, these symptoms may manifest as students' inability to concentrate, complete work on time, or understand schoolwork; feeling scared, frustrated, stupid, or bad about themselves; achieving low grades; and/or being told they are lazy or slow (Lee, 1995). Lee noted that sexual abuse survivors also cope in negative ways that create problems for them in school, such as lying, making up excuses, placing blame on other people or situations for not completing schoolwork or paying attention, acting apathetic about or refusing to do homework, and getting angry at the teacher. Inability or failure to attend to the academic milieu could result in issues of promotion, retention, and dropout. In a prospective cohort study, Widom (2000) found that the group of children who were abused and neglected by the age of 11 or younger completed significantly fewer years of school and were less likely to have completed high school (fewer than half) than those in the control group (two thirds).

In addition, children who have been sexually abused also may be at risk for other types of victimization, such as physical abuse at home or bullying at school (Finkelhor, Ormrod, Turner, & Hamby, 2005). Finkelhor and colleagues explained that victim vulnerability might be better understood if one considers that some children experience multiple victimizations of differing types of violence and others do not. In a nationwide study, these researchers found that the average juvenile victim experienced three different types of victimization in separate incidents across the course of a year. Children in their study who had experienced a sexual assault of any kind also were highly likely (97%) to have been victimized in other ways, such as physical assault, witnessing the assault of another, child maltreatment, and having their property damaged or stolen. The researchers suggested that counselors inquire about the possibility of other victimizations once a child has been identified as having experienced one form of victimization.

By extension, for children who are repeatedly referred to the school counselor's office for victimizations committed against them, it may behoove the counselor to inquire about other forms of victimization, including those of a sexual nature, in order to identify more clearly and help victims of child sexual abuse. Once suspicions of abuse, sexual and other types, are raised, school counselors are mandated to report their concerns to the proper child protection authorities. School counselors also may be helpful in educating other school personnel about their mandated reporting responsibilities.

MANDATED REPORTING

Once the trauma symptomology is recognized, then the exacting and stressful tasks of mandated reporting are set into motion. At the local level, school counselors can train other educational personnel to understand the definitions of child abuse and maltreatment and to recognize the signs exhibited by abused children and those behaviors and indicators, specifically, of sexually abused children. Kesner and Robinson (2002) reported that helping educators become more familiar with the definitions and indicators of child abuse was paramount to increasing mandated reporting from educational personnel. They found that educational personnel underreported child maltreatment and also had the lowest rate of substantiated cases of abuse of all categories of mandated reporters, though only significantly less than legal personnel. This means that educational personnel were not reporting all suspicious cases and that investigators found either no evidence of maltreatment or the report was not supported by a preponderance of the evidence (N. Bailey, personal communication, January 17, 2008). One difficulty for school personnel related to reporting is in defining and understanding what "suspicion" of abuse means (Schmidt, 2004).

All school counselors should follow the written mandated reporting protocol and procedures outlined by their school district and local school administration when submitting their report to the appropriate child protection authorities, as state laws require educators to notify Child Protective Services (CPS) agencies of suspected maltreatment (USD-HHS, 2006), and failure to do so may result in penalties (Remley & Fry, 1993). Hollander (1992) suggested that the school counselor take a leadership role in establishing local school reporting procedures. In many school districts, school counselors are responsible for taking reports from teachers, other school personnel, parents, and others concerning their suspicions of abuse. In certain districts, teachers and others are considered to have met their mandated reporting obligations by having told the school counselor of their suspicions, though this may directly contradict applicable state laws, which often explicitly list teachers, administrators, and school guidance counselors among mandated reporting professionals (e.g., Remar & Hubert, 1996). Once the school counselor proceeds to speak with the child(ren), he or she must document the exchange, utilize professional discretion to decide whether a report is warranted (Foremen & Bernet, 2000; Remley & Fry), and then make official referrals to the appropriate authorities.

Professionals often are first alerted to sexual abuse concerns from a third party (Foremen & Bernet, 2000; James & Burch, 1999). It is helpful to reporting agencies and for liability purposes for the school counselor to talk with the child and his or her siblings, if possible, to obtain more information prior to rendering a report. Additionally, Foremen and Bernet asserted that liability and retribution protection statutes are generally only applicable after performing some kind of initial inquiry into the suspicions of abuse. These authors cited a case in New York (Vacchio v. St. Paul's United Methodist Nursery School, 1995) in which a teacher reported suspicions of abuse to CPS without performing any initial inquiries into her suspicions. The judge cited the teacher's actions as grossly negligent and afforded her no protection under the mandated reporter statutes when the parents sued for unfounded and false allegations.

There is a delicate balance to strike, however, with gathering information to make a professional judgment and conducting a formal child sexual abuse interview. The latter should be left in the hands of the trained child protection authorities. Though talking to children or adolescents about suspicions of the occurrence of sexual abuse can be daunting, there are helpful things that counselors can ask and say when they suspect that sexual abuse has occurred. If information gathered from talking to children about suspicions (described below) in conjunction with other physical or behavioral indicators previously described further raise a counselor's suspicions that abuse may have occurred, the written mandated reporting policies and procedures in his or her school district should be closely followed. Recommended ways for school counselors to talk with children and adolescents about suspected sexual abuse are described next.

TALKING WITH CHILDREN AND ADOLESCENTS ABOUT SEXUAL ABUSE SUSPICIONS

Approaching a child or an adolescent to talk about the possibility that he or she may have been abused is a delicate matter. Sexual abuse is often intrusive and violent and initiated when a child is less than 8 or 9 years old by an adult in the mid-20s, usually a man (Briere, 1992a). Children who are sexually abused also are likely to experience psychological or emotional abuse in the forms of betrayal or threats and physical abuse in the forms of bodily harm or physical beatings to establish or maintain compliance (Briere). Perpetrators often induce feelings of shame, guilt, and worthlessness through blame or stigmatization (Briere; Finkelhor & Browne, 1985). For these reasons, children who have been abused are less likely to trust others, especially adults, who are supposed to protect them but from whom they have received abuse (Lee, 1995). Initiating a conversation with a child who may have experienced such abuses may incite fears within the child or adolescent of further victimization from their perpetrator or feelings of shame or embarrassment in being asked for details regarding sexual abuse.

Researchers have found that children are more likely to give accurate statements when interviewed in a warm and supportive manner (Wood & Garven, 2000). A trusted teacher or school counselor may be the first person to whom a child feels comfortable disclosing sexual abuse. Bradley and Wood (1996) found this to be the case in 13% of the 234 disclosures of child sexual abuse they examined. Victims have displayed a reluctance to discuss the subject of abuse or any specific details they may have experienced between 24% and 78% of the time (e.g., Bradley & Wood; Sorenson & Snow, 1991). Summit (1983) offered the insights that children may be afraid, confused about the nature of the abuse itself, or concerned about the potential outcome of disclosing. For these reasons, a reminder of the limits of confidentiality should be inserted at some point in time during the conversation where it seems natural to insert it.

Because sexually abused children have a difficult time trusting others, they may feel ashamed or embarrassed, or they may fear retribution from perpetrators who may have threatened them not to tell about the abuse; therefore, they may not directly disclose that they were sexually abused. Children may make an indirect disclosure, such as saying, "Mr. Jones has funny underwear" (something they should not know); they may make a disguised disclosure, such as, "What would happen if someone told her mother she was being touched in a bad way but her mother didn't believe her?"; or they may make a disclosure "with strings attached," such as, "If I tell you something, you have to promise not to tell anyone else" (Cobb County CPS, 2005). Such disclosures are vague or indirect, so using open-ended and non-leading follow-up questions and words appropriate to the child's developmental level may help to clarify what the child is trying to communicate without influencing or contaminating the statement itself (James & Burch, 1999; Wood & Garven, 2000). Foreman and Bernet (2000) stated that mandated reporters who suspect "that abuse has occurred should perform assessments that are compatible with their professional roles" (p. 191). For school counselors, such assessment may include using listening and facilitation skills and carefully observing and noting what the child says and does.

Making the child feel comfortable, listening carefully, not interrupting what the child has to say, and building rapport are also commonly recommended interviewing skills (Wood & Garven, 2000) that school counselors already regularly use. In fact, good rapport-building skills may make the difference between a child's disclosing and not disclosing (Wood & Garven), as "acceptance and validation are crucial to the psychological survival of the victim" (Summit, 1983, p. 53). DeVoe and Faller (1999) found that boys were less likely to disclose acts of sexual abuse than gifts, but once they did disclose, they provided as many details as girls. In light of these findings, the authors suggested that boys may require a longer "warm-up period" (p. 225) before they feel comfortable disclosing and talking about sexual abuse.

In its Mandated Reporter Handbook, Cobb County CPS (2005) offered several good examples of indirect disclosures and how good rapport building and listening skills may be used to obtain further clarification about possible instances of abuse. Another indirect disclosure may sound like, "My brother kept me up all night and wouldn't let me sleep." To which a counselor can reply, "I'm sorry to hear that. What was he doing to keep you up?" Another type of disguised disclosure may be used to indicate that a child knows of someone who is being maltreated. Although this may truly be the case, it is highly appropriate to ask if the child, himself or herself, is also being treated in that way. For example, the child may say, "I know someone who is being touched in a bad way." To which the counselor may reply, "That person is lucky to know someone strong and smart like you. I wonder if you can use your 'safe and unsafe touch' skills to tell me how they are being touched in a bad way?" And further follow up with, "You know a lot about safe and unsafe touches. Has anyone ever touched you in an unsafe way?"

In dealing with a disclosure "with strings attached," it is recommended that the counselor empathize with the student and also remind him or her of the limits of confidentiality in a way that reassures the student that he or she will be protected and kept safe. This may sound like,
 I'm glad that you let me know that you have
 a problem. That means a lot to me. Even
 though I cannot promise that I will keep
 your secret, I can promise that I will only tell
 people who will treat it with respect and keep
 you safe. So, what is your secret? (Cobb
 County CPS, 2005, pp. 11-12)


If a school counselor only has suspicions of abuse (i.e., the child has not indicated any type of disclosure) and wishes to ask the child about these, he or she may begin by saying something like, "I wanted you to come in today to ask you about something I'm concerned about. I want you to know that you are not in any trouble, but that I am worried and care about you." If a teacher or another school staff member has raised suspicions, it is helpful to state this along with any indicators the staff member or counselor has noticed, in order to be transparent with the child. For example,
 One of your teachers has told me that you
 have been falling asleep in class, ask to go to
 the bathroom and to the nurse a lot, and
 look very uncomfortable in your seat. Is
 there anything going on here at school or
 outside of school that I can help you with?


This open-ended beginning gives the counselor the opportunity to observe any nonverbal signs of anxiety and to follow up on those, as well as cue off of any verbal statements the child makes.

If suspicions are not confirmed, it is all right to gently say,
 I'm worried that someone may have hurt
 you or may have done something to you that
 was not OK with you. I am here to help you
 if you would like to talk, and I have some
 friends who can help keep you safe.


Using this tentative and non-leading language allows the child the opportunity to talk about any incident that may have made him or her feel uncomfortable without spoiling any potential forensic evidence (S. Stokes, personal communication, February 6, 2008). If the child does disclose abuse, there are some important next steps to take.

When a child does disclose that he or she has been sexually abused, it is important to note his or her exact words (Webster, 2001), including any slang words that he or she may use to describe body parts, actions, or other contextual details, in order to preserve valuable forensic evidence that may be used to retain and later prosecute the alleged abuser. DeVoe and Faller's (1999) study is consistent with others in that younger children may be willing and able to tell an interviewer that sexual abuse occurred. However, they noted that children may not be developmentally able to give many details or elaborate descriptions of the context surrounding the abusive acts or be willing to disclose details if embarrassment or threats were involved in the abuse. Their findings supported the notion that sexual abuse disclosure is a process that unfolds over time, rather than a discrete event.

Although indirect and disguised disclosures and disclosures "with strings attached" have been supported in the literature, it is most important for school counselors to let other trained professionals delve more deeply into the disclosure process. If a child begins to disclose alleged occurrences of sexual abuse, the school counselor should note the details disclosed, ask open-ended questions to gather relevant contextual information, and then report the child's exact words to the appropriate child protection authorities. Webster (2001) cautioned against attempting to glean specific details of the abuse or challenging the accuracy of the allegations. He also cautioned that one "must know exactly what they are doing or they may jeopardize the child's present and future safety" (p. 543) because of interviewing errors or legal missteps.

Summit (1983) stated that mental health professionals are instrumental to a child "in the crisis of the disclosure" (p. 53) in believing the child's statement and in gathering information that supports the child's statement as credible. After a counselor listens to a child or adolescent and gathers relevant information, there are several important things to say and do to reassure the child that he or she made a good choice and will be believed and protected. These include communicating that you believe what the child has said, thanking him or her for sharing such personal information with you, stating that sexual abuse is never the child's fault and that he or she made a good decision in telling, and reassuring the child that measures will be taken to ensure his or her safety.

Accurately recording notes after the session that include the child's nonverbal cues, affect, and verbal statements may provide additional protections for the child should these notes be subpoenaed at a later date (James & Burch, 1999; Webster, 2001). After concluding the session and recording notes, the school counselor should not continue to probe for more information but should allow the trained child protection authorities to do so in order to preserve the integrity of the disclosure(s) and collect other relevant information/evidence that will aid in the protection of the child and in the prosecution of the alleged offender. Those authorities are responsible for determining whether or not the reported suspicions of abuse are substantiated (i.e., whether there is enough evidence to support the suspicions; Schmidt, 2004).

For children for whom sexual abuse is substantiated by those police or other child protection authorities, further intervention is usually recommended. On the clinical treatment side, part of this intervention is better understanding which specific symptoms a child has so that treatment may be properly planned and implemented. A valid and reliable instrument that may be used to measure trauma symptoms for sexually abused children ages 8 to 16 is the Trauma Symptom Checklist for Children (Briere, 1996). It is helpful for school counselors to better understand trauma symptoms so that they can collaborate with other mental health professionals and further advocate for sexually abused children within their school.

MEASURING TRAUMA SYMPTOMOLOGY

It is important to note that sexual abuse, in and of itself, is an experience, not a diagnosis. However, the experience of being sexually abused may lead to some diagnosable disorders (Babiker & Herbert, 1998; Finkelhor & Berliner, 1995) with a great variety of symptoms reported by victims (Valle & Silovsky, 2002). Instruments widely used to measure a broader spectrum of clinical symptoms or behaviors in children and adolescents have been found to be less sensitive to the sequelae of sexual abuse (Elliot & Briere as cited in Briere, 1992b) than the Trauma Symptom Checklist for Children (TSCC).

The TSCC is "probably the most frequently used of all standardized trauma measures in the United States and Canada" (Wolpaw, Ford, Newman, Davis, & Briere, 2005, p. 159) and provides a template and framework for measuring several important dimensions of how children 8-16 years of age experience the trauma sequelae of sexual abuse. The symptom profile generated from the TSCC identifies concerns across six classic symptoms arising from sexual abuse (i.e., anxiety, depression, anger, posttraumatic stress, dissociation, and sexual concerns). When used, the TSCC helps clinicians to understand and assess an individual child's symptom profile from the child's perspective, to plan for treatment, and to gauge the child's progress (relative to symptom reduction) throughout the therapy process. Because the school counselor does not engage in these functions, he or she may not use the TSCC directly. However, under proper releases of information, the clinician can apprise the school counselor of the kinds of symptoms the child has reported and the school counselor can better collaborate in treatment efforts that are aligned with his or her role, such as coordination, advocacy, and provision of counseling-related interventions and follow-up care.

TRAUMA TREATMENT AND COLLABORATION

With adequate recognition of the abuse and measurement of the symptoms, treatment can begin on a solid foundation. Understanding methods of trauma treatment for sexually abused children enables the school counselor to provide better follow-up care and advocacy for the best interests of the child in the school setting. Schmidt (2004) suggested that the school counselor coordinate professional activities with outside agencies to ensure that primary care is provided to the child and family and to prevent "contradictory or confusing relationships from developing that would thwart the child's progress" (p. 175). Different approaches to trauma treatment and resolution exist, and it would be helpful for the school counselor to talk with the outside therapist, after obtaining all requisite releases of information, in order to understand how he or she may best support the child's treatment.

In general, there are three phases of trauma treatment that define the "inherently turbulent and complex" (Herman, 1997, p. 155) process of recovery from a traumatic event or series of events. These can be described as (a) establishing safety, which includes rapport building and installing coping strategies within the client; (b) remembering and mourning, which includes the client retelling the story, naming the horrors of the trauma, making meaning of the trauma, and mourning the losses that the trauma captured; and (c) reconnecting with others, which includes developing new relationships and creating a new future for oneself (Herman). However, progression through trauma recovery is neither a straightforward nor a linear process (Herman), and some clients may never complete the entire process. Within these different stages of recovery, child and adolescent clients will have different support needs within the school setting. The aim of this section is not to describe how to provide trauma therapy, which is beyond the scope of the school counselor's role (Remley & Fry, 1993), but to suggest, within the context of what generally occurs in trauma-focused therapy, how the school counselor may best support the interventions of the therapist while the child is in the school setting.

Stage 1: Establishing Safety

Within the first stage of establishing safety, the child will need to know that he or she will be physically protected from seeing or interacting with the perpetrator of the abuse. In the school setting, this may mean that the child will live with a foster family and transfer to another school for a certain period of time or, at the very least, that school information and emergency records be updated to prevent perpetrator contact with the child at school. The school counselor can talk discretely with other school staff to ensure that records are updated without revealing any confidential information. In addition, in the case of the child transferring to another school, the school counselor may work within the confines of the release of information to give contact information for the next school counselor to the child's outside therapist or to the parent. This way, new releases of information may be obtained and the next school counselor can coordinate school-based efforts for the child.

Also within this stage, the child will be developing a healing relationship with his or her therapist. It is important that the child experiences as much empowerment and autonomy as is safely possible (Herman, 1997). In cases of chronic abuse, children do not develop a sense of autonomy because their abuser repeatedly shatters any representations of trustworthy and dependable caretakers that people generally rely upon for coping in moments of distress (Herman). Because these children are unable to develop inner notions of security and safety, they often grow dependent on others and seek comfort and solace from external sources (Herman), which may explain why some children engage in clingy behaviors with adults whom they do trust, such as teachers, school counselors, and non-abusive caregivers. Teachers and school counselors may find the classroom management strategies outlined by Albert (2003) helpful for fostering autonomy, decisionmaking skills, limit setting, and appropriate boundary formation within sexually abused children.

Herman (1997) stated that survivors in this stage of therapy feel unsafe and out of control. In children and adolescents, these feelings may manifest through anxiety (Cohen & Mannarino, 2000), worry, or fright. For example, the child may talk excessively or ask many questions, express fears that bad things will happen, or freeze up in social or academic situations. For this reason, the greater the amount of predictability in the environment at home (Cohen & Mannarino) and at school, the easier it will be for the child to establish a sense of safety, order, and control. From this point in therapy, coping resources, such as recognizing and managing problematic feelings, thoughts, and behaviors (Soloman & Heide, 2005), are taught and practiced in order to prepare the child for trauma work. School counselors can help all children, and especially sexually abused children, build coping skills through classroom guidance lessons that teach problem-solving strategies (e.g., Shure, 2001), relaxation techniques, affect education, and self-esteem. Herman cautioned that although acute crisis symptoms may dissipate somewhat quickly, the trauma survivor is not completely recovered until he or she processes and integrates the traumatic events, which takes much more time in the later stages of recovery.

Stage 2: Remembering and Mourning

During the second stage of remembering and mourning, the child will remember and recount his or her sexual abuse experiences to the therapist and mourn the losses ensued as a result of the trauma, which may include the integrity of the child's body and the intactness of the child's social network and/or family. Some refer to this stage as the "abyss" (Brack, Brack, & Carlson, 1997; Brack, Carlson, McMichen, & Dean, 2005), as it is a deep and dark place in which the client must delve in order to resolve the traumatic experiences. The most intense part of the trauma recovery process occurs in this stage. Many sexual abuse survivors have the hardest time beginning their descent into the trauma work because of this intensity, and Oz (2005) stated that clients spend most of their time and energy in therapy before a "wall of fear" (p. 36). Some examples of such behaviors may include freezing up, not being able to complete things that one once could, and avoiding or actively resisting doing things or accepting help.

Herman (1997) noted that the client "will not be able to function at the highest level of her ability, or even at her usual level, during this time" (p. 176). This point raises a valid concern about who should or should not be informed about the child's abuse history. Confidentiality belongs to the client, the child in this case. Releases of information between an outside therapist and a school counselor do not include teachers and other school personnel unless specifically stated and consented to by the child's parent or guardian. Therefore, the number of people informed should be kept to the absolute minimum and the amount of information released also should be strictly guarded. In advocating for a child who is not functioning well, however, something may need to be said to justify a request for accommodation. In this instance, a teacher may be told that there is a "sensitive situation" the child is dealing with, the details of which cannot be revealed for the child's safety and for liability and legal concerns if the teacher knows these details, but that his or her understanding is appreciated for the period of time concerning the request. If teachers understand that they could be pulled into legal matters, such as potential court hearings that may arise as a result of the child's disclosure, they may be less inclined to inquire further and more inclined to comply with the request without hard feelings. Details regarding the disclosure or abuse also should be kept out of official school records, such as the permanent record, to which many different people have access.

Following the aforementioned recommendations on minimal disclosure, the school counselor can actively advocate for the child or adolescent to be accommodated with regards to classroom performance at this time. This does not imply that the child or adolescent be absolved of responsibility to complete assignments, but that empathy and understanding be employed as he or she struggles with the darkest parts of the abuse. The school counselor may advocate for extended deadlines or more support in completing assignments.

Because the child's intrusive symptoms need to be closely monitored at this time (Herman, 1997), school counselors may provide valuable insights to the therapist and the child's family by alerting teachers to the nature of intrusive symptoms, such as flashbacks, nightmares or negative daydreams, and negative thoughts, without revealing confidential information about the abuse. School counselors can, then, help teachers understand how to monitor such symptoms during the school day using tallies and objective descriptions of occurrences, and take the information and report it back to the therapist or parents themselves. In so doing, the school counselor can help the therapist and client evaluate the pacing of the therapeutic process without breaking client confidentiality.

While the client is reconstructing the traumatic event(s), Herman (1997) stated that conflicts typically arise with others important in the survivor's life. The child's sense of belonging often is shattered as he or she faces having to reconcile once shared values and beliefs about the world with new realities of making meaning of what the trauma destroyed and resolving differences with others. Children and adolescents may report feeling different from others their age (Cohen & Mannarino, 2000) and may isolate themselves from others. They may spend time alone, not talk to their friends, or not want to do anything that once gave them pleasure. At this time, validating and normalizing what the child or adolescent is experiencing is of the utmost importance (Herman). School counselors may do this by briefly and periodically checking in with students, providing non-trauma-related counseling about healthy friendships and other relationships, and encouraging them to continue their work in therapy, even though it may be a painful process at times.

Stage 3: Reconnecting with Others

The last stage of the trauma recovery process entails the client building new conceptions of himself or herself and more actively engaging with others and the world (Herman, 1997). Many survivors in this stage deal with an identity crisis because, until this point, they had identified as a "victim, and that is no longer appropriate; but they do not yet have an alternative identity" (Oz, 2005, p. 41). Jonzon and Lindblad (2004) noted that although children who have been sexually abused are a group that benefits from social support, they often have problems both seeking and receiving social support from others. This is an especially important task in the last stage of recovery.

Although group counseling may sound like an appropriate intervention, given the goals of this stage of recovery, some authors have cautioned against offering abuse-related group counseling to children or adolescents in the school setting, as they may not be ready or willing to share their experiences in a group and doing so may compromise their well-being (Schmidt, 2004; Smead, 1995). This type of counseling should be provided by professionals familiar with and trained to treat sexual abuse, as it can be an overwhelming and lengthy process (Remley & Fry, 1993), and confidentiality in groups can never be fully guaranteed (Jacobs, Masson, & Harvill, 2008; Smead). Groups that are not abuse focused but target communication or relationship skills, in general, may be appropriate for some children and adolescents as long as these groups work in tandem with the efforts of the outside therapist.

Group work may not be appropriate and may even be detrimental for children and adolescents who continue to experience strong feelings, symptoms, or reactions to their trauma, or who have difficulty giving and receiving feedback from others (Smead, 1995). Therefore, group members should always be carefully screened into any group (Jacobs, Masson, & Harvill, 2008; Smead), and this is especially true for children who have been sexually abused. School counselors also may use their coordination skills to pair the student with an adult mentor if the child or adolescent is willing to do so. Adult mentors can provide support, encouragement, and genuine interest in the child's life while promoting social relationships with other children.

What children come to understand in this stage is that they have been a victim of sexual abuse, that they now have control over their life, and that they can use this knowledge to further protect themselves in the future (Herman, 1997). Herman labels one goal of this stage as "learning to fight" (p. 197), which entails the victim taking calculated and planned risks to exercise new responses to perceived threats. School counselors could help children and adolescents in this stage to develop more assertiveness skills and to role-play those skills in a safe context. Herman advised that during this stage, victims focus on matters of desire and initiative. It would be fruitful for school counselors to encourage such children or adolescents to set some goals for their futures, including career goals, and to explore their creativity and imagination.

In this stage of therapy, survivors often report how strange "normality" feels (Herman, 1997), as many trauma survivors experienced chaotic home lives. Validating this experience is important as trauma survivors learn to cope with the mundaneness of ordinary life experiences. Because connecting to others is important and because adjusting to "normal life" is also a challenge for children in this stage of therapy, school counselors may use their specialized counseling, rapport building, collaboration, coordination, and advocacy skills to facilitate these therapeutic goals within the school setting.

SUMMARY

Many sexually abused children do not disclose their abuses to anyone. ASCA (2003) charges school counselors with the task of formulating strategies to help this vulnerable population in fulfilling its highest potentials academically, personally, and socially. This may begin with the recognition of sexual abuse symptoms, discussion of suspicions with the child, and referral to appropriate authorities and treatment agencies. Understanding the symptomology that sexual abuse survivors experience and how such symptoms manifest in children's and adolescents' behaviors and the school problems that result from them can be helpful in achieving these tasks. In addition, with knowledge of these symptoms and problems, school counselors and mental health professionals outside of the school setting can more easily communicate about a child's or adolescent's sequelae and collaborate in providing the best intervention and aftercare possible.

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The authors wish to thank Drs. Cathy Brack, Ken Matheny, and JoAnna White as well as the editor and reviewers for their comments on earlier versions of this article and Sheryl Stokes and Derita Swann for their input on forensic matters.

Sarah D. Brown, Ph.D., has been a school counselor educator and is currently living in Switzerland. E-mail: sarah.d.brown@mac.com

Greg Brack, Ph.D., is an associate professor and Frances Y. Mullis, Ph.D., is an associate professor emeritus at Georgia State University, Atlanta.
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