**3. Attachment**

138 Sexual Abuse – Breaking the Silence

There are several significant factors that contribute to the deleterious outcome from childhood sexual abuse. These factors, age at time of abuse, frequency of abuse, duration and severity of the abuse, originally identified by David Finkelhor (1984), formulates the

The age of the child when the abuse occurs signifies the interruption of a normal developmental trajectory. The traumatic sexualization occurs at a time when the child is not developmentally capable of understanding and processing sexual behavior and

Frequency and duration are two issues that create anticipatory fear and hyperarousal in a child. Frequency is how often the abuse occurs during a given time period. Duration is the ongoing nature of the abuse, (e.g., months, years) and can create a sense of futility in the child in that the abuse appears to be never ending. The longer-term consequences of frequency and duration are that they contribute to the socialization of trauma, creating a

The severity of the abuse creates fear, negative feelings regarding sex, (Sprei & Courtois, 1988; Jehu, 1989) and a general physiological hyperaroused state for the child (Teicher, Andersen, Polcari, Anderson, Navalta, 2002; van der Kolk, 2011). In cases where there was

While Finkelhor (1984) discusses the traumatic sexualization of the child as the core issue creating negative outcomes it is not, in and of itself, the primary contributing factor. The closer the relationship of the offender to the child, the stronger the level of betrayal, feelings of mistrust, and a damaged world-view and belief system. Courtois (2005) states, "Abuse by a stranger does not generate the divided loyalty and resultant denial or dismissal of abuse disclosure that is the case when abuse is intrafamilial, especially when it occurs in the

The presence or absence of familial support when disclosing abuse (Paine & Hansen, 2002) is another significant factor in the recovery process. There is significant literature that addresses the notion that when one is supported and believed by family members, the ability to heal and begin the recovery process has a better prognosis (London, Bruck, Ceci, & Shuman, 2005; Priebe & Svedin, 2008). The manner in which the family responds to disclosure is also important. Families who respond with demonstrations of aggressive anger and threats to the perpetrator in front of the victim only serve to instill fear and regret about

Resilience and the interplay of genetics combined with risk and protective factors have been examined with children in high-risk environments for over 15 years. Cicchetti and Blender (2004) define resilience as, "… comprehending the factors contributing to positive outcomes

Previous anecdotal information relied on the conceptualization that social support alone (a significant family member, a teacher, etc.) could provide the at-risk child with the required coping mechanisms to mediate adversity. Social support combined with the child's innate capacity to ward off the negative aspects of adversity are thought to be the primary predictors of the child's ability to deal with and successfully survive maltreatment, and thus

disclosing, due to the nature of the adults seemingly "out of control" behavior.

extreme, on-going abuse, the child may have been physically and genitally harmed.

**2. Factors that contribute to deleterious outcome** 

"how and why" children can be so harmed by sexual abuse.

subsequently robs the child of childhood innocence.

nuclear family (involving parent and/or siblings)" (p. 95).

despite the presence of significant adversity…" (p. 17325).

sense of victimhood.

considered resilience.

Bowlby (1980) presented the significance of early caregiving experiences on the ability of a neonate to attach to its caregivers, and thus internalize "working models" or representations of positive caregiving experiences. Van der Kolk (2005) states, "A child's internal working models are defined by the internalization of the affective and cognitive characteristics of their primary relationships" (p. 402).

For humans, brain development is optimally done in a social context, that is with primary caregivers providing not only sustenance but nurturance as well. When the caregiving relationship is less than optimal or in fact abusive, such as in the cases of neglect or physical and sexual child abuse, the child will experience deleterious outcomes.

For the CSA survivor's health, neglect may have reverberations on many levels throughout his or her life. Psychological and physical health, interpersonal functioning, and overall well-being are impacted by levels of neglect. A significant consideration is that the CSA survivor may lack the primary belief that he/she is an individual of worth, deserving to take care of her physical health. Therefore, her ability to be an educated health consumer, to ask questions during medical exams, and her ability to follow-up with annual visits, required immunizations, and diagnostic testing, etc., may all be compromised.

The CSA survivor may not have experienced good role models and thus may not have learned that brushing ones teeth every day is a necessary component of good health care. He or she may not have learned about the necessity of hygiene, immunizations, and annual check-ups and treatment for childhood illnesses, such as ear infections. Not having a good role model may have taught her that these types of behaviors are not a necessary part of life and certainly not a consideration for good health.

#### **Posttraumatic Stress Disorder (PTSD), chronic PTSD, and Developmental Trauma Disorder**

CSA survivors can suffer with posttraumatic stress symptomatology and PTSD. PTSD is defined as exposure to a traumatic event in which the threat of death or serious injury or witnessing threat or serious injury or the threat to physical integrity has occurred. In addition, intense fear, helplessness, or horror responses to a traumatic event may have occurred (DSM IV, TR p. 428). Symptomatology include avoidance of the initial traumatizing event or environment, frequent dreams or nightmares of the event, intrusive thoughts and images, flashbacks – feeling as if the event is occurring again – which is generally triggered by sensory stimuli, and physiological reactivity, e.g. a heightened state of agitation, motor activity, or physical reactions.

Chronic PTSD generally occurs when there is more than one traumatic event and/or if the initial ongoing traumatic event was severe and ongoing, e.g., combat situations. The CSA survivor may have been abused by a family member as a child, experienced dating violence, married an abusive spouse, and/or may have been sexually abused again by a stranger and/or another family member. Very often, these types of lifelong traumatic experiences involve the notion that many survivors carry; that life usually entails traumatic events that

Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 141

The hypothalamic-pituitary-adrenal (HPA) axis is a mediating pathway of the stress response (Neigh, Gillespie, Nemeroff, 2009, van der Kolk, 2011) and it's the function of the HPA to modulate hormones that address stressful events. To promote survival, a chain reaction of powerful hormones and neurochemicals are produced to assist the individual in dealing with the immediate stressful event (Neigh, Gillespie, Nemeroff, 2009). Deactivation of these hormones occurs through a "negative feedback loop" alerting the individual that

However, if the stress response becomes chronic due to repeated exposure to stressors, defects at different levels of the negative feedback system, or both, the result is a sustained increase in the level of stress hormones and the initiation of pathological changes across multiple physiological systems, resulting in stress related diseases (p. 391; also see McEwen,

The sympathetic nervous system (SNS) is dominant over the parasympathetic nervous system (PNS), and will not yield to the PNS until some form of resolution takes place. Resolution can take the form of fighting, jogging, meditating (Howard, 2006). The adrenal glands release enough adrenaline to get your attention at the first sign of stress. Adrenaline also helps to "imprint" an emotional or traumatizing event. If the stress continues, the hypothalamus secretes corticotropin-releasing factor. In this process cortisol is also released. Cortisol is a steroid hormone that is produced naturally in the body to assist in the adaptive struggle when an individual is facing acute traumatic situations. When the stress or the traumatic situation is chronic, high levels of cortisol become toxic. Prolonged cortisol production impairs the immune system and thus, healing. Vulnerability to stress-related disorders and diseases, such as gastrointestinal disorders (ulcers) and heart disease commences. Chronic trauma and stress induces lower cortisol production and this decrease creates an enhanced autoimmune system. In the absence of any other illnesses, the autoimmune system will attack various systems within the body and create illnesses such as Fibromyalgia, Chronic Fatigue Syndrome, thyroid diseases, and Krohn's disease (Bergmann,

Minor results of this stress-related impairment include colds, flu, backaches, tight chest, migraine headaches, tension headaches, allergy outbreaks, and skin ailments. More chronic and life-threatening results can include hypertension, ulcers, accidentproneness, addictions, asthma, infertility, colon or bowel disorders, diabetes, kidney disease, rheumatoid arthritis, and mental illness. Killers that can result include heart

Chronic trauma, coupled with the severity of the abuse itself, has long-term devastating impact on health and mental health due to the chronicity of these physiological states.

CSA survivors may experience shame and self-blame regarding the sexual abuse and approach both mental health practitioners and health professionals with distrust, fear, and anxiety. CSA survivors may also experience a range of PTSD symptomatology that includes

**5. Mental health features of the CSA survivor that impede their health** 

danger is no longer present. Neigh, Gillespie, and Nemeroff (2009) state,

2008).

2011). Howard (2006) states,

**outcomes** 

disease, stroke, cancer, and suicide (p. 816).

avoidant behaviors, depression, and dissociation.

one cannot escape. CSA survivors with chronic PTSD often experience hyperarousal and hypervigilience that are continuous physiological states. Chronic PTSD frequently includes the inability to self-soothe and emotionally regulate. Health risk behaviors such as alcohol and substance abuse, cigarette smoking, eating disorders, and self-injurious behavior (cutting) are correlated with childhood sexual abuse. These health risk behaviors can be considered attempts by the CSA survivor, albeit poor ones, in the adaptive struggle in which self-medicating is necessary for survival. They may also be attempts to avoid intrusive memories.

The sexual abuse field has struggled with the inadequacy of the PTSD diagnosis for child victims of sexual abuse. Because the nature of sexual abuse is chronic, usually perpetrated by a caregiver, and occurs during childhood, it impacts critical periods of neurobiological development (van der Kolk, 2011). When caregivers are abusive, absent or neglectful, and/or helpless in the face of trauma, children cannot develop a sense of safety and stability that emanates from the caregiver nor can they rely on that caregiver to restore a sense of calm and reliability. The child's responses to stress become diffuse and inadequate. The ability to self-soothe and emotionally regulate – managing stress, impulsivity, and anxiety – are markedly impaired. A significant issue is that the child experiences a sense of betrayal and perceives the world as a hostile and attacking environment.

Mental health practitioners and researchers have examined the concept of complex PTSD (Herman, 1992a, 1992b) and the tentative diagnosis of Developmental Trauma Disorder (Cook et al, 2005; van der Kolk, 2005). Cook et al (2005) state, "A comprehensive review of the literature on complex trauma suggest seven primary domains of impairment observed in (traumatically) exposed children: attachment, biology, affect regulation, dissociation, (e.g., alterations in consciousness), behavioral regulation, cognition, and self-concept" (p. 392). Included in these domains are the child's worldview and functional impairments such as academic, interpersonal, legal interactions, and vocation (van der Kolk, 2005). This tentative diagnosis, yet to be wholly accepted by the trauma field, appears to encompass the chronic and devastating nature of trauma to the developing child.
