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

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

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 subsequently robs the child of childhood innocence.

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 sense of victimhood.

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

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

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

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

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 considered resilience.

Cicchetti and Blender (2004) point out that predictive factors have been narrowly focused. They state, "…adequate prediction of either disturbance or resilience requires considering multiple risks and protective factors and their interplay" (p. 17325).
