Sexual Abuse of children is commonly associated with severe emotional problems. If we could keep children from being sexually abused, we could prevent considerable suffering. Unfortunately, and in contrast to other physical abuse or neglect of children, there is no known way to prevent sexual abuse. The best we can do is minimize the effect of the abuse after it has been experienced.

Treatment cannot begin for victimized children until someone learns that the abuse is taking place. When this disclosure takes place, a previously private act becomes public. Perpetrators almost never disclose their acts voluntarily---if disclosure takes place at all, it is the victim who somehow communicates. Abuse victims often do not tell, and some who do tell wait a very long time. In one study of adults, my colleagues and I documented that the average wait between cessation of abuse and disclosure was 14 years (Roesler and Wind¹).

Some may wonder why children being hurt hesitate to disclose, yet we know it is not reasonable to place the responsibility for behavior between an adult and a child on the child. Also, when it comes to believing one of two people with opposing messages, the one with more power as measured by age, size and experience, has the advantage. A child is correctly interpreting the world around her when she thinks others are more likely to believe the adult than her.

In the real world, disclosing abuse can have serious negative consequences including the breakup of the family---and, once having told, there is significant pressure to recant. Sorenson and Snow² reported that 80 percent of children in a large series eventually took back all or part of their original disclosure.

The reaction of the person to whom disclosure is made has consistently been shown to have an impact on the psychological sequellae of childhood sexual abuse. Our research demonstrated that the nature of the response to disclosure predicted the severity of symptoms experienced 25 years after the cessation of abuse (Roester³). We demonstrated that for adults who disclosed sexual abuse in childhood, primarily to close family members, those who experienced a negative response had worse scores on measures of general trauma symptoms, post-traumatic stress disorder symptoms and dissociation.

Alternatively, Fromuth⁴ found that parental support ameliorated the negative effects of child sexual abuse in a nonclinical sample of college women. In children, support from the non-offending parent was associated with better outcome in two separate studies (Friedrich et al.⁵ Everson et al.⁶).

It should be noted that when a child discloses sexual abuse to a family member, a supportive response is not necessarily forthcoming. In one study, 24 percent of mothers were judged to be unsupportive of their sexually victimized children (Everson, et al 1989). And Sauzier⁷ found that 19 percent of adolescents regretted having disclosed the abuse at 18 month follow-up.

Factors that affect the response of close family members to the disclosure include:

• Age of the disclosing person
• Who is told
• Intent of the disclosure
• Context in which disclosure occurs.

The significant people told of the abuse can be supporting or rejecting, may believe or disbelieve, may take the disclosure seriously or pretend not to hear.

Given what we know about the long term effects of sexual abuse, and the significance of the response of the support network upon learning of abuse, it makes sense to target prevention efforts on the nature of the response children receive to disclosure. Unfortunately, in today's world the family's concern often is self-preservation even if it means ignoring the needs of the affected child. Frequently, the community at large focuses on prosecuting the child molesters or, conversely, ensuring that persons accused receive a fair trial. These larger concerns leave the child at risk of not getting the support he or she needs from family members at the time when it is most valuable.

Current treatment efforts include short-term supportive psychotherapy of victimized children, and subsequent treatment for the long term effects which can include severe depression, anxiety symptoms, sexual acting out, running away, and increased alcohol and drug use.

A pilot project is underway at Hasbro Children's Hospital in Providence, R.I., to develop an immediate, crisis focused treatment intervention for children who disclose sexual abuse. We are targeting children with clear, unequivocal accounts of abuse. Many of the early participants have perpetrators who have confessed, or other objective confirmation of the disclosure. We systematically approach the existing natural support network of adults and siblings, not including perpetrators, and enlist them in validating the appropriateness of the disclosure. Though education, family therapy and multifamily therapy, we encourage an atmosphere of belief, support and affirmation.

The intervention is brief, eight to 12 weeks, and is focused on the response to disclosure. Early reactions have been encouraging. We hope to demonstrate the effectiveness of the intervention in a controlled trial beginning next year.

Thomas A. Roesler is associate professor of psychiatry at Brown University School of Medicine and director of the Hasbro Children's Hospital Partial Hospitalization Program and Family Support Program.

References:

1. :Roesler TA, & Wind TW Telling the secret: adult women describe their disclosure of incest. Journal of Interpersonal; Violence, 1994; 9:327-338.
2. Sorenson T & Snow B: How children tell: the process of disclosure in child sexual abuse. Child Welfare, 1991; 70:3-15.
3. Roesler, TA: Reactions to disclosure of childhood sexual abuse: the effect on adult symptoms. Journal of Nervous and Mental Disease, 1994; 182:618-624.
4. Fromuth ME, Burkhart BR: Long-term psychological correlates of childhood sexual abuse in two samples of college men. Child Abuse and Neglect, 1989; 13:533-542.
5. Friedrich WN, Luecke WJ, Beilke RL, Place V: Psychotherapy outcome of sexually abused boys. Journal of Interpersonal Violence, 1992; 7:396-409.
6. Everson MD, Hunter WM, Runyon DK, Edelsohn GA, Coulter ML: Maternal support following disclosure of incest. American Journal of Orthopsychiatry, 1989; 59:197-207.
7. Sauzier M(1989) Disclosure of child sexual abuse: For better or for worse. Psychiatric Clinics of North America 12: 455-469.