Addressing Childhood Abuse

Assessing child abuse issues with adults is a specialized field that requires specific training necessary to assess the types and severity of abuse as well as the emotional, cognitive and physiological impact of the abuse experienced. However, many adult perpetrators will disclose experiences of childhood abuse either in the assessment process or later in treatment. It is important that the clinician conduct a basic assessment of the types and degrees of abuse the client experienced in a careful and sensitive manner. The Child Abuse History Form (see Forms) may be utilized with clients when clinicians are conducting extended evaluations (more than three hours) rather than short-term screening interviews. Once the clinician has developed some rapport with the client, this form can be utilized to pinpoint the exact types of abuse and the degree trauma experienced during childhood. TheChild Abuse Injury Form (see Forms) will assist the clinician in beginning to assess the long-term effects of the abuse and thereby facilitate the diagnostic process.

When a client discloses childhood abuse, the first step is to first let him/her talk about their experience without interrupting the process with too many questions. The therapist needs to be careful not to label certain behaviors as abusive or not, initially. This may be the first time this client has talked about his/her experiences and may primarily need validation (for how painful their experiences must have been), acknowledgement (for their courage to disclose their story in the first place) and careful questioning as to where they would like to take this work (e. g. , either to continue working on the material or just stop and resume at another time).

At some point, either individually or in the group, the therapist may ask the client specific questions about the various kinds of abuse and neglect he/she possibly experienced, explore the feelings and thoughts associated with those events and help the client understand the effects from the maltreatment. However, there are several psychological problems that can arise in addressing this issue clinically. One hand, the violence in the client's family and surrounding community may have been so normalized and considered the typical way of life, that the client can minimize its occurrence and effects. On the other hand, the violence could have been so pervasive and traumatic that the client may have trouble remembering discrete incidents, and say things like, "It was horrible", but will be unable to describe specific incidents or types of abuse. Many clients have coped with their past by "sealing over " their pain and refusing to look at what happened. For these clients, it can be very difficult for them to talk about their abuse. For these reasons, clinicians must be extremely cautious about pushing a client to address these issues before they are ready. The most prudent approach would be to let the clients talk about these experiences at their own pace, with little pressure or labeling of the experiences by the clinician.

The Psychological Effects of Abuse

The research has documented a range of behavioral, emotional, and cognitive effects of abuse and neglect on children's development. Listed below are some of the most common effects seen with both men and women. When addressing childhood abuse issues with your client, you need to determine what effects are particularly salient for that individual and how these effects impact their life today.

Recent studies have indicated a high rate of neurological impairment in individuals who experienced severe head injury earlier in life. Many of these injuries occurred as a result of child abuse. Subjective symptoms include dizziness, blackouts, headaches, amnesia and episodic rages. These symptoms have been correlated to objective neurological dysfunction.

Many studies have demonstrated a strong relationship between abuse and delinquency. There is also substantial research supporting the connection between child abuse and aggressive behavior both inside and outside the home. Some clients develop a generalize pattern of aggressive reactions to stress whereas other become withdrawn and isolated from others. These individuals may alternate between aggression and passivity with difficulty in responding in an assertive manner. Abuse of alcohol and drugs is also very common with adults who were abused as children. These chemicals serve to medicate one against painful, angry, or anxious feelings. Sexual promiscuity is not uncommon with client who experienced sexual abuse. There is some evidence that self-mutilation activate endogenous opioids thus producing a sort of high.

Emotional reactions to child abuse include adult depression, often indicated by feelings of loneliness, sadness, feeling hopeless about the future, suicidal thoughts, feeling worthless as a human being. Feelings of rage are not uncommon, which are manifested by fighting, tantrums, refusing to follow directions and general oppositional behavior. Many adults who were abused as children experience tremendous fear and anxiety. These feelings, once adaptive to living in a dangerous environment, now manifest as needing to be on one's guard; feeling a sense of impending doom; needing to be vigilant to predict future exploitation or abuse, or fearful of being hurt or humiliated by others.

Research has identified numerous cognitive reactions to child abuse. In children there may develop learning problems in school that persist into adulthood. Abused children may have difficulty with tasks requiring attention and concentration. Early and severe abuse may have resulted in organic problems that interfered in with learning processes. Some abused children may do relatively well academically as participation in school is one way of getting away from home and that trying to get good grades is one way of not calling negative attention to yourself at home. With adults this may manifest as overachievement or over-emphasis on work or non-relationship activities, such as sport or other hobbies. Additionally, a teacher may have been seen as a nurturing, positive adult influence in the child’s life.

A child's experience of abuse or neglect typically does not occur in isolation from other serious family problems. As mental health professionals, we understand child maltreatment as stemming from incompetence in the role of caregiver in a context of extreme stress without mitigating personal or social resources. These are families whose lives are out of control in many ways. The most common problems associated with child abuse include: frequent geographic mobility; parental divorce; poverty and unemployment; parental abandonment; and alcohol and drug abuse.

It important to realize that research results describe a wide range of patterns of effects and therefore most clients will present their own unique display of symptomology, diagnoses and life experiences. However, common diagnostic disorders include: post traumatic stress disorder, the range of affective disorders, substance-related disorders, dissociative disorders and eating disorders. Because of the severity of family functioning many individuals growing up experience abuse have disorders of attachment or developmental disorders giving rise to diagnoses such as narcissistic, borderline or schizoid personality disorders.

The Effects of Specific Types of Abuse

Research studies on the effects of the various types of child maltreatment on children's emotional and cognitive development indicate that behavioral effects of the various forms of maltreatment tend to be patterned after the type of abuse experienced.

The Minnesota Mother Child Interaction Project looked into the differential effects of maltreatment on children from infancy to six years of age. The groups consisted of physically abused children, verbally abused children, neglected children, victims of psychologically unresponsive parenting, and a control group.

The physically abused group at 24 months was more anxiously attached; angry, frustrated and noncompliant with their mothers, and exhibited less enthusiasm for tasks. At 42 months the physically abused group were hyperactive and distractible, lacked self control, expressed more negative affect, showed little creativity to problem solving, demonstrated low self esteem and low agency. With mothers they were noncompliant, negativistic, non affectionate and avoidant of their mothers. They lacked enthusiasm and persistence for tasks and generally had a poor quality experience. During 4-5 years in preschool they lacked self-control, were noncompliant, experienced adjustment problems and expressed a great deal of negative affect.

The verbally abused group had similar reactions to physically abuse group. The neglected children were also similar to physically abuse group; however, they seemed the unhappiest, presenting the most negative and least positive affect of all groups. The children with the psychologically unavailable mothers were also similar to the physically abuse group but were anxious-avoidant and the least able to relate to peers and adults.

All groups were reevaluated at age six and their problems persisted. The psychologically unavailable group showed a dramatic decline in cognitive and social-emotional functioning; and neglected groups had the most severe and a varied problems, because of history of deprivation in social and emotional areas as well as those pertaining to cognitive and language development.

Each group seemed to characterized by the type of abuse they experienced, physically abused children were fighting more, hostile children were more verbally abusive, neglected children were disorganized and incompetent and the psychologically unavailable group were indifferent and apathetic, reflecting the behaviors of their maltreating mothers. The children developed expectations of self and others based on their early experiences with their primary care giver(s). These children have histories that lead them to expect that they will not be cared for and/or that they will be hurt or taken advantage of and the have learned to expect that they are not worthy of being treated otherwise. Thus they behaved in ways that perpetuate those expectations.

Abuse and Attachment

Studies on attachment indicate that child maltreatment may result in disorders of attachment that result in problems in interpersonal relationships.

Recent studies suggest that many male batterers may be suffering from a disorder of attachment that results in high levels of anxiety, as well as other dysphoric mood states, when involved in intimate relationships. These men regulate their mood state by adjusting closeness and distance (degrees of attachment) or by changing their environment (controlling their partner and children). Hence many male batterers withdraw from potential conflict, inappropriately intrude on personal boundaries of others, and attempt to control the perceived external cause of their discomfort. These men are so sensitive to rejection that they are likely to interpret any disagreement or uncomfortable emotional interaction as potentially threatening. Ironically, even though these men find intimacy so threatening, they are very dependent on their partner for a sense of self — that is, who they are; their value and worth are partly determined by their partner’s love and acceptance. So when she leaves or wants a separation, the men find this situation very threatening and therefore anxiety-producing. Getting the partner to return is one way of managing this anxiety and is an attempt to soothe himself. One of the ways these men escalate their anxiety is through either conscious or unconscious thought patterns that reflect negative beliefs about self and others. These thoughts relate to global core beliefs about oneself or others. From an attachment point of view, these thoughts represent a person’s perception of himself — that is, his personal sense of worthiness (e. g. , “Am I lovable?”). These thoughts also represent one’s perception or schema of others — that is, the other’s trustworthiness or reliability (e. g. , “Will I be rejected?). Male batterers typically view themselves as either unworthy of love, untrusting that others won’t reject them, or both and therefore separation, whether it is literal or symbolic will lead to dysphoric mood states and potentially acting out aggressively.

Years of studies examining child-parent attachment patterns have yielded valuable results supporting the claim that maladaptive emotional, cognitive and behavioral patterns swiftly emerge if healthy attachment patterns between child and his or her primary caretaker do not occur. Although many of these studies look at very young and school aged children, researchers are now looking at how these attachment patterns persist into adulthood and ultimately impact interpersonal relationships.

Protective factors

Not all abused children grow up to experience serious behavioral or psychological problems. This fact raises the issue of why some abused children grow up to be relatively well-functioning individuals and non-abusive parents, while others are coping with a variety of psychological problems such as depression, alcohol abuse or chemical dependency, violent tempers, and so on, and still others become involved in the criminal justice system for committing violent crimes. A recent body of research has described a number of factors that discriminate those abused children who are more likely to have serious problems from those who are less likely to evidence serious dysfunction.

These "protective factors" include:

The presence of a warm, caring relationship with at least one adult;
Access to another warm family environment;
Intelligence level (higher being more protective);
Gender (female being more protective);
Early intervention;
Small, rather than large-sized family with more than 2 years apart between siblings.

There appears to be a direct correlation between severity if adult impairment and the severity (as measured by multiplicity of types of maltreatment, frequency, length of exposure and severity of each type) of child maltreatment, and lack of most of the protective factors. Psychotherapy can be viewed as a protective factor from further suffering of the long term effects of child maltreatment.

Memories and Childhood Abuse

For the past two years, much debate has occurred on this issue of memory as it relates to client's retrieval of experiences of child sexual abuse. Clinicians deal with the issue of memory all the time in psychotherapy. Clients may reconstruct their memories from the past week or since a symptom has begun. More psychodynamically oriented therapists will often ask the client to talk about their childhood experiences, particularly their relationships with their parents. For better or worse, the clinician has to depend on the client's memory with the understanding that it may sometimes be accurate and other times be distorted. A common example of how two people can have completely different memories is evident when a couple attempts to describe the same argument to their therapist but from completely different perspectives. Similarly, because many clinicians adhere to one clinical theory, the types of questions and materials brought into the session by the client and the types of questions asked by the therapist become heavily determined by the frame or theoretical orientation. There can become a symbiotic relationship where at times the therapist leads the client and at times the client leads the therapist.

Therefore, it would be important that before taking a child abuse history that clinicians understand how the client's memory and/or the clinician's expectations might impact the material received from such an interview.

Research in the area of memory, specifically as it relates to trauma, indicates that heightened arousal during an event it likely to promote retention over time of central focus details. The term "flashbulb memory" suggests that certain experiences are preserved as an accurate and vivid record in our mind. These memories may also carry with them an emotional tone as well. The tradeoff for this retention is the scope of focus. The person's peripheral focus memory is decreased whereas their central focus memory is increased. For example, many people who remember the assassination of JFK, probably remember what they were doing at the time their heard the news, but may not remember what day of the week it occurred, the weather or what they were wearing.

Evidence also indicates that emotionally charged events are also well retained in the memory over time. This can be a result of rehearsal (telling the story over and over again) or because of physiological encoding that occurs on the biochemical level. This encoding may be affected by numerous factors, such as the amount of arousal generated by the event, amount of attention given to the event, and the familiarity of the event. The last is particularly interesting in that it suggests that novel events are likely to be retained whereas repeated events may not stand out as vividly. Repeated events may result in a script or general pattern that is retrieved rather than one specific event. For example, a child of an alcoholic father may not remember specific events as much as the general pattern of when he came home drunk.

Most importantly, however, depending on the length of the intervening period of time, even with the most traumatic memories, the specifics may eventually fade while only the bare backbone of the memory remains.

The concern of suggestibility has been the most hotly debated aspect of this issue. Some studies have clearly shown that suggestibility can be a powerful factor in the retrieval of memories whereas others say it is overstated. In either case, there are some suggestions (suggestibility) that have been made by writers in this field to help minimize the risk of contamination and therapist liability.

Focus on enhancement of functioning rather than finding out the "truth" of what happen to cause the problems. Although, according to some, an important part of treating childhood trauma is the revisiting of the traumatic event, this does not mean necessarily taking the material at face value. It is not the truth of the event that is as important as the defusing the emotional charge and providing the client with a corrective experience through his or her relationship with the therapist.
Do not contaminate interview with suggestions, but ask the client open-ended questions that let him or her disclose and describe at their own comfortable pace.
Do no impose your values, expectations and beliefs on the client. Not everyone who has certain problems today was abused as a child. Likewise, not all abused children develop psychological problems. And lastly, not all clients who were abused, and who have problems, have them because of that abuse. There may have been other intervening factors contributing to the present problem.
Be extremely cautious in the use of hypnosis because the client's increased vulnerability to suggestions.
Use only bibliotherapy and problem focused group therapy only when the client is reasonably sure that the abuse did in fact occur and that the additional support during treatment is needed.

Lastly, it is important to remember that the majority of adults abused as child remember clearly their experiences and that for them, it is not a matter of did it happen, as much as how it did affect them. For many clients it is not whether or not the memory is accurate, but whether the memory contains essential truths that need to be expressed and validated.

Required Reading

The traumatic origins of intimate rage