Brief Treatment and Crisis Intervention Advance Access originally published online on December 7, 2006
Brief Treatment and Crisis Intervention 2007 7(1):25-33; doi:10.1093/brief-treatment/mhl019
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Sexually Abused Children Who Exhibit Sexual Behavior Problems: Victimization Characteristics
From the Graduate School of Education, University of Bristol
Contact author: Samantha Chromy, Lecturer, Graduate School of Education, University of Bristol, 8-10 Berkeley Square, Bristol BS8 1HH, England. E-mail: sam.chromy{at}bristol.ac.uk.
The recognition of sexual behavior problems (SBP) in children has implications for child protection. Research needs to focus on identifying factors that indicate and contribute to the development of SBP. SBP is a common aftereffect of sexual abuse, but not all sexually abused children develop SBP. The child's experience of abuse is thought to impact the development of SBP. This study used a retrospective chart review of the clinical records of 125 children who received services at a counseling center specializing in sexual abuse concerns. The children who exhibited SBP and those who did not were compared on variables related to their experience of sexual abuse. Analysis showed a statistically significant difference between the two groups on the frequency and the age of onset of abuse. The children who exhibited SBP were abused with more frequency and at a younger age than those who did not.
KEY WORDS: sexual, abuse, children, behavior, behavior problems, victim
There is increased awareness that childhood sexual abuse is perpetrated not only by adult offenders but also by children (Araji, 1997). Many adult and adolescent offenders began perpetrating or displayed sexual behavior problems (SBP) at young ages (Araji, 1997; Burton, 2000). Data from child protection agencies have indicated that 40% of all childhood sexual abuse is performed by youth under 20 years of age and up to 18% is performed by children under 13 years of age (Gray & Pithers, 1993). The incidence of sexual abuse by children is likely escalating (Vermont Social and Rehabilitation Services, 1996).
Research has indicated that few children will disclose sexual "misbehaviors," even when interviewed (Gray, Pithers, Busconi, & Houchens, 1999). The recognition of SBP in children, and those at risk for developing such problems, is of vital importance in order to facilitate early treatment and prevention. Such recognition has important implications for child protection. Research needs to focus on identifying the factors that indicate, and contribute to, the development of SBP in children.
SBP in Sexually Abused Children
A number of studies have reported that the presence of SBP appears to be one of the most common aftereffects of sexual abuse (Gray, Busconi, Houchens, & Pithers, 1997; Gray et al., 1999). In a review across 13 studies regarding children's sexual behavior, of 1,353 sexually abused children, 28% exhibited highly sexualized behavior (Kendall-Tackett, Williams, & Finkelhor, 1993). Friedrich (1995, p. 1) reported, "sexual behavior is one of the more reliable and valid markers of sexual abuse," though not all studies support this conclusion (McNicol & McGregor, 1999; Silovsky & Niec, 2002).
Although increased frequency of sexual behaviors may be one of the most common aftereffects of sexual abuse, not all sexually abused children develop SBP. In one study, for example, only 25% of sexually abused children developed SBP (Pithers & Gray, 1998). Across the 13 studies that Kendall-Tackett et al. (1993) reviewed, 28% of sexually abused children exhibited sexualized behaviors.
Friedrich (2002) emphasized the importance of assessing the characteristics of, and variables associated with, the development of SBP in sexually abused children. A number of researchers have attempted to identify the: demographics; individual, family, and victimization characteristics; and the risk factors associated with the development of SBP in sexually abused children (Friedrich & Luecke, 1988; Gray et al., 1997, 1999; Hall, Matthews, & Pearce, 1998; Pithers & Gray, 1998). The characteristics pertinent to this particular study are discussed.
Victimization Characteristics of Children With SBP
The child's experience of his or her own abuse is thought to impact the development of SBP (Hall & Matthews, 1996). Hall and Matthews (1996) identified as the most significant factors in the development of interpersonal SBP to be those related to the child's experience of his or her own sexual abuse. These included the sexual arousal of the child during the abuse, sadistic abuse, the active involvement of the child in the sexual abuse, the acting in the "offender" role in child to child acts, and the child blaming himself or herself or being ambivalent as to who is to blame for the abuse (Hall & Matthews, 1996).
Some researchers have indicated that the more severe the abuse the child experienced, the more likely they are to present SBP (Friedrich, 1993; Gray et al., 1997). Others have found no such relationship (Hall et al., 1998). Some indicators of abuse severity, which have been linked to greater psychological impact, include the presence of penetration or intercourse (Finkelhor, Hotaling, Lewis, & Smith, 1989), greater duration (Elliott & Briere, 1992) and frequency of abuse (Elliott & Briere, 1992; Friedrich, 1993), abuse at an early age (Zivney, Nash, & Hulsey, 1988), multiple perpetrators (Peters, 1988), and physically forced sexual contact (Fromuth, 1986). However, others have found that the physical intrusiveness of the abuse, the duration of the abuse, and the relationship of the child to their perpetrator was not associated with the increased likelihood of the sexually abused child exhibiting SBP (Hall et al., 1998). Simple linear connections between sexual abuse and outcome are elusive (Friedrich, 1998). There continues to be a need for additional research to clarify the relationship between the child's experience of his or her own sexual abuse and the development of problematic sexual behaviors.
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Research Question
Is there a difference between sexually abused children who exhibit SBP and sexually abused children who do not exhibit SBP, in regard to the characteristics of their experience of sexual abuse victimization?
Null Hypothesis
There is no statistically significant difference in the sexual abuse victimization characteristics of sexually abused children who exhibit SBP and sexually abused children who do not exhibit SBP, as measured by the duration of the abuse, the perpetrator's age, the frequency of the abuse, the duration of the abuse, the nature of the abuse, and the age of onset of the abuse.
Sample
The research sample for this study was children aged 4–12 years, who received services at a single outpatient counseling center specializing in the treatment of sexually abused children in Central Florida. These were children who had disclosed sexual abuse, whose family or caregivers had initiated counseling services, and who had completed the initial intake assessment between the years 1997 and 2000.
Data Collection
This experimental design was "ex post facto" as the data generated are based on a retrospective chart review of the clinical records of the identified sample. The data were derived from the initial intake assessment session. The intake assessment took place prior to therapeutic treatment, was completed by a therapist or counselor, and was based on interviews conducted with the child and parent or caregiver. It included information pertinent to therapeutic intervention, including demographic data, history of abuse, personal and family background, and psychological, behavioral, and emotional functioning. The data and clinical files were systemically coded to ensure confidentiality and protect the identities of the participants.
Data for each child subject regarding his or her experience of sexual abuse were collected. The variables included the type of sexual abuse experienced, the age of the perpetrator, the age of onset of the abuse, the frequency of the abuse, and the duration of the abuse. The type of sexual abuse experienced was classified as watching sexual activity, fondling, digital penetration, oral sex, and penetration, including rape. The age of the perpetrator, when known, was classified as under 13 years of age, between 13 and 17 years of age, and over 18 years of age. The duration of the abuse was classified as a single incident, less than 1 week duration, between 1 and 4 weeks duration, between 1 and 12 months duration, and more than 1 year in duration. The frequency of the abuse, if known, was classified as a single incident, less than once per week, once per week, more than once per week but less frequently than once a day, and daily. The demographic data on each participant collected included the child's age, race, gender, and family income.
Participants
The sample consisted of 125 children, 65.6% (82) of whom were Caucasian, 22.4% (28) were African American, 9.6% (12) were Hispanic, 1.6% (2) were Asian, and 0.8% (1) was of unknown ethnicity. The sample consisted of 58.4% (73) females and 41.6% (52) males. The mean age of the children was 7.5 years, with a range of 4–12 years and a SD of 2.60 years. The families' annual income levels were reported as 29.6% (37) earning below $15,000 per year, 12.8% (16) earning between $15,000 and $19,999, 20.0% (25) earning between $20,000 and $29,999, 16.8% (21) earning between $30,000 and $39,999, and 13.6% (17) earning over $40,000 per year. The income was not reported for 7.2% (9) of the sample.
The participants were divided into two categories, those children who reportedly exhibited SBP and those who did not. The intake assessment reviewed indicated the presence or absence of SBP in the form of a "yes," "no" or "not known" checklist. The sexual behaviors varied in terms of their nature and severity, from the least severe, such as excessive masturbation, to the most severe, including abusive acts. All were included in one category. Of the sample, 52.8% (66) reportedly exhibited SBP and 47.2% (59) reportedly did not.
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Sample Composition
Prior to testing hypotheses, mean group comparisons were performed to determine whether the two groups differed on certain demographic variables. There were no significant differences between the groups on gender, race, and income level. There was a significant difference between the groups in age, using the independent t test procedure. The children with SBP (M = 6.9, SD = 2.53 years) were significantly younger than the children without SBP (M = 8.2, SD = 2.52 years) (t = 3.00, p = .003*, df = 123).
Hypothesis Testing
Tables 1 and 2 show the descriptive statistics of the two groups on the characteristics of the children's own experience of sexual abuse. Regarding the ordinal-level data, the Mann–Whitney test of independence was used to test any differences between the two groups on the frequency of the abuse, the duration of the abuse, the nature of the abuse, and the perpetrator's age. Regarding the interval/ratio-level data, a two-tailed T test for independence was used to test any differences between the two groups on the age of onset of the abuse. To reduce the likelihood of a Type I error, the Bonferroni approach was used for this group of variables, and significance was set at the .01 significance level. That is, the significance level of .05 was divided by the number of variables tested for this group (five). By analysis with Levene's Test for Equality of Variance, equal variances were assumed for all the victimization characteristics measured. The results of the hypothesis testing are summarized in Tables 3 and 4. Statistical significance is indicated by a bold asterisk (*).
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The analysis showed that there was a statistically significant difference between the medians of the two groups on the frequency of the abuse. The children who exhibited SBP were abused with more frequency than those children who did not. There was a statistically significant difference between the age of onset of abuse between the two groups. The children who exhibited SBP were abused at a younger age than those children who did not. There was no statistically significant difference between the medians for the two groups on the age of the perpetrator, the duration of abuse, and the type of abuse.
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Discussion |
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This discussion includes a focus on the limitations of the study, the results of the analyses as they pertain to the identified hypothesis, the literature in the field that supports the findings, and the implications of the study.
Limitations
The data for the study were drawn from the clinical files of one of the largest and most comprehensive counseling programs in Central Florida specializing in the treatment of sexually abused children. Though the study was limited to children receiving services at a single site, the results may be generalizable to children in other sexual abuse treatment programs; however, the results are limited in their generalizability to a wider population.
Sample
The generalizability of the results of the current study to the larger population of sexually abused children presents limitations. This sample may not be representative of the population of sexually abused children in general. It is entirely possible that being in treatment is related to the presence of symptomatic behavior including SBP. In addition, families that seek treatment may not be representative of families where sexual abuse occurs in general. This sample was limited to children that disclose abuse and does not include children that are sexually abused and do not tell. The results of this study, though, can be specifically defined to represent a sample from the population of sexually abused children who disclose sexual abuse and enter treatment.
The sample possessed further inherent biases. The demographic data of the sample showed that the majority of families of the sample had an average annual income of less than $15,000. The treatment center provided services to clients receiving State-supported health services. It is likely that the center served a disproportionate number of low-income clients.
Missing Data
Using existing sources of data presents inherent problems regarding missing data. The clinical files reviewed in the current study relied on information gathered by multiple counselors at different time periods. Circumstances frequently arise where assessment procedures may change at a clinical setting over time or clinicians place differing emphasis on the pertinence of particular clinical information, and this is reflected in the data collected. Further, given the sensitive nature of the subject matter discussed, particular information may not be reported to the assessor. As a result, the sample contained a significant amount of missing data, and the individual subsamples for each analysis varied in size and composition depending on the response rate for the particular variable tested. Such limitations are inherent in any study reviewing post hoc data or researching a subject matter of such sensitivity.
Classification of Groups
The counselors at the agency were specifically trained in the treatment and assessment of sexually abused children, and it is probable that their assessment of the presence on absence of SBP is accurate; however, it should be considered that the appropriate classification into the two groups is affected by a lack of consensus in the field as to which sexual behaviors in children are considered problematic (Cunningham, & MacFarlane, 1991, 1996; Friedrich & Trane, 2002; Johnson & Feldmeth, 1993; Larsson & Svedin, 2001). It is unclear how the individual assessors distinguished the participants' sexual behaviors as normal or problematic. It is possible a behavior classified as problematic by one assessor may not be classified as such by another.
Additional sources of bias are inherent in a study of a matter so personal and potentially stigmatizing, and these may challenge the validity of the classification of the defined groups. Parents or caregivers may not be aware of their child's sexual behaviors, and if aware, they may not provide such information to a counselor, even if asked. Failure to provide such information may be based on their lack of recognition that particular sexual behaviors are problematic, a desire to protect their child, or a denial of the presence of such behaviors. The child may present similar reluctance to disclose (Gray et al., 1999). It might be expected that adult observations would underestimate the extent of the exploration, experimentation, and sexual activity as children are socialized from an early age into not displaying sexual behavior in public or in the family (Larsson & Svedin, 2001).
Demographic Differences Between the Groups
The two groups did not differ significantly on the demographic variables, gender, race, and income. The groups did differ significantly on the variable age. The children with sexual behaviors were younger (M = 6.86, SD = 2.53years) than the children without (M = 8.22, SD = 2.52 years). This finding supports that of Gray et al. (1999) who, using the Child Behavior Checklist (Achenbach, 1991) scale of Sex Problems, reported that younger children engaged in sexual behaviors more frequently than older children. Larsson and Svedin (2001) reported a peaking of sexual behavior in children at the age of 5 years. The findings of Friedrich and Luecke (1988) did not reflect this finding and reported that the group of sexually abused, sexually aggressive children studied had a mean age of 7.6 years, compared to 6.6 years for the group of non-sexually aggressive children.
Other differences may have been present between the groups on other variables not included in the current study. For example, children with SBP have greater instance of family distress and instability (Gray et al., 1999). Assessing such pertinent variables and performing matching between the two groups on these variables are important directions for future studies. This would minimize the likelihood that the results are biased by an intervening variable and increase the validity of the findings.
Implications
In overview of the current study, the sexually abused child who exhibits SBP, compared to the sexually abused child who does not exhibit SBP, presents a picture of a child with a more severe experience of sexual abuse victimization (see Tables 1 and 2). In general, the sexually abused children with SBP experienced more severe sexual abuse based on each measure of victimization assessed, though not all differences observed between the two were statistically significant. There were statistically significant differences between the two groups on the variables age of onset of abuse and the frequency of abuse.
A number of dimensions are thought to contribute to the severity of the sexual abuse experience, including the type of abuse, age of onset, age of the perpetrator, the frequency, and the duration (Friedrich, 2002). Penetration, including rape and intercourse, is typically considered the most severe type of abuse (Friedrich, 2002). Abuse by older perpetrators, starting at younger ages, for longer durations and with greater frequency is also typically considered more severe (Friedrich, 2002). The current study reported that those children with SBP experienced more severe forms of abuse than the children without SBP. This result supports the literature indicating that children with SBP typically have severe victimization histories (Burton, 1999; Burton, Nesmith, & Badten, 1997).
In their study comparing sexually aggressive and non-sexually aggressive children, Friedrich and Luecke (1988) reported that 100% of the sample of sexually aggressive children who had been sexually abused had experienced oral, anal, or vaginal intercourse. The Friedrich and Luecke study also reported that the frequency of the abuse in sexually aggressive children was greater than would be expected in a random sample of sexually abused children and appeared to contribute to a predilection for sexually aggressive behavior (Friedrich & Luecke, 1988). They found also that the sexually aggressive children had been abused by older perpetrators than the non-sexually aggressive children (Friedrich & Luecke, 1988). These findings were reflected in the current study.
The mean age of sexual abuse onset for children with SBP in the current study was 4.88 years, compared to 6.65 years for the children without SBP. Gray et al. (1999) in their study of children with SBP reported that the average ages of onset in their sample was between 3.3 and 4.8 years. There has been mixed evidence regarding the connection between age of onset of sexual abuse and symptomology. Several studies have indicated that earlier onset of sexual abuse is correlated with greater symptomatic behaviors, including SBP (Friedrich, 1986; Russell, 1986). Other studies have indicated that older onset may have a greater impact on child functioning (Conte & Briere, 1989), whereas others have concluded no relationship between age of onset and later effects (Gomes-Schwartz, Horowitz, & Cardirelli, 1990). The results recorded here supported the findings of McClellan, McCurry, Ronnei, and Adams (1996) that earlier onset of abuse appears to be related to the development of sexual acting-out behaviors. McClellan et al. further noted that early age of onset of sexual abuse was the most significant predictor of hypersexuality, exposing behaviors, and sexual perpetration.
It is likely that any form of sexual victimization in childhood increases the risk of mental health problems, including those regarding sexual behaviors (Berliner, 1991), although certain aspects of sexual abuse appear to be particularly associated with greater trauma and psychological impact (Briere, 1992). The research in this area in far from conclusive, however, with some studies showing an effect of one abuse characteristic and others not (Briere, 1992). It is probable therefore that more severe experiences of abuse are associated with greater trauma, greater psychological trauma, which may be acted out in a number of ways, including sexual behaviors.
The results of the current study have potential implications in the early identification of children at risk of developing SBP. The study further adds to our understanding of the development of SBP in children and the factors that may influence such development.
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Acknowledgments |
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Conflict of Interest: None declared.
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