Introduction

Child abuse, regardless of type, usually involves the inappropriate use of power and control over a child, typically driven by anger, poor parenting skills, lack of commitment to parenting and ensuring the well-being of the child. In sexual abuse, the perpetrator is out to seek sexual gratification through power and control over the child.

Rehabilitation

In families who are living in poverty or a poor distribution of social or family responsibility, a caregiver may experience a sense of failure that may lead to low self esteem and poor emotional control. This can result in poor frustration and anger management during crisis, which can result in abusive episodes.

Therefore in the rehabilitation, it is essential that in relevant cases, the financial and social stressors should be alleviated, or there is education and intervention regarding anger management and impulse control to reduce the risk of ongoing abuse.

Human response to trauma

There are 5 major characteristics of human responses to trauma .

• A persistence of startled response and irritability
• Tendency to have explosive outbursts of aggression
• Thoughts fixed on the trauma
• Generally constricted level of personality function
• An atypical dream life

Emotional and behavioural aspects

The child survivor of child abuse may have a post-traumatic stress disorder (PTSD). The patterns of acute PTSD are typically noted by the parent or caregivers.

The avoidant pattern is characterized by denial of the event. The child appears distant, with a lack of energy for learning and living, often appearing to be day-dreaming. These children may turn to substance abuse, display phobic behaviour (scared of certain situations), have difficulty adjusting to changes in home or school, look depressed, and exhibit conduct disorders.

The aggressive pattern is characterized by angry behavioural displays. This is a form of ‘acting out’ which may be bold or secretive. The children may test and break rules, with increased impulsiveness. The child may fight with peers and siblings or show open defiance towards adults.

If the child is able to integrate the abusive events in his young life into his belief system, that is he is able to appraise the situation and process the life event as not being his fault, he is likely not to be mentally or emotionally affected.

Abused children may act as if the trauma is happening again and have frightening dreams that have unrecognizable content. During this stage the child may have fears that the perpetrator will come and ‘get’ him just as the person did before.

The abused child may also play out the trauma either in the role of the abuser or in the role of the victim. Bullying of children who are smaller and weaker is an example of this, in an attempt to gain control over the trauma that originally happened to him.

Behaviours and thoughts of the trauma may also manifest as a dream or fantasy. This may lead to disclosures in the symbolic form of the violent act. This symbolic fantasy may lead to a psychotic reaction later.

When a child is unable to link ongoing, self-defeating, disrupting behaviours to the original abusive trauma, there is no resolution and the underlying fear persists. This leads to an inability to use new experiences to develop and grow. The child may be numb to new information, or hyperalert and distrustful.

When a child informs about Abuse…

When a child informs any adult he trusts about abuse, it is important to believe the child and report the abuse. It is far more dangerous not to believe the child and send the child home to an abuser than to believe the child, report, start an investigation and the abuser found innocent. It is important to understand that for an abused child to tell of the abuse, it is one of the most difficult and daring act of his life. If the child tells and is indeed telling the truth and no action is taken, this would potentially reinforce the child’s belief that the situation is not within his control and he is beyond rescue.

Working with children who have experienced Abuse

The child’s developmental level should be taken into consideration.

Communication with young children usually takes the form of play therapy, drawing pictures, story telling and expressive non-verbal methods. Trust has to be gained from the child and actions are performed within an environment of honesty and a display of healthy interpersonal boundaries.

Short term goal of therapy

To develop trust and communication
To empower the child to regain some control of his environment
To feel safe to explore
To realize the cause of his fears in relation to the abusive events

The child has to learn to explore, experiment and play and feel in control of his environment to heal. Health staff will also check from time to time if the child is anxious and understanding of his anxiety and fears.

Useful phrases to help the child reintegrate are :

• “It was a terrible thing that happened to you”
• “It wasn???t your fault that it happened to you”
• “Sometimes adults make bad decisions and do things that are wrong”
• “Now it is time to focus on yourself and to figure out how to get back to your everyday life”
• “Forgetting about what happened is not really the answer. Remembering what happened may be scary at first, but thinking about it in a new way can help you learn to live with it and continue to do things that other children do”

Long term goals

To help the child face past trauma without fear and anxiety
To be able to face new challenges such as peer pressure, identity and role perceptions, self esteem, and moral development

The length of treatment will depend on the nature, severity and duration of abuse and the child’s coping skills.

References

Giardino E.R., Giardino A.P. 2003. Nursing approach to the evaluation of child maltreatment.
G.W.Medical Publishing Inc., St Louis
Van der kolk B., 1987. Psychological trauma. Washington DC: American Psychiatric Press