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Section 24
Childhood Sexual Abuse: A Developmental Perspective

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In the following section, I use the example of child sexual abuse to illustrate how the encapsulation of long-term trauma hinges on developmental features, and how development in turn can be disrupted by abuse. This discussion also explores how the self-memory system may be affected by sexual abuse and how psychosocial pressures, such as a family's efforts to hide the abuse, may affect the encapsulation process by encouraging the victim to actively deny or distort her memories of the trauma.

Recent studies have explored the relationship of trauma, including sexual abuse, to measures of neurophysiological functioning." This research expands the PDP developmental model by linking psychological and developmental states with biological mechanisms. For example, it appears that sexual abuse can disrupt the hormonal systems of victims. Putnam and Trickett found that sexually abused girls may have hormonal levels that are associated with high levels of sexual and aggressive behavior. Other research has found a higher than expected incidence of precocious puberty in sexually abused girls.

Bremner et al. (see also Chapter 3 in this volume) found an average 8% decrease in the volume of the right hippocampus of 26 Vietnam combat veterans. As they note, these alterations in brain morphology may be consistent with the kinds of deficits in explicit memory functioning that are seen in posttraumatic stress disorder patients. In the case of sexual abuse, physiological and psychosocial responses may work hand in hand to exacerbate the developmental problems of its victims. Abnormal hormonal responses, coupled with the possible changes in brain morphology described by Bremner et al. are some of the neurophysiological disruptions these children may face. It is important for the therapist to consider how these abnormal hormonal levels may compound the psychosocial problems of a sexual abuse victim. Clearly, a hormonally induced precocious puberty may further disrupt the psychosocial, affective, and interpersonal development of sexually abused girls by creating numerous problems at home and at school. These children, for example, may be subject to teasing and suggestive remarks by adults and their peers. This in turn could lead to self reproach and poor body image as well as learning problems due to attention deficits at school.

Sexual abuse has profound effects on the developing personality of the victim. A history of sexual abuse may in fact be linked to malevolent expectations in subsequent relationships. Severe developmental problems can occur surprisingly early in sexually abused children. Sherkow described the behavior of a child named Tina who had likely been sexually abused by her father. Tina was unable to sleep in her own bed and could not tolerate a moment's separation from her mother. She purposely defecated and urinated all around the house. Tina's play and motor movements were filled with sexually explicit gestures, and she was obsessed with the idea that men were staring at her. Tina was 2 and three-quarters years old at the time of this behavior. It is interesting to note that Tina' s precocious expressions of her sexual abuse (the explicit motor movements) were coupled with behaviors (such as the purposeful defecating) that expressed her current developmental issues around toilet training.

I believe that Tina's obscene gestures represent expressions of the sexual abuse that were incorporated directly into her self-memory. A recent study on 11-month-old babies has shown that symbolic gestures may be incorporated into a child's memory even if the child is at a preverbal level of language development. A group of children 11 months of age was exposed daily to eight spoken words (e.g., "kitty") while another group of babies was exposed to eight symbolic gestures (e.g., flapping the arms for "bird"). The researchers found that symbolic gesturing is a highly effective way for parents or other adults to communicate with young babies. Babies in the gesturing group learned a higher number of words. The addition of symbolic gestures to the babies repertoire increased their overall vocabularies. Thus, the ability to understand and communicate by using symbolic representation in the form of gestures is present before verbal communication takes place.

The researchers in this study, of course, used symbolic gesturing to positively influence children's preverbal language development. In Tina's case, however, her father's obscene posturing was a powerfully negative use of symbolic gesturing. Gestural aspects of the sexual abuse were directly incorporated into Tina's self-memory. It is important to consider how the incorporation of obscene gestures into a child's self-memory system may affect her future development. An abused child's use of explicit gestures may further exacerbate her developmental problems, as she may be ostracized from other children, scolded by adults, or otherwise suffer from assaults on her self-esteem.

Research has shown that the age at which a child is sexually abused influences her ability to recall, verbalize, and make meaning of the experience. For example, Herman and Schatzow, in their study of female outpatients who had been sexually abused as children, found a strong association between the degree of reported amnesia and the age at which the abuse first occurred. Women who reported no memory deficits were those women whose abuse had begun in or continued through adolescence. Mild-to-moderate memory deficits were usually associated with abuse that began in latency and ended by early adolescence. Marked memory deficits were associated with abuse that began early in childhood. These researchers also found that a period of prior amnesia was associated with more violent abuse.

Duration of the abuse is also a factor in the ability to remember. Terr believes that repeated trauma during childhood is more likely to result in dissociation than a one-time traumatic event. In a study of adult women with documented histories of childhood sexual abuse, Williams found that sexual abuse is more likely to be remembered at any age when the abuser is a stranger. Molestation by a stranger is more likely to be easily remembered because of its novelty or because it is more likely to be discussed with family members than would ongoing abuse by a family member.8'

From the perspective of my developmental model, abuse by a family member is a deeper assault on the self-memory system, thus increasing the likelihood of dissociation. The greater the need to protect the self, the greater are the chances that a child will dissociate. Under conditions of complete dissociation, it may be impossible to ever remember what happened, since it is not possible to have an explicit memory of something that was never taken in through the cognitive system.

Williams also found that abuse by a family member or another person close to the victim is more likely to evoke feelings of fear, guilt, conflict, and betrayal, which may lead to confusion about the experience and subsequent difficulty in remembering and making meaning of it. Also, other members of the family may try to hide or ignore the abuse, actions which communicate to the child that she should make an effort to forget the episode.

I believe that ongoing sexual abuse by a parent or close care giver is one of the deepest possible assaults to a child's self-memory system. A child's need to be soothed and held is strong; but sexual abuse serves the diabolical function of partially meeting the child's desire for parental attention and love while simultaneously attacking the child's physical and moral being. Aspects of the abuse, such as cuddling or stroking, may be experienced as pleasurable or soothing. Yet the child senses something is morally wrong. The resulting guilt can permeate the abused child's self-memory system. Her self-memory fills with shame, humiliation, and reproach. Whereas they may have a strong sense of right and wrong, young children do not have the cognitive or psychosocial skills to make more than limited moral sense of the abuse. All of us know that sexuality has the power to access the core of any individual's interiority. In sexual abuse, the child's self-boundaries are repeatedly weakened or perforated; the self has been accessed by a malevolent sexual force during a time in development when the child does not have the cognitive, moral, psychological, sensorimotor, or neurohor. monal abilities to make meaning of the event. The self-memory system walls itself off in an effort to contain the shame, guilt, and humiliation. Sequestering itself through full or partial dissociation from the cognitive system, the self-memory system may fill with malignant representations, narcissism, and omnipotent fantasies.

Developmentally, the situation of a child who experiences a one-time trauma is different from that of a child living under conditions of severe and chronic abuse. Because it may cause neuronal systems to be remodeled over and over again, chronic trauma, including ongoing abuse, may adversely affect a child's ability to learn by impeding the formation of effective meaning-making networks. Early childhood educators have long known that learning and neuronal growth are best enhanced by an enriched environment that includes a variety of developmentally appropriate activities and materials. Remedial programs such as Head Start attempt to provide underprivileged preschoolers with a super-enriched learning environment that includes music, art, writing, and drama. Chronic childhood trauma creates what I term a disenriching environment for all aspects of development, including learning. In the case of chronic sexual abuse, for example, meaning-making itself is impossible; young children simply do not have the physical, sensory, cognitive, or moral capacity to make sense of sexual contact with an adult. When chronic abuse occurs, this kind of disenriched environment for development can be present even in those homes that are filled to the brim with books, music, and art.

It is important to remember that children who are subjected to sexual abuse may also be subjected to other kinds of chronic trauma. This is especially true under severe conditions such as war or imprisonment. Rosemary, a patient, was hospitalized for severe anorexia nervosa when she was 16 years old. Rosemary was born inside a Mexican prison camp while her mother was serving a sentence for drug smuggling. Her history as an imprisoned child included sexual abuse as well as numerous other traumas which occurred on a daily basis from the moment of her birth. Rosemary was sold for sexual favors by her mother and used as a bartering chip for food and other amenities. She remained in the prison until early adolescence, when she and her mother were released by Mexican authorities and allowed to return to the United States. This horror story was confirmed by her mother and other authorities at the time of her admission into the hospital.

Both Rosemary's cognitive and self-memory systems had incorporated real and fantasized memories of trauma, which were expressed as numerous encapsulations in the sensory, motor, cognitive, affective, and psychodynamic domains. Rosemary was severely depressed, and exhibited psychotic mentation and major distortions in body image and boundary articulation. She suffered the full range of PTSD symptoms, including flashbacks and hallucinations. Because of the extent and duration of Rosemary's dissociation during childhood, she had no words to cognitively link affect and meaning-making efforts; she offered few words in therapy and mostly gestured to signal her basic needs, in therapy, we were left with many disjointed fragments, a swirling mélange of isolated images, sensations, emotions, and ideas.

Rosemary represents one of the most severe cases of ongoing childhood trauma that I have seen. I believe that Rosemary did not "witness" many of the atrocities that were perpetrated against her during childhood. Instead, she utilized dissociation to completely disengage her self-memory system from her cognitive system. Many of the traumas were in fact cognitively bypassed (not witnessed) rather than being forgotten through repression. This accounts for the fragmentary nature of her ideas, thoughts, and feelings.

Freud discussed the concept of negation in relation to repression: "The content of a repressed image or idea can make its way into consciousness on condition that it is negated" (p. 235). Negation, according to Freud, is an intellectual judgment task that requires "taking cognizance" of whatever is repressed in order to affirm or negate its content. The cognitive system is subject to this process. Self-memory, however, as the nonlinguistic meaning-making system, is always operative. In this context, then, repression is the energy that wards off or pushes away unwanted thoughts, images, ideas, events, behaviors, and feelings from the self-memory system. Because this pushing away was constant in Rosemary's case, an integrated self-memory system was impossible. Rosemary had multiple encapsulations along all developmental domains. Dissociation itself became a part of her self-memory and was necessary for physical survival in the environment. In this context, then, I define dissociation as an irnpairment to mentation, whereas I define repression as a defense of the psyche.
- Appelbaum, Paul, Uyehara, Lisa, & Mark Elin, Trauma and Memory: Clinical and Legal Controversies, Oxford University Press: New York, 1997.

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Personal Reflection Exercise #10
The preceding section contained information about a developmental perspective on childhood abuse. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 24
What were Freud's ideas on the concept of negation in relation to repression? Record the letter of the correct answer the Answer Booklet.