Child and Adolescent Social Work Journal

Volume 16, Number 2, April 1999

Post-traumatic Stress Disorder

in Childhood Sexual Abuse:
A Synthesis and Analysis of
Theoretical Models

Patrick J. Morrissette, Ph.D., NCC, LCPC

ABSTRACT: The notion that post-traumatic stress disorder (PTSD) may be
found in children who have experienced sexual abuse has become an important issue in research and clinical practice. To date however, there is a lack of
consensus on what theoretical model(s), if any, best account for PTSD within
this population. As a way of contributing to the existing body of literature
pertaining to PTSD and its relationship to childhood sexual abuse, this paper
synthesizes and presents a critical analysis of contemporary theoretical models.

As evidenced in the literature, there has been an explosion of information regarding child sexual abuse over the past decade. Within the
data pertaining specifically to the area of symptomatology, some attention has been rendered to post-traumatic stress disorder (PTSD)
(Finkelhor, 1987). In an early paper, Gelinas (1983) for example, elaborates on chronic traumatic neurosis and notes that when female survivors of childhood sexual abuse seek treatment they typically show a
characteristic of disguised presentation which can be misleading and
result in unsuccessful therapy. Gelinas affirms a report by Rosenfeld,
Nadelson, Krieger, and Backman (1979) indicating that repercussions
of incest may be, ". . . subtle and varied and multi-determined, and
may manifest themselves immediately after the event or considerably
later in life" (p. 327). According to Gelinas (1983) the symptoms and
Patrick J. Morrissette, Ph.D., NCC, LCPC is Assistant Professor, Department of
Counseling and Human Services, Montana State University-Billings.
Address communications to Patrick J. Morrissette, Ph.D., NCC, LCPC, 1500 North
30th Street, Billings, Montana, 59101-0298; e-mail: Morris@WTP.NET.
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1999 Human Sciences Press, Inc.

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problems experienced by victims of sexual abuse can be accounted for

by three underlying negative effects resulting from: (a) chronic neurosis, (b) continuing relational imbalances and, (c) increased intergenerational risk of incest.
In an effort to advance and expand an understanding of PTSD
among sexual abuse victims, Herman (1995, 1992) suggests that the
current PTSD diagnosis is inaccurate and proposes the alternative
diagnosis of Complex Post-Traumatic Disorder. She argues that the
existing criteria for PTSD are primarily derived from survivors of
circumscribed traumatic events and therefore, fails to capture the
complexity of prolonged, repeated trauma that is often experienced
by victims of sexual abuse. In her view, an expanded concept of
PTSD would include a spectrum of disorders, ". . . ranging from the
brief, self-limited stress reaction to a single acute trauma, through
simple PTSD, to the complex disorder of extreme stress that follows
prolonged exposure to repeated trauma" (Herman, 1995, p. 97).
Although there have been relatively few studies pertaining to
PTSD among sexually abused children, it appears that this specific
disorder is nevertheless significant and worthy of further investigation. For example, in their extensive review of empirical studies regarding the impact of sexual abuse, Kendall-Tackett, Meyer-Williams, and Finkelhor (1993) found that PTSD has shown to be of
consistently high frequency among sexually abused children; particularly those who were pre-school and school aged.
A careful examination of the PTSD diagnosis, and its utility with
childhood sexual abuse, is important in order to appreciate the broad
range of other distress that such abuse might incur and to clarify the
appropriate diagnosis of PTSD. In addition, in order for professionals
to gain a better understanding of PTSD among sexually abused children, it is essential that they first become familiar with the various
existing theoretical models. The current challenge is to develop a theoretical formulation that is broader than PTSD and one which distinguishes sexual abuse trauma from other forms of trauma. This paper
synthesizes and provides a critical analysis of contemporary theories
regarding PTSD and provides foundational information in an effort to
advance understanding and perhaps trigger future research.
As a way of organizing information pertaining to each theory, the
various theories have been grouped into three broad categories including internal processing models, cognitive/behavioral models, and
formative models. To summarize the information a synopsis of the

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research is also presented. A table designed to provide a quick reference of each model has been included (Appendix).
Learning Models
The Psychodynamic Model
Historically, the psychodynamic conceptualization of trauma was
based on the notion of energy overload in which the individual's stimulus barrier became overloaded (Lyons, 1987). The more recent formulations have focused on the individual's lack of schemata to assimilate the new information and the subsequent interference with daily
functioning to a significant extent.
A basic tenet of the psychodynamic perspective is that human behavior is viewed in a historical context. This means that there are
some childhood events such as sexual abuse that are linked to longterm harmful consequences and the onset of adult disorders (Beitchman et at., 1992; Friedrich, Beilke & Urquiza, 1987; Scott & Stradling, 1992). Within this framework, anxiety ensues when the ability
to cognitively process an event is thwarted. Psychodynamic models
(e.g., Horowitz, 1976; Marmar & Horowitz, 1988) assume that until a
traumatic life event is assimilated and satisfactorily integrated into
existing schemata, the psychological aspects of the event will continue to be activated in active memory storage. According to Horowitz
(1976) traumatic events provide information that must be integrated
by individuals into their view of self, of others, and of the world. For
example, a child who has been sexually abused may experience fear
at bedtime because of the recurring image and thoughts of the perpetrator.
Furthermore, the psychodynamic formulation proposes a phasic response in which individual differences are involved in the oscillation
that occurs between the intrusive experience state and the denial/
numbing state (Marmar & Horowitz, 1988). This framework of the
sequential phases of normal response (e.g., outcry, denial, intrusion
experiences, working through, and the completion of the response)
serves to organize pathological variants that may be seen as intensifications of these normal response tendencies (Marmar & Horowitz,
1988). Within this model it is possible to account for the presence of
common symptoms such as nightmares and flashbacks, the repres-

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sion of memories, denial and emotional numbing. Symptoms begin to

subside when new information that has been stored in active memory
becomes part of the individual's perception of self.
This model may account for why sexually abused victims experience nightmares and flashbacks, but is not without its limitations.
Individual differences are not accounted for in any substantial detail.
In other words, some individuals may not experience sufficient symptoms to warrant the diagnosis of PTSD. Therefore, it is possible that
psychic overload is a symptom for some children and not for others.
This model also fails to account for the particular internal or external
resources and environmental conditions that might be available to
some children in curtailing the severity of their trauma. In addition,
Finkelhor (1987) notes the following limitations: (a) it provides a superficial explanation of the trauma of sexual abuse, (b) it does not
account for the anger, the worthlessness, and the self-blame that victims often feel, and (c) it incorrectly assumes that failure to integrate
the sexual abuse experience is the problem. Finkelhor (1987) suggests
that PTSD involves an over-integration of the experience whereby,
the victim transfers the behavior learned in the abusive situation and
indiscriminately applies it to other situations.
From the standpoint of traditional psychodynamic theory and child
development, the mother as the primary caretaker, is perceived as the
main source of psychopathology (Waites, 1993). Furthermore, the emphasis on the development of psychopathology during the first few
years ignores the reality of abuse occurring over the life span. It also
bypasses the role and contribution of fathers and family dysfunction
in the perpetuation of sexual abuse (Waites, 1993).
The Trauma Learning Model
Based on the tenets of psychodynamic formulations, information theory, and theories of stress response syndromes (Hartman & Burgess,
1988), this model describes how the victimized child processes information about sexual abuse. The four major phases include: pretrauma, trauma encapsulation, disclosure, and post-trauma phases.
Such factors as the child's personality, developmental stage, and
the coping/defensive mechanisms are important considerations. This
model also explains how general anxiety symptoms emerge as the
child attempts to process the offender's behavior and the continued
abuse (Hartman & Burgess, 1988). Of equal importance is the place of
secondary learning. That is, what happens if the child discloses/con-

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ceals the abuse? The resulting behavioral responses can include a

number of possible patterns such as integrated, anxious, avoidant,
disorganized, and aggressive.
A strength of this model is its inclusion of multiple factors that
contribute to the child's conceptualization and processing of the
abuse experience. Recognition of developmental stages and the various stages of information processing can assist in identifying the
child's behavioral symptoms and strengths. The potential pattern of
response also provides a guide for enhancing assessment procedures
and treatment planning. If a pre-adolescent and adolescent were
abused by the same individual, cognitive, emotional, social, and personality differences need to be accounted for. In this model, attention is given to the child's perceptions and behavioral responses. Unfortunately, information is lacking regarding how these responses
are shaped by the nature and extent of the abuse, characteristics of
the perpetrator, the relationship of the perpetrator to the child, role
of others (e.g., teachers, counselors, social services workers) and the
role of social support. Consequently, this model would benefit from
expanding its present framework to examine the cognitive, social,
emotional, and academic ramifications of abuse.
The Social Learning Model
According to this model, what a child learns from being sexually abused
is mediated through social learning processes (Bandura, 1969, 1977).
The behavior of the offender can be viewed as,"... a form of instrumental aggression that produces sexual gratification" (Berliner & Wheeler,
1987). Sexual abuse exposes a child to social attitudes, beliefs, and
behaviors that are inappropriate and maladaptive. In addition, abuse
can interfere with the child's ability to learn healthy, adaptive ways of
being. The offender provides a modeling template for the child verbally,
behaviorally, and cognitively. For example, an abused child may come to
believe that sexual contact is an expression of love as well as a sign of
maturity. Additionally, the child may be led to believe that punishment
or threat of punishment will follow any refusal to cooperate sexually.
This process typically culminates in the child's perception of his or her
body as worthless, unacceptable, and vulnerable. Being a good child
becomes directly associated with obeying the requests or commands of
the offender.
The social learning model offers a reasonable framework for understanding some of the contextual factors pertaining to sexual abuse.

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For children who are able to report the abuse to a supportive adult,
who in turn instigates corrective action, the potency of the maladaptive learning may be reduced. This critical aspect is absent in the
social learning model. Furthermore, this model does not account for
children who exhibit a capacity to reject erroneous messages conveyed by the offender. In the counseling session, for example, there
are children who realize their innocence while acknowledging the
pathological behavior of the offender.
Contrary to the suppositions of social learning theory, children
are not equally vulnerable. Factors such as: the age of the child,
supportive influences, and the cognitive and social capabilities that
mitigate maladaptive learning need to be addressed. An additional
shortcoming of this theory pertains to the underlying perception of
the offender's behavior and influence as negative and aggressive.
What needs to be considered however, are situations wherein the
child is not threatened or punished but rather offered rewards. This
model also falls short in distinguishing the possible differences between the experiences of those children who are abused one time
and those who experience multiple abuse.
The Psychosocial Model
This model stresses the role of differences in psychological outcome as
a function of the person's experience (Green, Wilson, & Lindy, 1985).
That is, individuals who are present at the same event (sexual abuse)
will have different outcomes because their experiences vary and the
unique characteristics that they bring to the situation are also distinct. An individual's ability to gradually assimilate the traumatic
event and re-stabilize are contingent upon personal characteristics
that involve perception, understanding, and emotional processing
(Green, Wilson, & Lindy, 1985). Within this framework, the individual's coping mechanisms, personality characteristics and any preexisting psychopathology are acknowledged. Moreover, the social environment in which the event and personal processing take place may
play an important part in the child's eventual adaptation (Green,
Wilson & Lindy, 1985). For instance, victimized children are likely to
have a healthier level of adjustment over time if they are supported
by a family who takes responsible action in reporting the abuse and
seeking appropriate counseling. This scenario is in stark contrast to
situations wherein a family responds in a non-supportive fashion,
blames and ostracizes the child, and dissuades contact with appropri-

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ate professionals. In the latter scenario, the secrecy of the abuse is

maintained and the child has limited options to process the trauma
which they have experienced.
An advantage of this model is that it emphasizes individual characteristics that contribute to the psychological response and outcome with respect to post traumatic stress symptoms. Treatment
planning, in turn, can be tailored to address individual issues more
appropriately. In essence, this framework appears to be more person-centered in its approach to personal trauma. The interactive nature of this model is better suited to understanding the role of environmental factors, cognitive processing, recovery environment, and
individual characteristics in diminishing or exacerbating post traumatic stress outcome.
An overview of the aforementioned models demonstrates the need
for further examination in several areas. For example, child vulnerability tends to be generalized and as a result, individual uniqueness
warrants consideration. Additional attention is also required in the
areas of internal resources (e.g., child resiliency) and external resources (e.g., parental support and corrective measures). Furthermore, the varying degrees of symptomatology must be accounted for,
and situational versus multiple abuse discussed. Within the psychosocial model however, individual coping mechanisms and individual
characteristics are acknowledged, thus providing inroads for conceptualization and individual treatment plans.
Behavioral/Cognitive Models
The Behavioral Model
The application of the behavioral model to conceptualize PTSD is
based on two-factor learning theory (Lyons, 1987). Instrumental/operant conditioning and classical/Pavlovian theories constitute this
model. In classical conditioning, the traumatized individual encounters reflexive distress as a result of the threatening aspects of the
traumatic event (unconditioned stimuli). The presence of other neutral cues (conditioned stimulus) at the time of the trauma become
classically conditioned, thereby eliciting anxiety. Thus, if a young girl
is sexually abused by a teenage male who was entrusted with her
care, she may experience feelings of fear and anxiety when in his
presence. Such fear and anxiety may become heightened in situations

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that resemble the incident of abuse (e.g., nighttime, in the park alone
together). As the process of generalization and/or higher order conditioning ensue, the youngster might experience feelings of anxiety in
response to persons or situations that are only remotely connected to
the original abuse context (Berliner & Wheeler, 1987). For example,
she may fear going to the park, being alone with a male, or being in
the care of those aside from trusted adults. Inherently neutral cues
become classically conditioned in such a way that they also become
associated with the traumatic event. Anxiety is elicited even though
these cues do not represent inherent danger or harm.
In instrumental/operant conditioning, the individual learns to voluntarily behave in a way that elicits a desired consequence, which is
usually relief from anxiety (Lyons, 1987). The individual learns to
avoid or escape from the trauma-associated cues (both unconditioned
stimulus and conditioned stimulus) as a means of reducing anxiety.
What begins as an experience with one individual (the perpetrator)
becomes the basis for overgeneralized responses to others. Berliner
and Wheeler (1987) state that, ". . . as the processes of generalization
and/or higher-order conditioning proceed, the child might experience
anxiety in the presence of persons or lessened situations far removed
from the initial abusive experiences" (p. 419). Using the previous example, the young person may try to avoid contact with the other male
teenagers and protest whenever she is to be supervised by someone
whom she deems untrustworthy. These attempts are designed to minimize or reduce exposure to trauma-related cues and decrease personal anxiety.
According to the behavioral framework some symptoms are regarded as involuntary anxiety responses which are associated with
the UCS/CS (e.g., sleep disturbances, startle responses and nightmares) while other symptoms (e.g., emotional numbing and behavioral avoidance) are seen as instrumentally conditioned avoidance
response (Lyons, 1987). Such an explanation is plausible in some
situations. This model provides an account of how abused children
make adaptive attempts to manage their anxiety. It also accentuates
the potential for this process to contribute to maladaptive and debilitating responses. However, this account provides only one possible
explanation. Research indicates that individual differences in response to childhood sexual abuse relates to three mediating variables: severity of the abuse, availability of support, and attributing
styles with respect to the cause of negative life events (Wolfe, Gentile & Wolfe, 1989). The emphasis on the behavioral manifestations

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of the child's fear and anxiety, as well as avoidant strategies, limits

examination regarding other factors such as: the cognitive level of
the child, age, social maturity, social support, and how developmental factors play a role in diminishing the level of anxiety and avoidance responses. Furthermore, what needs to be considered are the
differences in the behavioral responses between infants, pre-school
children, elementary school children, and adolescents. This model
fails to provide an explanation of why some children who have been
victimized do not display debilitating levels of emotional numbing or
sleep disturbances while others do. By underscoring the behavioral
components of sexual trauma in childhood, other critical issues such
as trust, social relationships, self concept, intimacy, body image and
self-esteem are not addressed in this model.
The Cognitive Impact Model
Sexual abuse may not only shape a child's behavioral effects but it may
also impact their values, beliefs and attitudes. Janoff-Bulman (1985)
postulates that PTSD symptoms can be traced to a traumatic event
that can dismantle the basic assumptions about self, the world, and
reality in general. The victimization experience disturbs the personal
theories that otherwise assist in goal setting, planning, and ordering
behavior. Moreover, the experience of trauma does not provide room
for continued conformity to previously held expectations and assumptions. A child's cognitions based on prior experience can be severely
challenged and may no longer be viable (Janoff-Bulman, 1985). A boy
who has enjoyed years of companionship, social activities, and learning opportunities with his mother's boyfriend may become generally
withdrawn and isolated after being abused by this individual. No
longer does the youngster believe that his childhood is one of safety but
instead, grapples with a sense of insecurity and perceives older males
as exploitative and untrustworthy.
Within this framework, Janoff-Bulman (1985) highlights three particular types of assumptions that are affected. First, there is the belief in personal invulnerability. The aftermath of trauma may result
in the individual's realization that vulnerability and a sense of danger
are the new realities. In other words, the world is no longer a place of
safety and security. Second, there is a basic belief that the world is
just, orderly, and optimally benign. Being victimized often does not
make sense and defies the belief in social justice. The aftermath of
victimization involves the replacement of these assumptions with per-

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ceptions of danger, threat, self-questioning, and insecurity. The third

assumption pertains to the notion that individuals tend to regard
themselves as essentially decent and worthy. Such self-perceptions
and self-images are challenged. The adoption of a negative self-image
is evident in the experience of helplessness, self-blame, and powerlessness. According to Janoff-Bulman (1985), this state of disequilibrium is marked by symptoms that are characteristic of PTSD. The
re-establishing of an assumptive world that includes the victimization
experience is a vital part of the recovery process.
This model presents only a partial description of what happens to
many sexual abuse victims, and considers only some of the cognitive
impacts (e.g., I must be bad because something bad happened to me).
As suggested by Finkelhor (1987, 1990), some of the characteristic
sexual abuse symptoms, such as sexualized behavior do not fit. This
framework also raises the question of whether PTSD theories that
pertain to adults can be superimposed onto a child's experiences of
sexual trauma, given the significant differences in cognitive development and processing of information. Consideration needs to be rendered to the age and cognitive abilities of the child. That children
believe that they are safe and secure in the world is not a universal
assumption of all children, at all times prior to sexual abuse. The
same can be said of the assumption that the world is basically a benign place. Little is said in this model about the prior experiences
that can often impact the maintenance and change of cognitive assumptions. For some children, the abuse experience involves a series
of indoctrinations whereby the perpetrator uses influence, power, and
coercion to convince the child that he or she is safe and secure or that
the sexual abuse is benign. The compelling nature of the abuse relationship may result in these assumptions remaining acceptable for
the child, however temporary. The child is presented with a rational
explanation of the abuse thus, effectively reinforcing his or her indoctrination (Waites, 1993). This model does not accommodate such an
explanation.
Although it is proposed that children generally assume a sense of
security, safety, and personal worthiness, there is no mention of how
youngsters actually arrive at these conclusions. To assume that children begin with and pursue such an untainted life seems simplistic
and unrealistic. As such, the presence or absence of prior victimization needs to be recognized. According to Boney-McCoy and Finkelhor
(1995) the extent of impact and symptoms of sexual abuse may be
related to the experience of prior victimizations (sexual and non-sex-

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ual). These authors further note that additional research is needed

regarding the impact of indirect victimization on perceptions of vulnerability and also on other factors that may link this experience
with subsequent child sexual abuse.
The area of cognitive development requires attention since a child's
thinking process could influence his or her interpretation of sexual
abuse and the possible symptoms that are later manifested. A closer
examination of age differences, sense of responsibility, guilt, and the
relationship with self abuse or destructive behavior might provide
valuable information regarding some of the intervening variables that
influence the effects of abuse (Kendall-Tackett, Williams & Finkelhor,
1993). For example, research suggests that family conflict/cohesion,
and support of the child, are factors that are significantly related to
the extent of behavior problems in sexually abused children (Friedrich, Beilke & Urquiza, 1987). Lastly, PTSD-related symptoms represent only a small proportion of the symptomatology that is often observed (Kendall-Tackett, Williams, & Finkelhor, 1993) in childhood
sexual abuse. Therefore, a wider scope of post-assault functioning
needs to be explored.
The Cognitive Behavioral Model
This model shares some overlap with the cognitive impact model as
outlined by Janoff-Bulman (1985). The effects of childhood sexual
abuse may be manifested in nightmares, fears, flashbacks, hyper-vigilance, and other aversive feelings and intrusive thoughts which, in
turn, become linked with memories of the abuse or certain evocative
stimuli (Berliner, 1991; Scott & Stradling, 1992). This model accommodates the PTSD framework while punctuating the negative implications that such experiences can have on self-esteem, self-concept,
trust in others, sexuality, and a sense of personal efficacy. The dynamics of sexual abuse often are associated with inaccurate beliefs
about the victimization experience and the whys [italics added] of
such an event. Particular attention needs to be paid to modelled or
reinforced behaviors stemming from the abuse. Furthermore, it is essential to consider how the child processes the meaning of the abuse
and the extent to which there might be some identification with the
aggressor. According to this model, cognitive adjustment is a significant variable (Berliner, 1991; Wolfe, Gentile, & Wolfe, 1989). The possible negative attributions that may evolve into an attributional style,
and the result of lowered self-esteem and depression also warrant

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careful consideration (Berliner, 1991). An abused child may subscribe

to a specific belief system, however irrational, because it provides a
protective shield against uncontrollable shock or stress. For example,
a child may rationalize the abusive behavior of a parent by believing
that the abuse was for their own good or that people who love him or
her have to hurt them.
According to Goddard and Stanley (1994) the responses of a sexually abused child to the abuser has parallels with the Stockholm syndrome. The child is placed in a helpless and vulnerable position and,
like the hostage, begins to turn to and accept the explanations of the
offender. In order to survive, the child may begin to alter his or her
beliefs about self and/or the abuser. Beliefs of unworthiness and being
deserving of punishment may be incorporated in the child's cognitive
set. Furthermore, the child may become more accepting of the offender's rationale for the abuse and even develop positive feelings toward the abuser and his or her behavior (Goddard & Stanley, 1994).
Similar to other theoretical models, the cognitive-behavioral framework provides an explanation which has merit and is perhaps fitting
for some sexual abuse victims. Specifically, this model accounts for
situations in which the child does indeed experience change in his or
her own belief systems that are aligned with the abuser. However,
this framework does not accommodate exceptions. Additionally, by focusing on the cognitive experiences resulting from the abuse, other
critical experiences such as emotional reactions, changes in sleeping
patterns or academic functioning and difficulties in concentrating are
not discussed.
When carefully examining this model, questions regarding several
pertinent issues emerge such as: (a) the self efficacy and survival
strategies used by resilient children to counter or diminish the abuser's beliefs, (b) the ages of children who are likely to be most cognitively vulnerable, (c) the significance of other factors with respect to
the child's cognitive experiences of the abuse (e.g., relationship of perpetrator to child, characteristics of the victim, developmental stage of
the child, frequency/duration/intensity of the abuse, and family dynamics) and finally, (d) variables that contribute to a more favorable
cognitive outcome. According to Kiser, Heston, Millsap, and Pruitt
(1991) the development or prevention of PTSD in children is linked to
many contextual factors. The cognitive-behavioral model does not
consider some of these important elements.
The models that fall within the preceding category need to better
distinguish among age groups and to accommodate exceptions (e.g.

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resilient children). Furthermore, significant differences in cognitive

development and processing of information, requires elaboration. Due
to a focus on the individual, important contextual factors appear to be
overlooked. In an effort to advance these models, critical issues (e.g.
trust, self-concept, self-esteem) and emotional reactions need to be
considered.
Formative Models
The Developmental Model
The developmental view posits that a child moves through a series of
progressive developmental stages. Within each stage there are salient
issues linked to developmental tasks that need to be sufficiently resolved in order for the child to adapt to his or her environment.
The manner in which PTSD is manifested hinges on the developmental stage of the individual at the time of the trauma (Goodwin,
1984; Wilson, Smith, & Johnson, 1985). In general, clinical reports
support the assumption that the impact of trauma will be a function
of the developmental stage of the child (Browne & Finkelhor, 1986;
Lyons, 1987; Monahon, 1993). In a study of pre-school, school-age,
and adolescent children who had been sexually abused, it was found
that disturbed pre-schoolers displayed cognitive impairment and severe stress reactions (Gomes-Schwartz, Horowitz & Sauzier, 1985).
Furthermore, these researchers found fearfulness, destructiveness,
and aggression to characterize school-age children while adolescents
showed signs of depression, anxiety, and obsessive thoughts. Age-appropriate developmental tasks are believed to be disrupted by sexual
stimulation and pre-occupation with the sexual relationship while legitimate prior developmental needs remain unaddressed (Tharinger,
1990). Based on the belief that the indicators of trauma vary according to the child's age, developmental guidelines have been established
to summarize the signs of trauma according to what typically appears
for children ranging from infancy to age 18 years (Monahon, 1993).
Terr (1991) outlines four characteristics that are of particular relevance in traumatized children regardless of the child's age at the time
of abuse. These include: (a) strongly visualized or otherwise repeatedly perceived memories, (b) repetitive behaviors, (c) trauma-specific
fears, and (d) changed attitudes about people, aspects of life, and the
future. It appears that age shapes the child's experience of trauma

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and his or her subsequent reactions. For example, Terr (1991) contends that with the exception of children under the age of two and one
half years to three years of age, ". . . almost every previously untraumatized child who is fully conscious at the time that he or she
experiences or witnesses one terrible event demonstrates the ability
to retrieve detailed and full memories afterward" (p. 14).
Eth and Pynoos (1985) note that children, according to age, are
more or less susceptible to the effects of intrapsychic, familial, and
societal pressures. Another developmental concern is the influence of
the processes of trauma resolution with other tasks of childhood such
as play, school work, and interpersonal relationships. With respect to
overt sexual behavior problems, Tharinger's (1990) review of previous
studies has resulted in the tentative conclusion that the nature of the
overt sexual behavior problems manifested by sexually abused children varies according to age. Further research and investigation
needs to be conducted into children's coping processes, their developmental determinants, and trauma mastery so that vulnerable and resilient children can be better understood (Pynoos & Eth, 1985).
The developmental perspective enables the trauma of childhood
sexual abuse to be examined at a specific age or point in time. For
example, a youngster can be assessed for the presence of PTSD symptoms one year following the abuse experience. However, this framework also needs to address the developmental perspective over an
extended period of time in order to account for what happens to sexually abused children in terms of recovery.
Since there are many facets of development that are important considerations, the developmental framework needs to carefully examine
the effects of sexual abuse on cognitive and social development. At
each developmental stage, children's thoughts, emotions, and behaviors undergo change. As such, this framework needs to account for
these changes and the impact of sexual abuse experiences at each
stage (Kendall-Tackett, Williams & Finkelhor, 1993). Since the mid1980's, the impact of sexual abuse pertaining to the sexual functioning of children has been empirically researched (Tharinger, 1990). A
developmental approach also needs to include the multiple dimensions that contribute to and impede child development following sexual abuse experiences. Mediating variables need to be included in the
assessment and treatment process. Issues that merit serious consideration include: (a) the nature and extent of the child's emotional relationship with the perpetrator; (b) change in the status of the victimperpetrator relationship over time; (c) the status of the child's sense of

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self-efficacy and adult influence that has been instrumental in this

process; (d) the victim's relationship to peers, authority figures and
other adults; (e) the child's experience of his or her sense of self; (f)
the child's beliefs about self, the abusive event, the offender and the
future; and (g) the changes that occur with time and those factors
that influence the course of these changes.
Longitudinal research regarding developmental issues might also
elucidate important adjustment factors such as how children's coping
skills change with increasing age and how children re-conceptualize
their abuse experience over time (Black, Dubowitz & Harrington,
1994). This knowledge might also provide useful information regarding what factors might place a child at high risk with respect to the
course of PTSD.
On a cautionary note, theoreticians and clinicians need to be prudent regarding strict adherence to the developmental criteria outlined
in this model. Acknowledgment of individual differences that characterize young victims is crucial. Otherwise, those who do not meet particular age-appropriate criteria may be overlooked or inaccurately assessed and diagnosed. Understanding individual differences or factors
that contribute to resilience to sexual abuse might provide valuable
information regarding a child's capacity to thrive. A comprehensive
model must provide multi-dimensional markers that guide clinicians
and researchers as they examine the short-term and long-term implications of childhood sexual abuse.
The Traumagenic Dynamics Model
This model originated as a response to the limitations of applying the
PTSD model to sexual abuse. Finkelhor (1987) underscores the problems that plague the PTSD model and notes that it only addresses
specific symptoms and victims. A more useful model would incorporate some aspects of the PTSD model and aspects of sexual abuse that
are not identifiable under the rubric of PTSD.
In an attempt to account for the effects of sexual abuse, Finkelhor
and Browne (1985, 1988) propose a comprehensive model that presumes that the experience of sexual abuse can have different effects.
Suggested in this model is the idea that there are a variety of different dynamics to account for the variety of different types of symptoms. This approach stresses the importance of viewing the trauma of
sexual abuse as resulting from the abuse itself and the conditioning
process that exists prior to and after the abuse. The effects of sexual

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abuse depend on the character of the abuse and on four main areas of
children's development including ability to trust in personal relationships, self-esteem, sense of ability to affect the world, and sexuality
(Finkelhor, 1990).
According to this model there are four trauma-causing factors or
traumagenic dynamics that correspond to the four areas of children's
development. The four traumagenic dynamics are: betrayal, stigmatization, powerlessness, and traumatic sexualization. These dynamics
result from the abuse experience, the child's level of pre-abuse adjustment, and the impact of others' responses following the disclosure of
the abuse. As organizational constructs, the four dynamic qualities
outline how the abuse process alters the abused child's cognitive and
emotional interactions with the world, and in turn, effect the nature
and extent of ongoing trauma by distorting the child's self-concept,
world view, and affective capacities (Tharinger, 1990).
A strength of this model is the incorporation of the PTSD diagnostic
category as one distortion (affective capacities) among others (Finkelhor, 1987). As such, affective and cognitive distortions are included. A more complex assessment of the potential for trauma is
made possible by emphasizing the extent to which the abuse was
traumatically sexualizing (e.g., what was the duration of the experience) and the level of stigmatization resulting from the abuse (e.g.,
the degree to which others blamed the child after disclosure). This
model also provides a conceptualization of sexual abuse that goes beyond an event by stressing the involvement of an ongoing process
(Finkelhor, 1987). Attention is therefore rendered to the traumagenic
dynamics before, during, and after the offense (Finkelhor, 1987). For
example, some children may experience their greatest sense of powerlessness during the sexual act. Other children may find the disclosure process renders them most powerless.
The dynamics outlined are also specific to sexual abuse and do not
occur in other childhood traumas such as parental death or psychological maltreatment. By addressing sexual abuse exclusively, rather
than as one of several trauma types, a more comprehensive picture of
the course of sexual traumatization is possible. Of the models outlined, the traumagenic dynamics model holds promise with respect to
understanding the multiple factors that shape the sequelae of abuse
and recovery repercussions.
A review of the preceding two theories indicates that additional research is required regarding children's coping processes, developmental determinants, and trauma mastery to better understand vulner-

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able and resilient children. There is also a need to examine the effect
that sexual abuse has on the social and cognitive development of a
child at various stages. The multiple dimensions (e.g., relationship
with perpetrator, sense of self) that contribute to and impede child
development following the abuse warrants attention. Further longitudinal research pertaining to the recovery process would also add
substantially to the existing data.

PTSD in Childhood Sexual Abuse: Merits and Limitations

Finkelhor (1987, 1990) highlights the salutary effects that the PTSD
framework has had on the phenomenon of sexual abuse and includes:
(a) the provision of a clear label and description of a phenomenon that
victims of sexual abuse suffer from, (b) a perspective that sexual
abuse is a syndrome with an etiological core rather than simply a list
of symptoms, (c) assistance to researchers of different trauma areas
to study sexual abuse as another manifestation of their subject matter, and (d) the disempowering stigma that victims often experience
because of the inclusion of the effects of sexual abuse as a form of
PTSD.
Another advantage of the PTSD diagnosis is the notion that it normalizes the presenting problems for clients and their families, and
depathologizes the survivor (Dolan, 1991; Kirschner, Kirschner, &
Rappaport, 1993). As a diagnostic category, it is broad enough to encompass the host of symptoms often associated with sexual abuse
(Courtois, 1992). Moreover, the drawing of parallels between sexual
abuse symptoms and the causes of PTSD such as natural disasters or
car accidents helps individuals to make sense of their experiences. A
greater sense of control may emerge after a PTSD diagnosis is provided. This diagnosis also recognizes that symptoms can be predictable consequences of external events such as sexual abuse (Blume,
1990). According to Friedrich (1990) a PTSD diagnosis enables clinicians to give voice and raise awareness to the prevalence of child sexual abuse by proclaiming, "There are bad things happening to our
children; take notice [italics original], in the same manner that we
were forced to notice PTSD in Vietnam veterans" (p. 23).
The idea that sexual abuse trauma is a form of PTSD suggests an
association between sexual abuse and the understanding of other
kinds of trauma. In terms of the counseling process, the PTSD diagnostic framework allows for the identification of specific behaviors

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that may be important to address in therapy. The application of PTSD

therapies for other traumas can also offer a blueprint or model for
sexual abuse treatment (Finkelhor, 1990). Advocating the need to refocus on disruptive factors rather than categorizing clients, there is a
need to re-orient clinical treatment to how and why people become
organized (or disorganized) around past experiences.
There is the existing view that PTSD remains the best available
psychiatric framework for understanding the effect of abuse trauma
(Blume, 1990). The limitations inherent in this model however warrant ongoing investigation and further refinement. The PTSD framework appears to be forced upon the symptoms of sexual abuse as the
emphases are different (Finkelhor, 1987, 1990). In addition, PTSD
symptoms are absent for many victims of sexual abuse. For example,
the concept of PTSD does not help in understanding children who
experience abdominal pain or youngsters who bully their peers. Finkelhor (1987, 1990) warns of the inherent dangers in relying on PTSD
for diagnosing sexual abuse. For example, an erroneous conclusion
could be drawn that in the absence of sufficient symptoms to warrant
a PTSD diagnosis, a child may be perceived as being less traumatized
by the sexual abuse.
With the emphasis on assessing for pathology and symptoms, the
PTSD diagnosis may, ". . . fail to acknowledge the admirable survival
spirit and inevitability of the emotional and behavioral consequences
it describes" (Blume, 1990, p. 78). Consequently, the PTSD diagnosis
can potentially bypass human feelings and life, and overemphasize
symptoms instead. The seductiveness (Friedrich, 1990) and popularity of this framework has also resulted in clinicians randomly applying it to children who have experienced other traumas such as
family alcoholism and with children who are verbally or physically
abused (Blume, 1990).
In a comprehensive update on the early and long-term effects of
child sexual abuse, Finkelhor (1990) further highlights some of the
objections to the PTSD formulation. First, he argues that the PTSD
conceptualization seems narrow as victims of sexual abuse often experience more than symptoms that fall under this diagnostic description. Second, the PTSD conceptualization fails to consider the cognitive distortions resulting from sexual abuse that include areas such
as self-worth, family relations, and sexual behavior. Instead, there
appears to be an overemphasis on the affective realm and the constriction of affect. Third, this framework provides little guidance with
respect to individuals who may encounter problems that are not explicitly categorized as PTSD symptoms.

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Furthermore, the theory behind PTSD fails to account for the possibility that abused children who do not experience PTSD as adults are
less traumatized. In many ways, the PTSD model is inadequate in its
explanation of sexual abuse. The inherent danger in solely viewing
sexual abuse trauma as a PTSD classification is that the more serious
effects may be overlooked (Finkelhor, 1990). In a review of the literature pertaining to the applicability of the PTSD diagnosis in childhood sexual abuse, Rowan and Foy (1993) offer counter-arguments to
Finkelhor's (1990) position. The relevant points outlined include: (a)
the purpose of a diagnostic framework is to classify the main features
of a person's difficulties, not to explain specific details; (b) there are
diagnostic limitations inherent in Finkelhor's model; and (c) contrary
to Finkelhor's (1987) suggestion that PTSD lacks sufficient acknowledgment of cognitive issues, general cognitive difficulties are considered in the symptom classifications (Rowan & Roy, 1993).
Conclusion
As demonstrated in the literature, attempts have been made to effectively utilize a PTSD diagnosis with children who have been sexually
abused. Further investigation into this practice however, reveals that
the PTSD diagnosis is not as straightforward as one might initially
anticipate. The difficulty in providing a definite PTSD diagnosis is
complicated by a number of complex issues and queries.
Despite the recognized advantages of a PTSD diagnosis (e.g., a
clear label and description of a phenomenon, symptom prediction and
normalization), it is not without limitations. For instance, the uncertainty regarding what actually constitutes a traumatic event exemplifies one such pertinent issue. In addition, questions around resiliency and why some children exhibit PTSD symptoms, while others
do not, also persist. It appears that the ongoing challenge is to discover a theoretical model that is broader than PTSD, while distinguishing sexual abuse from other childhood traumatic events.
Clearly, there are a growing number of theoretical frameworks that
provide conceptualizations of post-traumatic stress in sexually abused
children. Needless to say, it would be premature for the professional
to uncritically adopt one particular framework at such an early point.
It has only been within the past ten years that the field of sexual
abuse research has become more sophisticated and has moved beyond
the examination of mere symptoms in an effort to conceptualize the
impact of sexual abuse (Finkelhor, 1990). While there is considerable

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acceptance of the conceptualization that the impact of sexual abuse

can be accounted for under the PTSD nosology, the number of debates
on the efficacy of this model is increasing.
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