Chapter 1

General Introduction
 General Introduction 11

The impact of child sexual abuse (CSA) on short- and long-term mental health out-
comes has been well-established (e.g., Chen et al., 2010; Maniglio, 2009). A growing
body of research, however, highlights the importance of understanding the impact of
CSA in an interpersonal context. CSA victims’ relationships with parents, friends, and
1
romantic partners are found to both mediate and moderate the effects of CSA on
mental health (e.g., Collishaw et al., 2007; Sperry & Widom, 2013). Currently, little
is known about these relational processes among children and high-risk young adults
(i.e., delinquent, antisocial). To address these gaps in the literature, the aim of this
dissertation was to get a better understanding of the interpersonal context of CSA
and the role of relational processes in the development of mental health problems
among these understudied samples of abuse victims. Additionally, we examined the
impact of CSA on non-offending mothers’ mental health, and risk factors associated
with these mental health problems. The current chapter provides a background and
outline of the studies described in this dissertation.

Child sexual abuse: definition, prevalence, and risk factors

CSA is defined by the Consultation on Child Abuse Prevention of the World Health
Organization (WHO; 1999) as follows: “the involvement of a child in sexual activity
that he or she does not fully comprehend, is unable to give informed consent to,
or for which the child is not developmentally prepared and cannot give consent, or
that violate the laws or social taboos of society” (p. 15). This definition includes both
adult and child/adolescent perpetrators, provided that the perpetrator overpowers
and/or takes advantage of the child and the sexual activity satisfies the needs of the
perpetrator (WHO; 1999). Furthermore, sexual activity may or may not involve physi-
cal contact.
Recent meta-analyses reveal that CSA is a global and large-scale problem affecting
millions of children around the world (Pereda, Guilera, Forns, & Gómez-Benito, 2009;
Stoltenborgh, Van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011; Stoltenborgh,
Bakermans-Kranenburg, Alink, & Van IJzendoorn, 2015). Females are particularly at
risk for experiencing CSA, with global prevalence estimates ranging from 18%-19.7%
(Pereda et al., 2009; Stoltenborgh et al., 2011). Among boys, global prevalence rates
are significantly lower with estimates ranging from 7.6%-7.9% (Pereda et al., 2009;
Stoltenborgh et al., 2011). However, these findings must be interpreted with caution
in light of findings that boys are more hesitant and less likely to disclose CSA (O’Leary
& Barber, 2008; for a review, see Paine & Hansen, 2002). In the Netherlands, 9.1%
of youths (age 12-17) report having experienced CSA with equal prevalence rates for
boys and girls (Alink et al., 2012). Among adults, 19% of women and 4% of males
reported experiencing sexual violence before the age of 16 (Vanwesenbeeck, Bakker,
& Gesell, 2010).
12 Chapter 1

A number of risk factors are identified for experiencing CSA, with most factors
being related to socio-economic status and family adversity. For example, a lower
family income, parental drug and alcohol abuse, and parental discord are associated
with a higher risk of CSA (e.g., Alink et al., 2012; Collishaw et al., 2007; Fergusson,
McLeod, & Horwood, 2013; Putnam, 2003). Furthermore, children with intellectual
and physical disabilities are particularly at risk (Fergusson et al., 2013; Putnam, 2003).
In the Netherlands, the risk for CSA is higher among children in out-of-home care
(i.e., residential and foster care) with a self-reported year prevalence rate of 24.8% as
compared to 5.8% in the general population (Euser, Alink, Tharner, Van IJzendoorn,
& Bakermans-Kranenburg, 2013).

Impact of CSA on victims

Abundant evidence shows that CSA is associated with a variety of short- and long-
term negative mental health and developmental outcomes among children, adoles-
cents, and adults. First, CSA is associated with an increased risk for lifetime diagnoses
of several psychiatric disorders, including depression, anxiety disorder, posttraumatic
stress disorder, and personality disorders (Chen et al., 2010; Cutajar et al., 2010;
Fergusson et al., 2013). Other indications of mental health problems among CSA
victims include higher levels of self-harm and suicide attempts (Chen et al., 2010;
Trickett, Noll, & Putnam, 2011), and alcohol and drug abuse (Fergusson et al., 2013;
Trickett et al., 2011). Second, victims of CSA are at risk for distortions in their psy-
chobiological development (e.g., hypothalamic–pituitary–adrenal dysregulation) and
diminished physical health (e.g., obesity and non-epileptic seizures) (Irish, Kobayashi,
& Delahanty, 2010; Maniglio, 2009; Trickett et al., 2011).
Third, CSA is associated with maladaptive cognitive development and victims
of CSA have lower educational outcomes than their non-abused peers (Trickett et
al., 2011). To illustrate, CSA is associated with lower levels of language abilities and
intelligence (Trickett et al., 2011). Fourth, CSA victims often engage in risky sexual
behavior, including early age of onset of sexual activity and a lack of birth control
usage (Fergusson et al., 2013). Also, they have been found to have more sexual
partners and unplanned (teen) pregnancies than their non-abused peers (Fergusson
et al., 2013; Trickett et al., 2011). Fifth, victims of CSA may have difficulties with
fulfilling a variety of adult social roles, such as establishing and maintaining high
quality romantic relationships, acquiring a well-paid job, and developing positive
and effective parenting skills (for a review, see De Jong, Alink, Bijleveld, Finkenauer,
& Hendriks, 2015). Finally, there is a high prevalence of severe child maltreatment,
including CSA, among delinquent youth (e.g., Abram et al., 2004; Dixon, Howie, &
Starling, 2004). Converging with these findings, CSA is found to be a risk factor for
delinquency among adults (De Jong et al., 2015). In sum, CSA can have devastating
 General Introduction 13

effects on developmental outcomes in childhood and adolescence, which may even

persist well through adulthood.

The interpersonal context of CSA 1

Victims’ interpersonal relationships may moderate and mediate the impact of CSA on
mental health (e.g., Collishaw et al., 2007; Sperry & Widom, 2013). The most consis-
tent protective factor against the negative effects of CSA is a stable and supportive
family environment (for reviews, see Marriott, Hamilton-Giachritsis, & Harrop, 2014;
Yancey & Hansen, 2010). For example, a supportive parent-child relationship is linked
to a variety of mental health outcomes among CSA victims, including lower levels of
depression, anxiety, and posttraumatic stress (e.g., Deblinger, Steer, & Lippman, 1999;
Godbout, Briere, Sabourin, & Lussier, 2014; Musliner & Singer, 2014). Importantly,
among child victims of CSA, parental support is found to be an even stronger predic-
tor of children’s adjustment than abuse-related factors (for a review, see Elliott &
Carnes, 2001).
Despite the importance of parents in children’s adjustment to CSA, only a few
studies examined the quality of parent-child relationships among child CSA victims as
compared to non-abused children. Nevertheless, these studies reveal links between
CSA and difficulties in the parent-child relationship. For example, sexually abused
children report a lower overall parent-child relationship quality (Boney-McCoy & Fin-
kelhor, 1996; Hotte & Rafman, 1992) and a more negative perception of their mother
(Stern, Lynch, Oates, O’Toole, & Cooney, 1995) as compared to non-abused children.
To date, key aspects of the parent-child relationship that may be of particular impor-
tance for sexually abused children have remained unexamined. To address this gap in
the literature, Chapters 2 and 3 report on studies examining parent-child emotional
communication and secrecy in the parent-child relationship. Importantly, we put effort
in more fully capturing relational processes by including both parents’ and children’s
perspectives on the parent-child relationship as well as by observing both parent and
child contributions in dyads’ communication about emotions.
As victims of abuse grow up, other sources of social support, beside parental sup-
port, may become increasingly important. As such, supportive relationships with friends
and romantic partners are associated with resiliency among victims of abuse (e.g., Col-
lishaw et al., 2007; DuMont et al., 2007). However, these relationships may not fully
reflect the scope of the interpersonal context. Social networks at the workplace may
be an important source of social support among victims of abuse, because abuse is
associated with difficulties in establishing and maintaining stable and positive intimate
relationships (Colman & Widom, 2004; De Jong et al., 2015). In the absence of positive
intimate relationships, social contacts at the workplace may be an alternative source of
social support, which, in turn, increases mental health (Selenko, Batinic, & Paul, 2011).
14 Chapter 1

Yet, researchers have not examined employment as a protective factor against

the negative effects of abuse on mental health. Chapter 5 addresses this issue by
examining associations between employment, as well as romantic relationships, and
depression among victims of abuse. Importantly, we studied these associations in a
sample of formerly institutionalized females, who have, despite the high prevalence
of child abuse in this group (Abram et al., 2004; Dixon et al., 2004), received relatively
little attention in abuse literature.

The impact of CSA on non-offending parents

Although an extensive body of research suggests that CSA is associated with negative
outcomes, much less is known about the impact of CSA on non-offending parents of
abused children. Research does reveal that CSA has short- and long-term consequences
for parental mental health. Mothers often exhibit high levels of psychopathology (e.g.,
depression, anxiety, posttraumatic stress) following disclosure of their child’s CSA (Cyr,
McDuff, & Hébert, 2013; Elliott & Carnes, 2001; Hébert, Daigneault, Collin-Vézina,
& Cyr, 2007). Furthermore, mothers report feelings of shame, guilt, and self-blame
for not being able to stop the abuse from happening (Kilroy, Egan, Maliszewskab,
& Sarma, 2014; Plummer & Eastin, 2007). To date, little is known about risk factors
for these problems among non-offending parents. This gap is surprising, given the
negative association between parental mental health problems and parental support
after CSA (Cyr et al., 2013). Chapter 4 of this dissertation fills this gap in the literature
by examining predictors of posttraumatic stress symptoms among non-offending
mothers.

Aims and outline

Given the crucial role of non-offending parents in the adjustment of children to CSA
(Elliott & Carnes, 2001; Yancey & Hansen, 2010), we examined two key aspects of the
parent-child relationship (Chapter 2 and 3) and predictors of parental mental health
(Chapter 4) in the aftermath of CSA. Specifically, we investigated general mother-child
emotional communication patterns by studying mother-child dialogues about chil-
dren’s emotional experiences (Chapter 2). We examined the quality of mother-child
emotion dialogues among dyads with CSA victims as compared to dyads with children
who have not experienced CSA. Furthermore, we examined whether mother’s own
experiences of childhood maltreatment and maternal psychopathological symptoms
were associated with the quality of mother-child emotion dialogues.
Chapter 3 zooms in on sexually abused children’s secrecy toward their mothers.
We examined children’s general tendency to keep secrets as well as children’s secrecy
of CSA-specific information. Specifically, we examined whether, as compared to chil-
dren who have not experienced CSA, CSA victims have a greater tendency for secrecy
 General Introduction 15

as reported by mothers and children. Furthermore, we tested a mediation model in

which CSA victims’ higher levels of secrecy explained the association between CSA
and psychopathology (i.e., internalizing and externalizing behavior problems).
Shifting our focus to the non-offending mothers, Chapter 4 describes a study into
1
the role of disgust sensitivity in the development of posttraumatic stress symptoms
among non-offending mothers of sexually abused children. We examined whether
mothers who reported higher levels of disgust sensitivity had higher levels of posttrau-
matic stress symptoms. Also, we examined whether mothers’ own CSA experiences
and biological relatedness of the perpetrator to the child predicted posttraumatic
stress symptoms.
Finally, Chapter 5 adopts a broader perspective on the interpersonal context of
CSA. To study a broader scope of social connections, we examined the protective
effects of employment and romantic relationships on depressive symptoms among
adult victims of childhood maltreatment (i.e., physical abuse, sexual abuse, neglect,
and exposure to domestic violence). To this end, we examined associations between
childhood maltreatment, employment, romantic relationships, and depressive symp-
toms over time among high-risk females, who were institutionalized in their youth
and followed-up in adulthood.
Chapter 6 summarizes and integrates findings from all four studies to provide
new insights into the impact of sexual abuse on children and their families. Given that
the presented data in Chapters 2, 3, and 4 are derived from a larger study, overlap in
the Method sections across articles was inevitable to ensure that all chapters can be
read as separate articles.

Research project
The studies described in Chapter 2, 3, and 4 of this dissertation were conducted within
the Academic Collaborative Centre Child Abuse (Academische Werkplaats aanpak
Kindermishandeling). This large-scale project aimed to (a) develop and implement a
multidisciplinary child abuse center, in which the police, the justice department, youth
care, and physicians work together in severe cases of child abuse to ensure a quick
and family-centered approach; (b) develop, implement, and examine the effectiveness
of treatments for children exposed to domestic violence and sexual abuse; and (c)
provide professionals with education and training to boost their knowledge about
best-practices in the field of child abuse.
The data presented in Chapter 2, 3, and 4 of this dissertation was collected
within two concurrent studies of the research project. We examined characteristics
of families with sexually abused children as compared to families without sexually
abused children (Study 1). Furthermore, we examined the effectivity of the Horizon
group therapy (Lamers-Winkelman, 2000; Lamers-Winkelman & Bicanic, 2000) for
16 Chapter 1

Study 1 Study 2
169 families 25 families
invited invited

59 110 18 7
Declined Accepted Accepted Declined

84 16
Participating Participating
families families

Figure 1. Participant flow of families with sexually abused children.

Note. Numbers of accepted and participating families differ due to attrition and post-hoc exclusion.

sexually abused children and their parents (Study 2). The participant flow in both
studies that comprise the final sample of families with sexually abused children (N =
84) is presented in Figure 1.
In Study 1, sexually abused children aged 4-16 and their families referred for treat-
ment of CSA to the Child and Youth Trauma Center Haarlem, Fier Fryslân, De Rading,
and Accare were approached for our study. The final sample of 84 participating fami-
lies with children exposed to sexual abuse consisted of 81 mothers, 24 fathers, and 84
children. Families participated in the study before the start of treatment. To compare
characteristics of families with abused children to families without abused children, a
comparison group was recruited from Dutch primary schools and through the social
network of research assistants. A total of 63 comparison families participated in the
study consisting of 61 mothers, 45 fathers, and 76 children. For more information
about the participants, procedure, and measures we refer the reader to Chapter 2, 3,
and 4.
In Study 2, sexually abused children and their families referred to the Horizon
group therapy were approached to participate in a multicenter randomized controlled
trial. The Horizon therapy is partly based on the principles of trauma-focused cogni-
tive therapy (Cohen, Mannarino, & Deblinger, 2006) supplemented with components
derived from psychomotor therapy. The Horizon group therapy consists of 14 weekly
parallel sessions for children (aged 4-12) and their non-offending parents. For more
detailed information about the Horizon therapy, please see Martens, Van Delft, and
Visser (2012). An important component of the Horizon therapy is the trauma narra-
tive, in which children disclose the abuse by talking, writing, and/or drawing about
what happened to them, guided by a therapist. Our research specifically focused on
examining the impact of sharing this trauma narrative with parents. To this end, we
compared two conditions in which the child either shared the trauma narrative with
 General Introduction 17

their therapist only or shared the trauma narrative also with their parent(s). Treatment
outcomes were measured before the start of the intervention, during the intervention,
one week after the intervention, and at follow-up after six months. In this dissertation,
we were only able to present data collected before the start of the intervention.
1
18 Chapter 1

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