Depression, anxiety, and self-esteem in sexually abused children

The devastating impact of childhood sexual abuse is well documented in the clinical literature. Whether studying a clinical or general population, research on adults consistently indicates elevated levels of depression and anxiety and low self-esteem in survivors of childhood sexual abuse. On the other hand, results of research on child victims have been quite inconsistent regarding these dimensions.

RESEARCH ON ADULTS

Studies with both clinical and nonclinical populations appear to support a higher prevalence of depression, anxiety, and low self-esteem in sexually abused women than in their nonabused peers. Greenwald, Leitenberg, Cado, and Tarran (1990) found that in a nonclinical population of nurses, the sexually abused group scored higher on measures of depression, anxiety, and phobic anxiety than did the nonabused group. However, no differences on measures of self-esteem were found. In a random sample of Canadian women, Bagley and Ramsey (1986) discovered that those who revealed histories of childhood sexual abuse were more likely to be depressed, have chronic psychoneurosis, and have poorer self-esteem than were persons in the nonabused group. Female undergraduate students who had been sexually abused had poorer physical self-concepts and family self-concepts than did the nonabused group (Alexander & Lupfer, 1987).

A study in which subjects were solicited by advertisements found that those who had been sexually abused had higher levels of depression, lower self-esteem, and poorer body images than did the matched nonabused cohort (Jackson, Calhoun, Amick, Maddever, Habif, 1990). Gold (1986) determined that sexually abused subjects had higher levels of depression and psychological symptoms and lower self-esteem than did nonabused subjects. Sexually abused female college students were discovered to have higher levels of depression and anxiety than did nonabused students (Briere & Runtz, 1988). Similarly, professional women with a history of sexual abuse had higher scores on anxiety and depression than did those who had not been abused (Elliott & Briere, 1992).

Studies that have examined clinical populations indicate similar findings. Among clients seeking therapy, those who were incest victims had personality profiles higher in anxiety and dysthymia than did clients who had not experienced incest (Wheeler & Walton, 1987). Sexually abused women seeking crisis counseling reported more suicide attempts and anxiety attacks than did nonabused clients (Briere & Runtz, 1987).

Although studies of males abused as children are less prevalent, the results of existing studies are similar to those of women. Among men requesting crisis counseling, those who had been sexually abused had higher levels of depression and anxiety than did nonabused clients (Briere, Evans, Runtz, & Wall, 1988). In another outpatient sample, the sexually abused men scored higher on both depression and anxiety than did their nonabused counterparts (Swett, Surrey, & Cohen, 1990). In Hunter's (1991) volunteer sample, male victims rated higher on aspects of depression and lower on self-esteem than did nonabused controls. Urquiza and Crowley (1986) found that males who had been sexually abused scored higher on depression and lower on self-esteem than did nonabused males.

In summary, with only a few minor exceptions, research indicates that adults who are survivors of childhood sexual abuse have higher rates of depression and anxiety and lower self-esteem than do nonabused groups.

RESEARCH ON CHILDREN

Research on children seems to be equally divided between studies finding higher rates of depression and anxiety and lower self-esteem in sexually abused children and those finding no differences between abused and nonabused children on these dimensions. Cohen and Mannarino (1988) found that sexually abused girls aged 6 to 12 were not significantly different from a normal sample on either depression or self-esteem. Einbender and Friedrich (1989) compared sexually abused and nonabused girls and discovered that the abused group had poorer self-concept but was not significantly more depressed. Elliott and Tarnowski (1990) saw a trend toward more problems with depression in the abused population. These findings were similar to those of Livingston (1987), who found that the majority of his sexually abused inpatient population was diagnosed with major depression. Similarly, McLeer, Deblinger, Atkins, Foa, and Ralphe (1988) found that more than 58% of their sample of sexually abused outpatient children scored in the clinical range of depression.

In a study of incest victims and nonabused siblings of incest victims, the sexually abused group was found to be more depressed. Neither group scored in the clinical range of depression. Although the groups showed no differences in levels of anxiety or self-esteem, both victims and siblings scored in the clinical range on a self-esteem measure (Lipovsky, Saunders, & Murphy, 1989). Wolfe, Gentile, and Wolfe (1989) found no difference between the sexually abused and nonabused children in their sample on levels of depression and anxiety. Cavaiola and Schiff's (1989) findings indicated that sexually abused and incest victims had lower self-esteem on identity and physical-self scales than did physically abused children. In a study by Gomes-Schwartz, Horowitz, and Cardarelli (1990), sexually abused children younger than age six had more positive self-concept than did control subjects; however, no differences were found between the two groups past age six.

Female incest victims aged 8 to 14 who were from dysfunctional families had significantly lower self-esteem than did those from similar families who were not sexually abused (Hotte & Rafman, 1992). Orr and Downes (1985) found sexually abused girls scored lower than did girls with acute medical problems on 3 of 11 self-image subscales. In contrast, Stovall and Craig (1990) found no difference among sexually abused children, physically abused children, and control children on self-esteem, whereas Tong, Oates, and McDowell (1987) found that sexually abused children had significantly lower scores on self-esteem than did controls.

The conflicting results with child samples and the differences in outcomes between studies of children and adults confound our understanding of symptoms and their development. Although serious trauma may result from events surrounding and following the abuse rather than from the abuse itself, limitations in the child studies may also be responsible for the discrepancies. Many of these studies relied on very small samples. In addition, differences in the measures employed, different age groups, study settings, and abuse circumstances of the populations surveyed make comparison among studies difficult.

The present investigation was undertaken precisely because of the conflicting results of outcome studies. If researchers could demonstrate that children who had been recently reported for sexual abuse had problems with depression, anxiety, and low self-esteem, the premise that sexual abuse itself is traumatic would be supported.

METHODS

The purpose of this study was to evaluate the extent of depression, anxiety, and the level of self-concept in a sample of children who had been reported for sexual abuse. Subjects were recruited through two programs serving sexually abused children in a southern California county. The first program was a specialized crisis program covering designated law-enforcement jurisdictions in the county. The program was developed to integrate all aspects of investigation and crisis intervention in reported sexual abuse cases in a single child-friendly site. The second site was a shelter facility for children taken into custody for abuse and neglect. Children in the crisis program (n = 21) were seen on the first or second visit. Children in shelter care who were identified as sexually abused (n = 26) were seen within five days of their detention hearing. Children in shelter care who were also in the crisis program (n = 36) were seen according to when they first became identified as possible research subjects. Both child and parent/guardian permission were required for participation. Only cases in which sexual abuse was confirmed were included in the analysis. The final sample consisted of 83 children (75 females and 8 males).

The children were given three self-report measures to evaluate the target symptoms: the Children's Depression Inventory (Kovacs, 1983), the Revised Children's Manifest Anxiety Scale (Reynolds & Richmond, 1985), and the Self-Perception Profile for Children (Harter, 1985). All measures were standardized on nonclinical populations, thus allowing a comparison of this sample with "normal" children. Information regarding the abuse was taken from the children's record to avoid further interviews that might add to their trauma.

MEASURES

CHILDREN DEPRESSION INVENTORY (CDI)

The CDI is a widely used depression measure adapted from the Beck Depression Inventory (Beck, 1967) for adults (Kovacs, 1983) It consists of 27 items, each of which can be scored from 0 to 2. The measure can yield a possible score of 0 to 54, with higher scores reflecting more serious depression. Norms for a nonreferred population have been established, with a mean of approximately 9.0 and a standard deviation of 7.0 (Smucker, Craighead, Craighead, Green, 1986). Children with major depressive disorder had a mean of 12.8, and children with dysthymic disorder had a mean of 11.7 (Kovacs, 1985). A score of 19 is considered the clinical cutoff score, discriminating the top 10% of persons with depression in standardized samples (Doerfler, Felner, Rowlison, Raley, & Evans, 1988).

REVISED CHILDREN'S MANIFEST ANXIETY SCALE (RCMAS)

The RCMAS consists of 37 items to which a child can answer yes or no (Reynolds 6r Richmond, 1985), resulting in a total anxiety score and three subdimensions of anxiety: physiological anxiety, worry/oversensitivity, and social concern/concentration, In addition, a lie scale is included to measure a child's tendency to report "ideal" behavior. Scores on the RCMAS have been standardized, allowing for comparisons across ages and gender. The total anxiety scale has a mean of 50 and a standard deviation of 10. Subscales have a mean of 10 and a standard deviation of 3.

SELF-PERCEPTION PROFILE FOR CHILDREN

The Self-Perception Profile for Children (Harter, 1985) was chosen to evaluate self-esteem and is a revision of Harter's earlier Perceived Competence Scale for Children. This 36-item scale contains six subscales that measure various dimensions of self-concept: global self-worth and the specific domains of scholastic competence, social acceptance, athletic competence, physical appearance, and behavioral conduct. Scores range from (lowest) to 4 (highest). Means for the standardization group fluctuate at around 3.0 (Harter, 1985).

RESULTS

DEMOGRAPHICS

Of the 83 children completing the measures, 75 were girls and 8 were boys. (Total number differs on outcome measures, because some children did not complete all measures.) Average age of the sample was 12.9 years (sd = 2.74)--13 years for girls and 11 years for boys. The sample was ethnically mixed and consisted of 40 white, 30 Hispanic, 4 African American, 7 Asian, and 2 other. All the children spoke English; some of the parents spoke Spanish only.

The abuse began, on average, when the victim was 9.64 years (sd = 3.7), with a mean age for girls of 9.8 years (sd = 3.6) and 7.7 years (sd = 3.7) for boys. The children had been abused for an average of 3.3 years (sd = 3.0), with an average abuse duration for the girls of 3.3 years (sd = 3.0) and for boys 2.8 years (sd = 4.0).

A male was the primary perpetrator in 81 of the cases (97.3% of the girls and 100% of the boys). In the two cases in which a female was the primary perpetrator (in both cases the victims were females), one case included a male perpetrator also. A female was the lone abuser in only one case.

The relationship of the perpetrator to the victim varied with the sex of the victim. Females were abused primarily by relatives, with father figures (father, stepfather, or mother's boyfriend) being the perpetrator in 62.7% of cases. Among males, the majority (62.5%) were abused by a nonrelative. A related finding indicated that 77% of the females were abused by an in-home perpetrator, whereas only 25% of the boys' perpetrators lived in the home (see Table 1).(Table 1 omitted) This finding is consistent with other research (Finkelhor, 1984) indicting that males are more likely to be abused outside the home by a nonrelative. Associated with the relationship and residence of the perpetrator, 45 (60.8%) of the girls and 2 (25%) of the boys were removed from the home after the abuse was discovered.

The number of perpetrators ranged from one to more than six, with 68.7% of the sample having one perpetrator (68% of females and 75% of males). Two perpetrators were involved in 16.9% of the sample, three perpetrators with 7.2%, four perpetrators with 4.8%, five perpetrators with 1.2%, and six or more perpetrators with 1.2%.

The nature of the abuse varied somewhat between boys and girls, as might be expected. (See Table 2 for complete description.)(Table 2 omitted) Twenty-three (28%) of the children experienced fondling only, whereas 62 (72%) experienced some kind of penetration-either intercourse, anal penetration, oral penetration, or penetration with a foreign object.

OUTCOME MEASURES

The study sample had scores significantly different from those of the normative samples on the three outcome measures. On the CDI, the mean of the entire sample was 13.7 (sd = 8.4), significantly higher (p

The distribution of the CDI scores revealed additional information about the level of depression in the female sample. The mean score of the girls (14.3) was higher than the level of 12.9 found in children diagnosed with major depression. Furthermore, 30.7% of the sample (23 girls) had a score on the CDI of 19 or higher, which indicates that these children had scores that fall in the top 10% of depression.

The level of anxiety, as indicated by scores on the RCMAS, was significantly higher than the mean of the standardized sample, with girls accounting for most of the difference. The sample as a whole scored significantly higher than norms on the total anxiety score and on each of the subscales of anxiety (see Table 4).(Table 4 omitted) When these subjects were broken down by sex, however, the males were significantly different from normals only on the lie scale, a dimension that measures social desirability. On this scale, boys scored more than one standard deviation above the mean of normals. Females were elevated on total anxiety and all subscales of anxiety. Comparison of means by sex did not show significant differences, although the difference on total anxiety approached significance (t = .84, p = .069). The small sample size of the males (n = 5) makes any assumption based on these findings untenable.

Examining the distribution of scores on the total anxiety scale revealed that 43 subjects (55.1%) scored more than one standard deviation above the mean, or in the top 16% of anxiety scores in the population, and 9 (11.5%) scored more than two standard deviations above the mean, or in the top 2.5% of the population on this anxiety measure. Differences between the standardization group and this sample were also found on four subscales of the Self-Perception Profile for Children. Different means exist for girls and boys on this measure, necessitating separate evaluations. Because of the small number of boys in the sample (n = 5), only the girls were compared. The girls had poorer self-perception in the areas of global self-worth, physical appearance, behavioral conduct, and scholastic competence. They did not score significantly lower on athletic competence or social acceptance (see Table 5).(Table 5 omitted)

DISCUSSION

This sample of sexually abused children had females who had higher levels of depression and anxiety and lower self-esteem than did the standardized samples taken from the general population. A subgroup showed very serious problems in relation to the study dimensions. The boys did not show significant differences from the "normal" groups.

When examining the rates of depression in the female sample, the mean for depression was not only higher than the norm, but was higher than the mean found for major depression in hospitalized youngsters (Kovacs, 1985). Furthermore, nearly a third of the girls scored at the highest levels of depression, indicating that these girls probably suffered from very serious levels of depression.

Likewise, the girls had elevated levels of anxiety in all measured areas of anxiety. Problems were noted in the areas of physical manifestations of anxiety, worrying and oversensitivity, concerns about relationships with others, and wanting to look good to others. Again, a subgroup had extremely high levels of anxiety, indicating that they may have been experiencing or might be at risk for anxiety disorders.

The girls' lower self-concept scores related to problems with their self-evaluation of worthiness, unhappiness with the way they look, feeling as if they did not conduct themselves as they were supposed to, and lack of confidence in their scholastic ability.

Although the male subjects did not seem to be more depressed, anxious, or to have lower self-esteem than the standardized samples, the small sample size precluded drawing conclusions from these findings. The inability to assess these data underscores the need for more research with male victims.

These results are consistent with studies of adult women that have found higher levels of depression and anxiety and poorer self-esteem among sexually abused women than among their nonabused peers. They lend support to the argument that sexual abuse is traumatic.

It is important to note that this sample may not be representative of sexually abused children as a whole. The abuse experienced by these children tended to be ongoing, averaging three years in duration, and rather serious, with nearly 75% of the children experiencing some kind of penetration. This level of abuse differs from retrospective studies of adults that have found that the majority of sexual abuse involves fondling and consists of a single episode of short duration (Russell, 1986; Wyatt, 1985). It is possible that the level of abuse in this sample is more serious than the abuse in studies finding no differences between abused and nonabused children. This is difficult to confirm because data about the abuse itself is frequently omitted from research reports. Further research is needed to clarify this confusion.

In addition, the present study was unable to access and thus evaluate factors such as socioeconomic status and family dynamics, which have been found to be predictive of the level of maladjustment in sexually abused women (Kilpatrick, 1992). These variables are important to evaluate and should be the focus of future studies.

PRACTICE IMPLICATIONS

Practitioners working with sexually abused children need to be aware of the probability that these youngsters may suffer depression, anxiety, and low self-esteem. A number of these children will have quite serious symptoms that require ongoing treatment. Given declining resources for children's mental health treatment, children who do not exhibit overt symptomatology may not receive the services they need. Clinicians should screen all children who have a history of sexual abuse for depression, anxiety, and poor self-concept. Using clinical measurement instruments, such as those described in this study, as part of the assessment of sexually abused children might be one way to evaluate symptoms quickly and inexpensively.

Given the accumulating evidence that sexual abuse itself causes symptoms in children, it is time to begin developing specific interventions for the problems these children exhibit. Treatment approaches for adult survivors have become more specific (Briere, 1989; Jehu, 1989), but child-treatment approaches lag behind.

Clinicians must be vigilant in ensuring that sexually abused children receive appropriate psychotherapy services in the face of resistance from various sources. Parents may minimize the severity of their children's problems and resist treatment. Public and private nonprofit agencies delivering mental health services to children face declining resources and limitations by third-party payers on length and type of services and thus may restrict both who is seen and the length of treatment. Advocates for children must resist these efforts and work at both the micro and macro levels to promote the availability of appropriate services for sexually abused children.

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Ferol E. Mennen is Assistant Professor and Diane Meadow is Adjunct Instructor, School of Social Work, University of Southern California, Los Angeles, California. Diane Meadow is also in private practice, Laguna Niguel, California. This article is based on research funded by a grant from the Faculty Research and Innovation Fund of the University of Southern California and a Rhoda G. Sarnat Junior Faculty Endowment.

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