Hello and happy September! We are pleased to share with you this month’s E-Press which includes a quick guide on how to use the A Training Manual for Florida’s Supervised Visitation Programs, problem-solving resources for parents and children, and information on how to teach adolescents to communicate effectively with an included activity. Additionally, the newest chapter, Impact of Child Sexual Abuse, from the Child Sexual Referrals Training Manual is provided at the end of the E-Press.

We hope you enjoy this month’s edition!

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Clearinghouse on Supervised Visitation
The Institute for Family Violence Studies
Florida State University

We are a small program and need help figuring out how to use the new supervised visitation manual. It’s over 500 pages, and a little daunting.
Read page5: we have spelled out for a you a few ways you can use the new manual. If you are still having trouble, please call us at 850-567-9464. Keep in mind that the Florida Supreme Court Standard for supervised visitation monitors remains 24 hours of training. This includes training for volunteers and interns – anyone who oversees contact between parents and children. So the training was not designed to be “one and done.” Visitation involves complex emotional, legal, and safety issues that can’t be taught in a weekend. We are here to help.

I want to be able to access your monthly calls in recordings. How did last month’s experiment go?
The experiment is ongoing. Right now, we are recording the sessions and providing the recordings to directors who ask for them by email. That helps us keep track of who is listening to them. I’m hoping that most people listen “live,” but I understand that things come up. We are continuing the process this month with the monthly call.

We have two parents at the program who met here and are now a couple. They want to be able to sync their visits so that they are here at the same time. They also want their children to get to know each other. Has anyone else had this problem? They are very persistent and double-team us.
I have given some thought to this issue, and I keep running into more questions. I do think that the custodial parents should know about this request. Otherwise, the custodians might mistakenly believe that you have sided with the visiting parents. Additionally, I see this problem as solely a group visit issue, because if parents were kept separated in individual visit rooms with their own children, the likelihood of this happening would be minimized. I know you’ve emphasized to both parents that the purpose of the visit is for THEM to spend time with their own children, but they are persistent. If these two parents got married, we might have to talk about the issue some more. Right now, my answer would be to keep the families separate. It is difficult enough for staff to understand the safety issues of one family, let alone two visiting at the same time. The parents are supposed to be strengthening their relationship with their own kids. I hope this is a time-limited issue that can be resolved once they both are no longer at your program. But we should think about how to prevent this problem in the future. I can see it getting sticky. Let me remind you that this is only my opinion, and that if you do allow the families to have a “joint” visit and the custodians agree, you should have more than one monitor. The complex family dynamics are going to present some unique challenges that even I can’t anticipate right now. Remember, supervised visitation programs were not set up to help parents create new blended families onsite. But there is no specific rule against what you have described.

My program used to have two separate parking lots, but the new facility does not allow for that. What can I do to enhance safety?
I appreciate your question, because the gold-standard for visitation is for custodians and visiting parents to use different parking lots and separate entrances. This keeps them apart, limits their interaction (and therefore threats and intimidation). However, SV is not a well funded service, and directors are making do with less than optimal circumstances. What your staff and advisory group need to do is engage in strategizing about how to keep those parents apart. That’s why staggered entrance and exit is so crucial – the goal is to identify the risks to the vulnerable parent and to the child, and to create a flow that minimizes parent contact. I’ve seen programs escort the vulnerable parent and or the visiting parent back out to the car at the end of the visit, I’ve seen programs cancel visits outright if one parent shows up at a non-designated time, and I’ve seen parents required to call from their cell phones in the parking lot and wait until staff come to walk in the program with them. I’ve also seen programs hire a staff person to perform a “security” function, although I do doubt that this enforcement provides anywhere near the level of security that an off-duty police officer would. I can not vouch for any of these methods, so I encourage your advisory board, your local referring judges, and your lead staff to engage in strategic planning for the sole goal of keeping families safe.

Using A Training Manual for Florida’s Supervised Visitation Programs at Your Program
In 2017, the Clearinghouse released the new Training Manual for Florida’s Supervised Visitation Programs. The manual is 535 pages long and consists of 16 chapters. Training program staff on the manual’s content is key for the success and safety of your program. There are a few ways that your program can use the training manual and ensure that every monitor and staff member is ready for what their job requires of them.
The manual can be accessed at this link: http://familyvio.csw.fsu.edu/wp-content/uploads/2017/07/Supervised-Visitation-Manual-2017-Edition.pdf
Remember, the Standards require all staff who supervise parent-child contact to have at least 24 hours of training.
Split the book up: only print out one chapter at a time for staff.
Or have staff read each chapter a certain week.
1. Assigned reading: With this option, program staff and monitors can read the training manual on their own time. We do not recommend reading the manual in one sitting. Instead, Lead Staff can assign chapters and have staff members turn in their chapter quiz answers by assigned due dates.

Keep copies of the quizzes in personnel files.

2. Train on your own: Lead Staff can train current staff on chapters periodically through a lunch and learn event or a weekly training held at the programs.

3. External Trainer: We understand that Lead Staff may not have the time to train program staff on the entire manual. In this case, feel free to use a trusted community professional (Ex. Mental health counselor, or local social service professional) who is familiar with the training to help “break up” the training and train staff members.

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We had such a great time learning about problem-solving in our last phone conference; here are problem-solving resources for parents and children.

Problem-Solving Resources for
Parents and Children

Problem-Solving Videos for Parents
1. How to Solve a Problem in Four Steps: This video teaches a simple yet effective four step problem solving process using the concept IDEA to identify the problem, develop solutions, execute a plan, and then assess your results. https://www.youtube.com/watch?v=QOjTJAFyNrU
2. MythBusters’ Adam Savage on Problem Solving: Adam Savage shares how he uses problem-solving skills in his daily life. https://www.youtube.com/watch?v=BhAt-7i36G8
3. Improve Your Problem Solving Skills: This video shares a seven step method to solve and deal effectively with any problem. https://www.youtube.com/watch?v=s1lt6pwIF1o
4. Parenting and Learning as You Go: In this video, parents talk about what parenting has taught them – having patience, not worrying about things, focusing on what matters, and enjoying time with their kids. http://raisingchildren.net.au/articles/parents_learning_video.html/context/813

Problem-Solving Videos for Children
1. Always a Solution (Problem Solving for Kids) Vol. 2: This video encourages creative problem solving as it takes the readers through a series of adventures. https://www.youtube.com/watch?v=NeOGRJvP50g
2. Social Skill Solving a Problem: This is an animated video walking through possible solutions to a problem experienced by a teenage girl. https://www.youtube.com/watch?v=CWf5LBfZVGQ
3. Teaching Kids How to Resolve Conflict with Smurfette’s Smurfin’ Conflict Adventures: This video was made by CYW’s attempting to teach kids about healthy ways to resolve various conflicts that they will encounter in their lives. https://www.youtube.com/watch?v=0DXhwv1bQVA
4. Katz Interpersonal Skills-Conflict Resolution with Sesame Street: Zoey and Elmo solves a problem by compromise and sharing. https://www.youtube.com/watch?v=jgxDMWEXO-s
5. Ramon Learns to Resolve a Conflict: A listen along story teaching children about communicating feelings, and resolving conflicts. https://www.youtube.com/watch?v=NLBY4PSFAI0
6. Conflict Resolution- Problem Solving with Gene Bedley: In this video, Gene Bedley demonstrates how children can solve problems by using talk it over chairs which encourages responsible communication. https://www.youtube.com/watch?v=yjhauTLFqfM
7. Process Over Product- Persistence and Problem-Solving for Young Children: As Anthony’s mother, and as an early childhood professional, Shannon understands the value of offering guidance to her four-year-old, but she also says that it’s very important to step back and allow him the opportunity to grapple with things on his own. Watch this video to see how Shannon provides a supportive environment for Anthony to create, reason, and problem-solve on his own. https://www.youtube.com/watch?v=xFbe7wPZrd4
Problem-Solving Games for Children

1. Scavenger Hunts: This scavenger hunt game involves solving a list of problem activities. Begin by giving each person or group a list of to do activities. The list should begin with some simple tasks, with increasingly more difficult activities.
2. Impromptu Skits: Prior to playing this game, write down a few age-appropriate situations in which the children can act out. Have each group choose a folded piece of paper on which you have written the subject of a skit they must create. Give a set amount of time to prepare the skit and then have each team present their skit to the group.
3. Block Duplicating: Build a model out of building blocks. Provide each person enough blocks to duplicate the model. Set a specific amount of time for completing the duplicated model. The person that is the first to finish – or gets the furthest in completing their model – wins.
4. Tower Building: This construction game challenges you to build the tallest skyscraper possible with the items of your choosing (blocks, candy, etc.). Keep on stacking floors until the tower falls! The goal is to see who can build the highest tower within a set amount of time.
5. Crossword: Many word puzzles require not just spelling skills and good vocabulary, but the ability to think logically and strategically. Cultivate problem-solving skills in children by giving them age-appropriate crossword puzzles. The goal of crossword puzzles is to complete the crossword by filling in a word that fits each clue.
6. Photo puzzles: Puzzle play is a wonderful way for children to have fun while developing problem-solving skills and shape recognition. Choose a well-known picture or cartoon full of detail and put the puzzle pieces together to create the photo.
Problem-Solving Books for Children
Children books are a fantastic way to introduce problem-solving skills to children. Below is a list of books that feature a clear problem and solution structure. These books can be purchased from Amazon and Barnes and Nobles for under $12.
1. What Do You Do With a Problem? by Kobi Yamada is a story about a child who has a problem that just will not go away. The longer the problem is avoided, the bigger it seems to get. When the child finally musters up the courage to face it, the problem turns out to be something quite different than it appeared.

2. Talk and Work It Out by Cheri J. Meiners teaches children the process of peaceful conflict resolution. Children learn to calm themselves, state the problem, listen, think of solutions, try one, evaluate results, and even agree to disagree when a solution isn’t possible. This book includes skill-building games and role plays for adults to use with children.

3. Stuck by Oliver Jeffers is a fun tale about a boy who has a problem and is resourceful. When Floyd’s kite gets stuck in a tree, he’s determined to get it out and employs various methods to do so.

4. The Little Engine by Watty Piper is a classic book that features a clear problem and solution structure. After an engine breaks down, a little engine helps the broken down engine climb over the mountain to deliver toys to all the boys and girls on the other side of the mountain.

5. Where the Wild Things Are by Maurice Sendak is another classic book that features a clear problem and solution structure. Max is banished to his room without supper because of his behavior and falls asleep only to “wake up” in a world of wild things. Max begins to long for home again and wakes up to find that his mother has left his supper in his room to eat. Sendak challenges kids to read between the lines to figure out how his supper got there and why.

Teaching Adolescents to Communicate Effectively
By Elena Simonsen
Introduction
Communication is the method by which people share information with one another. It is the way people give and receive messages. Communication facilitates peoples’ understanding of one another and is a necessary skill for everyone, especially teenagers. Teenagers are able to understand and talk about abstract concepts, and thus are able to speak in an adult manner. It is essential that teenagers have the skills that they need in order to communicate effectively as they transition into adulthood.

Objectives
This article will help parents and visitation monitors to understand:
• What effective communication is and why it’s important
• What teenagers need to know about effective communication
• The role of parents and supervised visitation monitors in helping teens to develop healthy communication skills

Effective Communication
Communicating effectively means that what is said is received and understood by the other person involved in the conversation in the way it was intended to be. Having the ability to communicate effectively is vital in many different spheres of life. Effective communication can improve the quality of teenagers’ personal relationships, enhance their school and work performance, improve their listening skills, and prepare them for events like interviews and presentations. Knowing how to communicate in an impactful way sets teenagers up for success, in both their present and future lives.
Ways Teenagers Can Improve Their Communication Skills
There are a number of different habits teenagers can adopt to help them become more effective communicators. Among these are:
• Becoming a good listener. This includes not interrupting others, as well as not trying to “one-up” someone else’s story with their own.
• Only giving advice when it is asked for. Advice-giving can come off as insensitive if it is not asked for.
• Don’t gossip. This is a bad habit to get into and can hurt others’ feelings.
• Don’t interrogate when asking questions. Questions are a good way to get to know others better, but be sure to share personal experience between questions if the other person repeatedly gives short answers.
• Allow the conversation to flow between both parties. One person should not be speaking the entire time.

The Role of Parents and Visit Monitors
Parents and supervised visitation monitors can play a powerful role in helping adolescents to improve their communication skills. The following are some ways that parents and visit monitors can help teens to enhance these skills:
• Make time to talk with your teen. Setting aside time for family dinners or taking a walk with your teen is a good way to connect. Having these conversations can help your teen to practice interacting with others appropriately. It also gives parents and visit monitors the opportunity to set an example of what healthy communication looks like.
• Demonstrate good listening skills. When your teen is speaking, give him or her your full attention. Put away your phone or any other sort of distractions, and make eye contact with your teen. This will help him or her to feel respected, and teach him or her to respect others while they are speaking.
• Discuss difficult subjects with your teen, such as what is currently going on in the news. This can help teenagers decide how they feel about a particular topic and makes it easier for them to voice their opinions in the future.
• Engage your teen in a role play. This will help him or her to practice what and when to communicate to others in particular situations. It will also help your teen to adjust his or her tone based on who the conversation is with.
• Play word games with your teen to teach communication skills. Games like charades, for example, can teach teens to focus on nonverbal body language.
• Encourage your teen to write through journaling or blogging. This can help him or her to learn to express thoughts and feelings.

Conclusion
Communication is an important skill to have in many different areas of life. Being able to communicate effectively can help teens complete group projects, give presentations, get help from a parent or teacher, do well in a job interview, and tell their friends how they truly feel. As teens are at a point in their lives where they are constantly interacting with others, it is especially important for them to know how to communicate appropriately and effectively with others. Parents and supervised visitation monitors can help teens to develop these skills in a variety of ways, thereby helping teens to achieve success in various spheres of their lives.

References
Brown, B. (2015, April 2). Definition of Effective Communication Skills. Retrieved from http://www.livestrong.com/article/67317-definition-effective-communication-skills/
Brown, B. (2015, April 17). What is Effective Communication? Retrieved from http://www.livestrong.com/article/69309-effective-communication/
Fine, D. 8 Steps to Teaching Teens How to Make Conversation (2014, April 30). Retrieved from http://www.huffingtonpost.com/debra-fine/8-steps-to-teaching-teens_b_5233380.html
Nemours (n.d.). Communication and Your 13- to 18-Year-Old. Retrieved from http://kidshealth.org/en/parents/comm-13-to-18.html#
Planned Parenthood (n.d.). All About Communication. Retrieved from https://www.plannedparenthood.org/learn/teens/relationships/all-about-communication
Wright, L.W. 10 Ways to Improve Your High-Schooler’s Communication Skills (n.d.). Retrieved from https://www.understood.org/en/friends-feelings/common-challenges/communication-issues/10-ways-to-improve-your-high-schoolers-communication-skills?view=slideview
Review the activity on the next page that can help adolescents practice their communication in a fun and educational way! This activity can be given to custodians to take home. (Level: advanced)
The following are graphics for your program that you can use in different spaces such as the waiting room, visitation room, or intake room.

The graphics are meant to be encouraging and positive so parents and children feel ready to engage at visitation.
Training Manual for Florida’s Supervised Visitation Programs
Referrals to Supervised Visitation in Child Sexual Abuse Cases
Child sexual abuse negatively affects the victimized child, the family of that child, and society as a whole. It is important for supervised visitation providers to become knowledgeable about the potential consequences of child sexual abuse, in order to effectively identify and address them. This chapter will discuss how child sexual abuse causes damage to child development, family dynamics, and societal functioning, and how monitors can address and prevent this damage during supervised visitation.
Upon completion of this chapter, a visit monitor will be able to:
• Recognize the physical, psychological, and social consequences of child sexual abuse on a child’s development.
• Identify factors contributing to the level of severity of the consequences of child sexual abuse.
• Understand the gender differences in the impact of child sexual abuse.
• Explain the impact child sexual abuse has on non-offending parents and siblings.
• Understand the impact of child sexual abuse on survivors who later become parents.
• Understand the costs of child sexual abuse on society as a whole.
• Learn techniques on how to supervise families with child sexual abuse allegations.
• Child sexual abuse is associated with the development of hypertension, hepatic disease, gastrointestinal disease, arthritis, and obesity (Afifi et al., 2016).
• Child sexual abuse more than quadruples the odds of developing PTSD compared to the general population (Teicher and Samson, 2013).
• Child sexual abuse survivors who report more hurtful responses to their disclosure of abuse had higher levels of posttraumatic stress disorder, anxiety, and physical symptoms than those who report more supportive responses (Palo and Gilbert, 2015).
• A 2015 study estimated that 595,458 (15%) of Florida’s current child population are or will become victims of some form of child sexual abuse (Lauren’s Kids Foundation).

The impact of child sexual abuse does not stop when the abuse stops. Child sexual abuse has adverse effects on a child’s development that can interfere with day-to-day functioning later in life. Child sexual abuse takes a toll on the victim’s physical, mental, and social health. However, not every child may be affected in the same ways. The severity of the consequences of child sexual abuse may depend on a number of different factors. Certain characteristics of the victim, such as gender, may also contribute to different outcomes.

Child sexual abuse is a strong predictor of health problems in adulthood. Those who have experienced child sexual abuse are one-and-a-half times more likely to have a health problem compared to those who have not been sexually abused. Child sexual abuse survivors may experience problems in their general health, sexual health, eating patterns, and somatic issues.
General Health
Research shows that there is a direct relationship between the number of adverse experiences and adult health risk behaviors, such as smoking, substance abuse, physical inactivity, and suicide attempts. These health risk behaviors can lead to obesity, cancer, heart disease, lung disease, liver disease, and death. Child sexual abuse survivors have been shown to:
• Seek health services more frequently.
• Have greater functional disability.
• Have more physical health symptoms.
• Engage in health risk behaviors more frequently.
Eating Disorders
Eating disorders are potentially life-threatening and affect both emotional and physical health. Child sexual abuse may distort a victim’s body image, which negatively affects victims’ eating habits. Child sexual abuse survivors may use food to cope with the trauma from the abuse, help victims feel more in control, and help them suppress overwhelming emotions. Bulimia nervosa and binge eating disorders are the two main eating disorders most strongly associated with child sexual abuse.
Bulimia nervosa is characterized by frequent consumption of large amounts of food followed by behaviors such as self-induced vomiting and/or taking laxatives to prevent weight gain. Its health consequences include:
• Electrolyte imbalances stemming from purging behaviors that can lead to irregular heartbeat, heart failure, and death.
• Gastric rupture during bingeing periods.
• Tooth decay from acids in vomit.
• Irregular bowel movements and/or constipation from laxative abuse.
Binge eating disorder is characterized by frequent consumption of large amounts of food without behaviors that prevent weight gain. Its health consequences resemble the symptoms of clinical obesity, including:
• High blood pressure
• High cholesterol
• Heart disease
• Type II Diabetes
• Gallbladder disease
Sexual Health
Female survivors of child sexual abuse have a greater risk of sex-related health problems. They are more likely to engage in high-risk sexual behaviors, such as engaging in consensual sexual intercourse at an earlier age, having a greater number of sexual partners, and inconsistently using condoms. This can increase the chances of:
• contracting sexually transmitted diseases and infections;
• genitourinary and gynecological problems; and
• unintended and aborted pregnancies.
Somatic Symptoms
Additionally, child sexual abuse increases the risk for functional somatic symptoms. Functional somatic symptoms are symptoms that are not medically well explained. A 2015 study showed that children who experienced child sexual abuse before the age of 16 experienced higher levels of somatic symptoms than those who were not sexually abused. These symptoms are very persistent and impairing, and are often unexplained by other diagnoses. These symptoms include:
• Gastrointestinal complaints
• Pain
• Fatigue

Research has established strong associations between child sexual abuse and adverse mental health outcomes for victims. This includes psychological disorders, self-injurious behavior, suicidality, and substance abuse.
Psychological disorders
A 2013 study found that child sexual abuse is associated with 47% of all childhood-onset psychiatric disorders and with 26% to 32% of adult-onset disorders (Perez-Fuentes et al.). Findings have consistently associated child sexual abuse with post-traumatic disorder, depression, and anxiety. When working with families with a history of child sexual abuse, it is important to know the signs of psychological disorders in order to promote the health and safety of all family members.
Psychological
Disorder Association with CSA Symptoms
Post-Traumatic Stress Disorder Occurs after a traumatic event that provoked an intense fearful response from an individual. For child sexual abuse victims, the traumatic event is the sexual abuse. • Recurrent recollections, dreams and/or flashbacks of the traumatic event
• Play that exhibits a theme of trauma
• Intense psychological and/or physiological reactions to cues that remind victims of the abuse
• Difficulty sleeping
• Angry outbursts and/or irritability
• Difficulty concentrating or hypervigilance

Anxiety Victims may develop beliefs that the world is dangerous and that they have little control over what happens to them. May also heighten an individual’s psychological response to stress. • Extreme sense of fear and worry
• Somatic symptoms, such as trembling and shaking
• Difficulty concentrating
Depression Most common long-term symptom of child sexual abuse. Characterized by sad, empty, or irritable mood that decreases an individual’s ability to function. May stem from the negative thoughts and feelings from the abuse. • Feelings of worthlessness
• Disturbed sleeping and eating patterns
• Fatigue
• Weight loss
• Suicidal ideation

Self-Injurious Behavior
A 2014 study found that victims of child sexual abuse are at three-fold increased risk of self-injurious behavior (Liv-Wiesel and Zohar). Self-injurious behavior is a motivated process of harming one’s self characterized by:
• Low lethality.
• Highly repetitive behavior.
• Absence of suicidal ideation.
It has been theorized that self-injurious behavior is used to relieve overwhelming negative emotions and feelings from the sexual abuse. Self-injurious behavior may also emerge after abuse as a way to self-medicate symptoms of psychological disorders. Types of self-injurious behavior include:
• Cutting
• Scratching
• Burning
• Punching
• Pulling hair
Suicidality
Individuals with a history of sexual abuse have an increased risk for suicide. Findings from a 2013 study indicate that the association between child sexual abuse and greater odds of attempting suicide remained even after taking psychiatric disorders into account (Perez-Fuentes et al.). Child sexual abuse survivors can develop feelings of isolation, stigma, and poor self-esteem, and may develop depression, which can lead to suicidal ideations later in life. Suicidal ideation often carries on into adulthood.
Substance Abuse
Adolescent victims of child sexual abuse are more likely to have alcohol and/or drug dependence problems compared to the non-abused population. Child sexual abuse can produce feelings of helplessness and chaos, and substances are used by the victim to escape or disassociate. Substance abuse is also used by child sexual abuse survivors to self-medicate symptoms of psychological disorders, such as depression and post-traumatic stress that arise from the abuse. Research shows the prevalence of abuse of nicotine, alcohol, and illicit drugs, including intravenous drugs.
The consequences of child sexual abuse do not just encompass physical and mental health, but also social functioning. Child sexual abuse adversely affects how survivors interact with the world around them. The abuse may cause the development of unhealthy and unnatural behaviors. The following adverse behaviors are prevalent in child sexual abuse survivors: traumatic sexualization, interpersonal relationship problems, delinquency and criminality, and economic problems. As a monitor, it is important to know what inappropriate behaviors may be exhibited and why they are occurring.

Traumatic Sexualization
Traumatic sexualization is the inappropriate development of a child’s sexuality as the result of sexual abuse. It can occur in the following ways:

• Child sexual abusers often exchange attention, privileges, and gifts for sexual behavior. This teaches the victim that sex is a tool to manipulate others.
• Abusers may fetishize a child’s body, leaving the child to feel either shame about their bodies or that their bodies are no more than sex objects.
• If abuse was perpetuated by someone the child loved, the child may believe that he/she must give sex to receive affection.
• The frightening memories of the abuse become associated with any sexual activity.

Traumatic sexualization causes child sexual abuse victims to become confused about their sexuality and can develop inappropriate and/or unnatural sexual behaviors that are carried on into later life. Often this is exhibited in either an increased or decreased interest in sex. Hypersexuality is a common high risk behavior, usually resulting from prior sexual/emotional abuse, in which survivors engage in frequent sexual encounters devoid of emotional content, as a way to feel more in control of their personal relationships.

The effects of traumatic sexualization include:

• Sexual interests at a young age, such as masturbation and/or intercourse
• Sexual aggressiveness
• Multiple sexual partners
• Sexualizing relationships that are not sexual
• Aversion to sex
• Flashbacks to sexual abuse
• Avoidance of physical contact
• Difficulty with arousal and orgasm
• Vaginal pain in women
• Negative attitudes towards body image

Interpersonal Relationships
Since child sexual abuse victims are often violated by people they know, love and trust, forming interpersonal relationships can be difficult. This may be due to disrupted parental attachment. Child sexual abuse victims tend to reject their caregivers’ attention after the abuse. Since a common component of abuse is isolation, with the child being kept at home as much as possible, they are unable to learn and develop social skills. As a teen or adult this can result in difficulty making friends, or being withdrawn. He/she may continue to become socially avoidant or may become clingy and overly dependent on others. Effects of child sexual abuse on interpersonal functioning include:
• Either difficulty trusting or overly trusting of others
• Desperation to find redeeming relationships
• Fear of abandonment
• Feelings of powerlessness and lack of assertiveness in relationships
• Formation of abusive relationships
• Anger and/or fear of authority
• Suspicion in intimate relationships
• Feelings of stigmatization and alienation from others
• Isolation and avoidance or relationships all together
Deviant behaviors, criminality, and delinquency
Victims of child sexual abuse often exhibit oppositional behavior, which can escalate to delinquency and criminality. This may be due to the “cycle of violence.” Exposure to maltreatment early in life increases the likeliness of developing maladaptive and antisocial behaviors. Additionally, children who are exposed to family violence may perceive violence as a way to solve problems.
Children who are sexually abused may display the following deviant and delinquent behaviors:
• Cheating in school
• Vandalism
• Fighting
• Stealing
• Truancy
• Running away
Child sexual abuse survivors are at increased risk for criminality in the following ways:
• Survivors of child sexual abuse are more likely to be arrested for committing a crime than those who have not experienced maltreatment.
• Survivors of child sexual abuse are the most likely to be arrested for prostitution compared to survivors of other forms of maltreatment.
• Some research shows that those who experience child sexual abuse are more likely to sexually offend than the general population and those who experienced other types of maltreatment.
Educational and Economic Outcomes
Child sexual abuse is also linked to poorer educational and economic achievement. The behavioral and mental health problems associated with child sexual abuse may also effect victims’ achievement in school and future economic well-being. Studies have found the following about child sexual abuse and educational and economic outcomes:

• Sexually abused children tend to perform lower on tests measuring cognitive ability, academic achievement and memory assessments compared children who were not sexually abused
• Sexual abuse is associated with absences from high school, increased need for special education, and trouble adapting at school
• Sexual abuse significantly increases the chance of dropping out of school
• Adult wages tend to be lower in female victims of child sexual abuse

Warning Signs of Child Sexual Abuse by Age

Age Range Warning Signs

Younger Children

• Toilet accidents, unrelated to toilet training
• Says new words for private body parts
• Reluctant to remove clothes during bath time, bedtime, toileting, or diapering
• Plays sexually with other children or toys

Adolescents • Self-injury
• Poor personal hygiene
• Substance Abuse
• Sexual promiscuity
• Running away
• Depression and/or anxiety
• Suicidality
• Fear of intimacy
• Disturbed eating patterns
Any Age • Nightmares or sleep problems
• Seems unusually distracted or distant
• Change in eating habits
• Sudden mood swings
• Expresses sexual images in writing, drawing, or play
• Thinks of self or body as bad or dirty
• Has money, toys, or other gifts without reason
• Exhibits adult-like sexual behavior
• Pain during urination or bowel movements
• Pain or bleeding of genitals, anus or mouth
The impact of child sexual abuse differs from person to person. Some victims may be able to make a full recovery without little physical, mental, or social difficulties. However, others may experience more extreme consequences. Resiliency is the ability to recover from trauma and restore healthy functioning. Resiliency depends on a number of factors. These factors include context of abuse, polyvictimization (those who experience multiple forms of violence), family functioning, and individual functioning.
Context of sexual abuse
The ability for a victim of child sexual abuse to adjust and recover from the trauma can depend on the context of the abuse he/she endured. The context of sexual abuse refers to frequency of sexual abuse, type of sexual abuse, age when sexual abuse was initiated, and relationship to the perpetrator
Frequency: Symptoms tend to be more extreme when the sexual abuse is recurrent and/or over time. Sexual abuse in high frequency may cause the child to perpetually be in fear and thus unable to cope.
Type of abuse: More negative outcomes are found when the sexual abuse is contact, rather than non-contact. Additionally, the more dangerous the abuse is perceived as, the increased traumatic impact it can have.
Age when sexual abuse was initiated: Child sexual abuse has a more adverse impact when the abuse begins at a younger age because it negatively affects development at an earlier time.
Relationship to perpetrator: Outcomes are more adverse when sexual abuse is perpetrated by someone the child knows.

Polyvictimization
The more adverse life experiences a child has, the greater the risk for developmental problems. When child sexual abuse occurs alongside another type of maltreatment, such as physical abuse, emotional abuse and/or neglect, more symptoms are reported.
Family functioning
The functioning of a victim’s family can either increase or decrease resiliency after child sexual abuse. Generally, the more support a victim gets from family members, the fewer behavioral and emotional difficulties are exhibited.
• A 2008 study found that family functioning had a significant impact on long-term adjustment of child sexual abuse survivors. Family cohesion was associated with positive relations with others and more effective management of daily life. Family conflict negatively affected self-acceptance and was associated with less effective management of daily life (McClure et al.).
• A 2011 study found that stable family environment and supportive relationships had a consistent association with resiliency after maltreatment (Afifi and MacMillian).
• A 2014 study found that social support from non-offending family members was a key component in providing effective intervention and promoting recovery after disclosure of child sexual abuse (Domhardt et al.).
Individual functioning
Certain individual characteristics have been found to promote resiliency more than others. These characteristics include:
• Intelligence
• Appealing, sociable, easy-going disposition
• Self-efficacy, self-confidence, high self-esteem
• Problem solving abilities
• Active coping
• Optimism

Child sexual abuse affects both males and females. However, because males and females may be victimized in different ways, the impact of child sexual abuse can vary.
Prevalence
Research shows that there is a higher prevalence of child sexual abuse among females.
• A 2013 study found that worldwide, 9% of females had experienced forced intercourse and 15% had experienced mixed sexual abuse, while 3 % of males had experienced forced intercourse and 8% had experienced mixed sexual abuse (Barth et al.).
However, these numbers may be lower than reality because of the unwillingness to report, especially by males.
Perpetrator
• For both males and females, most perpetrators are male. However, males are more likely than females to have a female perpetrator.
• Male victims perceive a female perpetrator as a rite of passage rather than abuse, while male perpetrators make them feel shame and confusion over their sexuality.
• Girls are more likely to experience abuse within their families, while boys are more likely to experience abuse by someone outside of their family. As discussed earlier, abuse occurring within families has been shown to produce more severe outcomes.
• Males are more likely than females to be sexually abused by peers or relatives closer in age. This may cause males to feel confused on whether it qualifies as “abuse” and may lead them to stay silent.

Age of onset/duration of abuse
Females are more likely to experience sexual abuse over a longer period of time than males, possibly because they are more likely to experience abuse within their families. Longer periods of abuse are associated with more adverse outcomes.
Type of abuse
Males are more likely than females to experience sexual abuse that is more violent and physically harmful, including repetitive penetrative acts. Research shows that more violent and forceful sexual abuse is linked to more adverse mental health outcomes.
Disclosure
Disclosure of abuse significantly influences the victim’s intervention and recovery process. The male recovery process may be adversely affected by the fact that males are less likely to report during childhood. When males do disclose it is not uncommon form them to wait to do so for 25 years, well into their adulthood, while women often disclose before adulthood.
The following are theories as to why males are so hesitant to disclose:
• Males may be fearful of being labeled as homosexual if their perpetrator was male.
• They may be feel shame because of the “boys don’t get sexually abused” myth and/or the fear that boys who are sexually abuse will become perpetrators.
• They may feel ostracized by other males because men are more likely to view victims of child sexual abuse more negatively.
Consequences
Male victims are more likely to display externalizing outcomes including:
• Aggressive behaviors
• Difficulties at school
• Delinquent behaviors
• Substance abuse
• Anti-social behaviors
Comparatively, females tend to display internalizing outcomes including:
• Withdrawal
• Depression
• Suicidal ideation
• Eating disorders

Child sexual abuse not only affects the victim, but also the victim’s family. The abuse significantly alters the family system and after disclosure, family members have to cope with their own trauma. When trauma extends to others outside the primary victim, it is called “secondary trauma.” Secondary trauma can be quite overwhelming to family members whose loved one was violated. It is important for family members to recognize and cope with their vicarious trauma in order to
provide adequate support for the victim who will rely on them during the recovery process.

The majority of non-offending caregivers experience psychological stress upon discovery of their child’s sexual abuse. Initial reactions to disclosure of child sexual abuse vary greatly from self-blame to denial.
Initial reactions may include:
• Anger toward perpetrator
• Displaced anger toward family members
• Guilt and self-blame
• Helplessness
• Panic
• Denial
• Shock
• Embarrassment
• Feelings of betrayal
• Desire for secrecy
• Fear for the child victim
A 2014 study explained how contextual factors may influence a non-offending mother’s type of reaction to a disclosure of child sexual abuse (Knott et al.).
• Non-offending mothers are more supportive of their sexually victimized child when they do not reside with the perpetrator, or when the perpetrator is not the father or step-father.
• Non-offending mothers were least supportive when the perpetrator was identified as a family member.
• Non-offending mothers were most likely to be protective when they felt hostility toward the perpetrator.
• Additionally, the non-offending mother’s capacity to protect could be diminished by substance abuse.
After a disclosure of child sexual abuse, stigma can often block communication and lead to more problems within families. The period after disclosure is a sensitive period in which extra familial support and communication is necessary to help the victim through recovery. Negative reactions, such as disbelief and blaming the child increase the risk for negative developmental outcomes.
Non-Offending Parent Trauma

Additional to initial stress after disclosure, non-offending parents can develop longer-term symptoms. Non-offending parents experience distress for an average of two years following child disclosure. They may present with symptoms of mental health disorders including:
• Depression
• Anxiety
• Post-traumatic stress
• Hostility
• Somatic symptoms
• Paranoid ideation
• Psychosis
Non-offending caregivers may also experience significant life changes, including adverse social and economic outcomes. This is especially extreme if the sexual abuse occurred within the family, because the non-offending parent may also experience a significant amount of loss. These changes may include:
• Increased isolation from extended family and strained family relationships
• Loss of partner
• Loss of income
• Change of residency
Research shows that non-offending caregiver support is vital to overall adjustment. It can buffer the child from adverse mental health and social outcomes. However, the overwhelming feelings from secondary trauma and all the life stressors occurring after disclosure can overwhelm a parent and diminish his/her effectiveness to support the child. For these reasons, it is important for non-offending parents to be involved in the therapeutic process after disclosure.
Impact on Non-Abused Siblings
Non-abused siblings may experience adverse psychological consequences from the disclosure of victim’s abuse. They may experience individual symptoms as well as having to cope with lots of change. This change is especially significant in circumstances of abuse occurring within families. Siblings may experience the following:
• If the sibling knew about or witnessed the abuse, they could experience severe psychological distress.
• After disclosure, they may feel increased isolation, shame, and stigma.
• If the sexual abuse is occurring within their family, they may feel torn between the perpetrator and the victim.
• Siblings may have to cope with the loss of a parent and change in family dynamics.
• Siblings may have to cope with a residence and school change.
• Siblings may come to resent the victim who they blame for all the sudden change.
It is important for non-offending caregivers to be open about the abuse with the other children in the family. Non-abused children should be educated on the dynamics of child sexual abuse in order for them to understand that it was not their victimized sibling’s fault. Since many siblings are often aware of the abuse, being open about the abuse can also allow for learning additional information about the victimized sibling’s abuse, or could lead to their own disclosure of sexual abuse.

Survivors of Child Sexual Abuse as Parents
Parenting is a challenging task, even without a history of abuse. When a survivor of child sexual abuse becomes a parent, trauma can hinder parenting capabilities. Not all survivors have difficulty in parenting, but many survivors report challenges unique to the child sexual abuse they experienced. Parenting challenges survivors may face include:
• Low confidence in parenting
• Lack of energy in parenting
• Role reversal with child
• Difficulty promoting age appropriate autonomy
• Excessive concern for child safety
• Difficulty addressing child’s sexuality
Parenting issues may be due to a number of factors relating to the survivor’s abuse including:
• Lack of an appropriate model of parenting
• Stress of parenting in the context of their recovery
• Psychological symptoms such as depression and/or post-partum depression
It is important for survivors to identify their parenting challenges and the core reasons for those challenges. Inadequate parenting by the survivor can result in the following unhealthy interactions with their children:
• Decreased sense of bond with child
• More negative attitudes towards child
• Difficulty communicating with child
• Less involvement with child
• Decreased satisfaction as a parent
• Abuse of the child under the guise of strict parenting
This unhealthy attachment between the survivor and child can result in adverse developmental outcomes for the child. According to attachment theory, if survivors are symptomatic and unable to give adequate attention to their child at a young age, the child could develop maladaptive emotional and social behaviors. Additionally, parents who have unresolved trauma may not be able to model healthy emotions, which can result in confused emotional development for the child.

Child sexual abuse does not just effect the victim and his or her immediate surroundings. Child sexual abuse negatively affects society as a whole. It poses a cost to communities and countries all over the world. This crime is so prevalent that child sexual abuse is increasingly being addressed as a public health issue. The burden of child sexual abuse results in direct and indirect costs to society. Direct costs are associated with the immediate needs of the victim, while indirect cost are the long-term and secondary effects of the abuse.
Direct costs include:
• Medical care
• Mental health care
• Child welfare
• Law enforcement
• Criminal justice
Indirect costs include:
• Long-term mental health care
• Productivity loss
• Special education costs
• Juvenile delinquency
• Future adult criminality

According to the U.S. Department of Health and Human Services, in 2014, there were close to 2,500 victims of child sexual abuse in the state of Florida. These victims will experience lost earnings and other costs as consequence of the abuse. A 2015 study found that in Florida, the estimated lifetime costs per individual CSA victim is between $210,012 and $241,600 (Lauren’s Kids).

In the United States, child sexual abuse ranks 12th in preventable risk factors and carries 0.7% of the disease burden (US Burden of Disease Collaborators 2013). Research has also found the following about child sexual abuse in the U.S.:
• 26.6% of girls and 5.1% of boys in the US have experienced sexual abuse or assault by age 17 (Finkelhor, 2014).
• The sexual abuse of children cost the United States $1.5 billion in medical expenses and 23 billion total annually in 1996. (U.S. Department of Justice).
• The cost per sexual assault victimization of children was estimated to be at least $184,000. (Minnesota Department of Health, 2007)

A 2009 study reviewed studies of child sexual abuse in 65 countries and found that 1 in
5 women and 1 in 12 men reported experiencing some form of sexual abuse before the age of 18 (Pereda et al.). The World Health Organization identifies child sexual abuse as a risk factor affecting the global burden of disease. This amounts to 9 million years of healthy life lost. Child sexual abuse is a risk factor for the following contributors to the global burden of disease:
• Depression

• HIV
• Alcohol use disorders
• Violence

• Self-inflicted injuries
• Unsafe sexual behaviors
• Obesity
With what we have discussed thus far, we know that the best chance a child has at recovery is through having a support network. However, it is vital that the safety of the victim is prioritized above all else, in which a responsible, trained adult supervises any contact between the alleged sexual offender and the child victim. It is important to be familiar with the behaviors of victims and perpetrators in order to know when to intervene.

Inappropriate behavior by alleged parent may include:
• Whispering or speaking to child in a way that visit monitor cannot hear
• Tickling child or encouraging other physical contact
• Playing with toys near the genitals of the child or parent
• Exposing genitals or leaving pants unzipped
• Using code words
• Masturbating
• Playing with toys that have meaning to child’s abuse
• Showing photographs that are reminders of child’s abuse

Behaviors of children with histories of child sexual abuse during visitation
• Toileting accidents
• Excessive crying
• Unusual clinging behavior
• Self-injurious behavior
• Inappropriate sexual behavior, language, and/or play
Children with histories of child sexual abuse may behave in different ways in order to cope with their abuse. It is important for visitation monitors to be able to recognize these stages of behaviors in order to put a stop to the alleged parent’s control over the victim.

1. Secrecy: The victim may comply with abuser’s demands out of fear of the implied consequences.
2. Helplessness: The victim feels powerless to stop the abuse because of the adult’s authority.
3. Entrapment and accommodation: The victim tries to get used to the abuse through denial and dissociating. May explain why victims appear to act normally with abusive parent during visitation.
4. Disclosure: During this stage, victims will drop hints to family members, friends, or other adults. Depending on the reaction received, the victim may disclose fully or stop discussion.
5. Recantation: Some victims recant because they are not believed or do not want to go through with the investigation that comes after disclosure.

1. There should be one visit supervisor to each visiting family.
o This allows monitors to be focused on one family and one family only in order to best ensure safety of all family members.
2. The visitor monitor must be fluent in the language of the child and parent.
o This rule allows for efficient communication between the family and the monitor. Monitors must be fluent in the preferred language of family. Language preference should be discussed at intake.
3. Families with sexual abuse allegations should be in their own private room away from other families.
o This rule allows the monitor the be vigilant in ensuring the safety of the child and prevent involvement of other children.
4. Physical contact between the visiting parent and the child should be minimal and closely scrutinized.
o Any inappropriate contact initiated by parent or child should be stopped immediately. Appropriate contact should be brief and fully visible to monitors.
5. The following physical contact should be prohibited:
o Tickling, lap sitting, rough housing, prolonged hugging or kissing, stroking, hand holding, hair brushing, changing diapers or clothes.
6. Neither the visiting parent nor the custodial parent should bring any items to the visit:
o Books, games toys, photographs, music, audio or video games, dolls or pets. This is to prevent the perpetrator from bringing reminders of the child’s abuse and/or bribes to the child for recanting.
7. Certain behaviors should be prohibited including:
o Whispering, passing notes, hand or body signals, photographing the child, audio or videotaping the child, exchanging money, gifts, or cards. This is to prevent verbal threats and to minimize the triggering of harmful memories.
8. Parents may not take their children to the bathroom or change diapers for their children.
o Children are to use the program bathroom and use the help of staff if needed. Only staff are allowed to change diapers.
9. Parents are not allowed to discuss the abuse during the visit.
o This rule is to prevent any further emotional trauma of the child. Parents are not allowed to question the child about abuse or talk about the abuse in anyway in front of the child.
10. Off-site visits are not allowed.
o Off-site visitation does not allow for the level of control needed for monitoring a sexual abuse case. It is vital for monitors to be able to react quickly and efficiently to inappropriate situations.
It is necessary for monitors to be vigilant of any contact that may be triggering and remind the child of the abuse. When you recognize any behaviors that may be sexual in any way, you must intervene. The following is recommended:

• Directing the parent to stop a certain behavior
• Calling a short time-out
• Terminating the visit all together

It is also a good idea to create a safety signal for the child to say or do to indicate that he or she is uncomfortable at any time and you can intervene. Just make sure it is not too obvious. Possible signals may include:

• A certain word or phrase
• A song
• Raising a hand
• Crossing Arms

Case 1 Discussion Questions:
1. What issues could the elder son be facing as a non-abused sibling?

2. What issues could Janet be facing as a non-offending parent?

3. What should a monitor keep in mind when supervising a visit in this case?

Case 2 Discussion Questions:
1. What issues could the two daughters be facing?

2. What are the benefits of Mary believing and supporting her daughter?

3. What are some aspects of this case that would contribute or hurt the daughters’ chances of resilience?

4. What issues could Mary be facing?

5. What can you as a monitor do to help Mary?
1. True or False: Sexually abused children are at an increased risk at exhibiting deviant behaviors.

2. ________________ is the inappropriate development of a child’s sexuality as the result of sexual abuse.
A. Self-injurious behavior
B. Traumatic sexualization
C. Resiliency
D. Depression

3. Which of the following is true about males who experience sexual abuse?
A. More likely to experience sexual abuse outside of their families
B. More likely to have a female perpetrator
C. Less likely to disclose in childhood than females
D. All of the Above

4. True or False: Contact between the accused parent and the child victim should be fully visible to monitors during visits.

5. During a visit, the visiting parent says something to his/her young child that makes the child cry excessively and become inconsolable. You should: (write out answer)
________________________________________________________________________________

Answers: 1. True 2. B 3. D 4. True 5. Visitation staff should have heard what was said. That’s a fundamental point. Answers should also include: Intervene and separate parent and child; talk to parent about what was said; decide whether to end visit based on parent’s behavior and statements. Document the incident. Depending on the parent’s statement, file critical incident report, making referring judge aware of the issue.
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