Sexual abuse is not straightforward to define either. Some children can be distressed if they witness adult sexual activity or see a sex video. Some are disturbed by one-off sexual abuse, whether or not there is penetration or sexual touching. Others seem to cope.
When the child has been distressed by serious abuse, patterns of response vary with age. Small children are aware of sexual feelings and have strong sexual feelings for their mother and father, but are confused about how babies are made and the different body parts. If they are physically or sexually abused, the experiences may be painful, frightening or exciting but the child does not have the capacity to process these responses - what are stored in their mind are merely sensations. If they are aroused, they might seek to provoke similar reactions from others, seeking sexual contact or behaving in a way that might lead to smacking. But these young children are unlikely to be able to talk about what is happening. It is their behaviour that gives the clues.
In primary schools, as with pre-school children, signs to look out for may be tummy aches, wetting or soiling of their pants. They may also become very tired, withdrawn or sad. Some become overactive or unable to concentrate and their learning drops off. Children can start avoiding people and giving up on relationships. Others throw themselves into school work and life and may do quite well. They are often reluctant to go home at the end of the day. Some retreat into a fantasy world of daydreams.
They may also suffer from post-traumatic stress disorder, when memories of what happened flood into their mind unexpectedly. These children may try to tell someone but often say no one wanted to listen; it may be the dinner lady or playground assistant who has the time. Or they may talk about what has happened but are afraid of the consequences. They could have been threatened and often do not want their family broken up, although they want the abuse to stop.
At puberty, boys and girls stop their sniggers and snide remarks about sex as they have to cope with their bodily changes and hormone surges. Physical or sexual abuse can be particularly confusing and distressing at this time. Body hair, menstruation and wet dreams already leave teenagers in a volatile state; if they have to manage physical interference as well, this is very disturbing. Some withdraw into despair and may even become suicidal; others take to drink or drugs to anaesthetise themselves; others become promiscuous.
Older adolescents can appear contemptuous, scathingly dismissive of adults and distant. Others throw themselves into school work as they see higher education as a means of escape - and often become members of the caring professions, such as nursing.
What is happening psychologically in all these children and young people is a mix of strategies to survive. If early attachments are good, they may have the resources to find help: a phone line, relative, family friend, or the parent of a school friend. But if the situation is difficult, they can retreat into a way of functioning that we call "splitting", where the good and bad are divided. Their peer group may be good and adults bad, or they may see themselves as bad and worthless and other siblings as good. Most difficult to manage is the impact on those around them, as they may unleash their unbearable feelings.
Most young people who have suffered abuse have problems trusting anyone and say it may take a long time of someone being reliable and available before they will open up. There are a few who indiscriminately talk to anyone.
Provided it is not life-threatening, physical abuse is not quite so damaging psychologically as sexual abuse. Sexual corruption and violation seem to give an extra dimension to the damage.
Professor Judith Trowell is honorary consultant child and adolescent psychiatrist at The Tavistock Clinic in London
- NSPCC Turning Points: a resource pack for communication with children (www.nspcc.org.uk)
- Family Violence In Primary Care, edited by Stephen Amiel and Iona Heath, OUP 2003
- Child Sexual Abuse: Responding to the experience of children, edited by Nigel Parton and Corinne Wattam, WileyNSPCC, Chichester, 1999.