Chapter 11: Part C - Behavioral Issues

Avoidant Behavior

Some children will avoid contact or interaction with adults or other children in an attempt to try to protect themselves from abuse. This behavior may be the child’s attempt to manage his/her anxiety about revictimization. However, this kind of behavior pattern often leads to isolation and alienation from peers and adults and can leave the child vulnerable.

Oftentimes, the child is undersocialized and feels stigmatized by the abuse or neglect. The child generally has low self-esteem, poor communication skills, and difficulties managing his/her feelings or behavior when in social situations. This child often appears quiet, watchful, and anxious in social settings. Although the child may be actively engaged in avoiding physical and social contact with peers and adults, he/she is often very lonely and longs for connection to other people.

A child who demonstrates avoidant behaviors is reticent in social situations and is fearful that he/she will say something silly or inappropriate or not be able to respond adequately. This child can benefit from participating in a supportive social and therapeutic group with children of the same age. It is important to remember that the avoidant child is probably anxious about the interaction with the therapist.

[QN.No.21.A child who demonstrates avoidant behaviors is: ]

In working with a child who demonstrates avoidant behaviors, the therapist can:

• Begin establishing a relationship with the child in a slow and deliberate manner. This allows the child to feel comfortable and safe. The avoidant child may need a much longer beginning phase of therapy in which to develop rapport, trust, and realistic expectations. The clinician can offer reassurance that the child is not in trouble or not going to be penalized for anything that he/she might say.
• Monitor body language, vocal quality, and reactions to the child’s statements. A calm tone of voice and willingness to slow the pace of the conversation can help the child attend to the information and process the experience.
• Give information about the format of the sessions and the therapist’s availability, such as what will happen if an appointment is cancelled. It is important for the professional to remember that simply because the child avoids contact and interaction does not mean that the therapeutic relationship is unimportant. Many avoidant children come to depend on the therapeutic interaction and are quite bereft when the therapist cancels or needs to terminate the relationship.
• Choose activities that support the child’s skills and abilities and enhance his/her self-esteem and competency. When a therapist asks the child for help arranging the playroom or deciding where to put the toys, these requests engage the child in an activity in which he/she feels productive and learns the way about the playroom.
• Help the child retain a sense of control and decision making. Provide choices.
• Use anticipatory planning, which not only tells the child what will happen but offers him/her options about how to respond or react. This increases the child’s repertoire of behaviors and gives him/her choices.
• Help the child develop coping skills that will allow him/her to manage his/her feelings and thoughts, memories, and disclosure about the abuse or neglect.
• Remember that the child may only be able to give small amounts of information at a time. Therefore, the professional should allow periods of nondirected play between statements about abuse. This provides the child with the opportunity to manage his/her anxiety and allows the child to note and monitor the therapist’s response to the disclosure. Davies and Montegna note that respecting the child’s pace may seem time-consuming and tedious, but can result in a more effective therapeutic relationship.²¹⁴

Dependent Behavior

Children are dependent on adults for their care and well-being. Often, a child who has been abused or neglected by an adult upon whom the child relied to care and protect him/her will regress to a previous developmental stage that feels safer and more comforting. This normal coping behavior enables the child to regain emotional energy for his/her passage into a new phase or stage of development.

However, a dependent pattern of behavior is more pervasive than regressed behavior. A child who exhibits this dependent pattern of behavior often allows other people to make important decisions, such as whether or not the child is hungry or needs help. Dependent children who fear rejection may agree with people even when the child knows that these people are wrong. The child may volunteer to do things that are unpleasant or demeaning in order to get other people to like him/her. A dependent child is vulnerable to exploitation and revictimization because he/she has a tendency to attach to anyone who he/she feels attends to their physical or emotional needs. This pattern of behavior can create major long-term developmental and relationship problems.

Initially, a dependent child is “easy” to engage in therapy. The child is compliant, offers little resistance to developing a therapeutic relationship, and welcomes the chance to participate in therapy. However, upon observation, the dependent child is often indiscriminate in his/her attachment to adults, has few opinions or issues to discuss in therapy, and can appear to the therapist as a “good” child who is a pleasure to have in therapy. The challenge in working with a dependent child is to generate separation and individuation, to elicit a strong and determined response from the child, and help the child integrate a sense of self that is based on worth, abilities, and individuality.

In working with dependent children, the therapist can:

• Be nurturing while expecting and teaching the child to behave in an age- and/or developmentally appropriate manner. In this way, the therapist is “pulling” the child into maturity while protecting the child from his/her fears of rejection or abandonment.
• Be consistent and continuously provide support and encouragement. Usually, this child did not bond with his/her parent/caretaker or have the opportunity to attach to a stable and consistent caregiver.
• Practice problem-solving skills and help the child determine what it is he/she needs and wants.
• Reinforce questions, requests for information, and the development of interest and curiosity in outside activities and support systems.

Aggressive Behavior

A high percentage of severely aggressive children have histories of suspected child maltreatment. These children may be identifying with the aggressor, have pent-up anger and rage, or problems with impulse control that make it difficult for them to control their behavior. The child who acts out his/her aggression must learn to take responsibility for the consequences or outcomes of the behavior. The potential recipients of the child’s aggression need to be protected from this kind of victimization.

A child who exhibits aggression often has been raised in families that are characterized by harsh and inconsistent discipline, little positive parental involvement with the child, and poor supervision of the child’s activities.²¹⁵ Structure, planning, continuity, consistency, and a nurturing environment are all factors important in working with aggressive children.²¹⁶

Some parents may not be able or willing to deal with their child’s behavior. They may be resistant to interventions that feel as if they are being “told what to do” or “how to raise their children.” At these times, CPS involvement is crucial in engaging resistant parents and protecting any vulnerable children in the household. The aggressive child also needs to be protected. Regardless of his/her behavior, the child deserves protection from dangerous or inappropriate adult-child behavior.

Ongoing family problems or disruption contribute to an adolescent’s vulnerability to peer pressure. Peers supply the adolescent with the attitudes, motivation, and rationalizations to support antisocial behavior; peers also provide opportunities to engage in specific delinquent acts.²¹⁷ Many antisocial and aggressive adolescents already have a deviant peer group that reinforces their behavior.

In working with an aggressive child, the therapist can:

• Determine whether the child is currently being abused.
• Provide opportunities for the child to anticipate and plan for the resurgence of past feelings and experiences. This can help the aggressive child become aware of underlying feelings and pain and develop a plan for managing his/her reactions. In extreme cases, medication as well as higher levels of care, including hospitalization, day treatment, or residential care may be useful to the aggressive child.
• Ensure that the treatment of young males addresses the issue of body image and its relationship to the victim’s self image. Sebold notes that the child may require more physical space during casual conversations.²¹⁸ He also notes that touching can elicit a rigid and uncomfortable physical response. He raises two important questions about sexually abused males ? Do sexually abused males become touch deprived? How can therapists develop treatment approaches that recondition sexually abused males to appropriate touch experiences?
• Teach a child to delay gratification, manage his/her impulsive behavior, and become aware of how his/her behavior affects others. This will help the child relate in more appropriate and acceptable ways to peers and adults.
• Assess if the child is a danger to him/herself or to others. The clinician must identify the problematic behavior as dangerous. Consequences to the recipient of the violence or to the aggressive child must be clarified. Risk taking, seeking out violent altercations, or assaulting others needs to be restricted. The therapist can portray these behaviors to the child as an indication of his/her need for protection. The therapist must connect the child’s experience of abuse with the anger, rage, or rebellious behavior.
• Explore the benefits and liabilities of participating in a peer group that reinforces aggressive and destructive behavior.

In addition, the clinician must address sexually aggressive behavior immediately. The therapist must report this behavior to the appropriate authorities and use law enforcement and CPS interventions to guarantee that other children are not victimized. Interventions useful to address sexually aggressive behavior can be found in the sections on identity and victimizing behavior.

Hypersexual Behavior

Browne and Finkelhor describe premature sexualization as a process in which a child’s sexuality (including sexual feelings, attitudes, and behaviors) is shaped in a developmentally inappropriate and interpersonally dysfunctional fashion as a result of sexual abuse.²¹⁹ In the same way that a physically abused child often demonstrates physically aggressive behavior as a coping and interaction style, the sexually abused child may also demonstrate sexualized behavior to express anxiety or socialization problems.

A children who has been sexually abused has been prematurely introduced to sexual behavior and often has been taught, reinforced, or rewarded for behaving in a sexual manner. The child may not be aware of how his/her behavior appears to other people. Most victims have little awareness that their behavior is seductive and may feel hurt or confused when people are put off by their behavior or are distraught and bewildered when adults accost them sexually.²²⁰ Suggestions for dealing with sexualized behaviors are provided in the following discussions.

Suggestive Sexual Behavior

Suggestive sexual behavior is learned behavior that is often reinforced by the perpetrator. It is disconcerting and sometimes frightening to parents. Many parents can become very punitive in their attempts to end this kind of behavior, but this approach can exacerbate the problem and alienate the child.

The therapist working with this type of behavior can:

• Help parents/caregivers intervene with inappropriate sexualized behavior, set limits on this type of interaction, and support and reinforce new behaviors.
• Help parents/caregivers understand that this type of behavior is not an uncommon response to sexual abuse and does not mean that the child is permanently damaged or going to become homosexual, a prostitute, or a child molester.
• Help the child address all the issues related to sexual abuse. This offers the child insight and an ability to manage his/her behavior in an appropriate manner.
• Bring provocative clothing, suggestive body language, and inappropriate sexual statements or innuendos to the child’s awareness. This awareness is important to protect the child from inappropriate adults and from peers who can tease, ostracize, or make inaccurate assumptions about the child’s motives or desires. By using examples of movie stars or rock stars to help explain how behavior and dress create an image, the therapist can help the adolescent understand the impact of his/her behavior without instilling a sense of shame or guilt.
• Provide sex education to the child by discussing the correct terminology for sexual body parts, functioning of genitalia, and normal sexual behaviors. Sex education can assist in correcting distortions in the child’s knowledge or belief system regarding sexuality.

Once the child becomes aware of these sexualized behaviors and has been exposed to alternative behaviors that are more appropriate, then he/she can begin to choose how he/she wants to present him/herself to others.

Masturbation

Masturbation is a fairly common occurrence among children and adolescents. However, the sexually abused child may be more likely to demonstrate this behavior in inappropriate places and at inappropriate times. Masturbation is often an attempt to soothe stress and anxiety generated by the abuse.

A five-part plan for working with families/caregivers whose child exhibits compulsive masturbation includes:²²¹

• Assessing parental/caretakers’ attitudes and behaviors related to the masturbation. Friedrich suggests that the parents/caretakers be educated regarding the possible relationship between sexual abuse and masturbatory behavior.
• Helping the parents/caretakers positively shape and reinforce the child’s non-masturbatory time.
• Creating a time and place for the child to masturbate. Isolating the child with the masturbatory behavior may reinforce that method of soothing his/her anxiety. Replacing the masturbatory behavior with pleasant, socially acceptable and engaging behaviors may be more productive.
• Normalizing values and attitudes about masturbation.
• Dealing with the child’s abuse experience because this, in part, is driving the masturbation.