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The Effect of Severe Child Sexual Abuse and Disclosure on Mental Health

during Adulthood

PATRICK O’LEARY University of Southampton, Southampton, UK

CAROL COOHEY and SCOTT D. EASTON University of Iowa, Iowa City, Iowa, USA

This study examined the relationship among severe child sexual abuse, disclosure, and mental health symptoms during adulthood. The sample consisted of 172 adults who were sexually abused in childhood. The multivariate model showed that respondents in their 30s and 40s who were abused by more than one abuser, who were injured by their abusers, who were abused by a biological relative, who told someone about the abuse when it occurred, and who did not discuss their abuse in depth within one year of the abuse had a greater number of mental health symptoms. Abuse severity and disclosure history should be assessed by professionals to identify clients who are at higher risk of mental health symptoms and to focus therapy.

KEYWORDS child sexual abuse, severity, disclosure, mental health

Researchers have consistently found a higher incidence of mental health problems among adults who were sexually abused as children than among adults who were not abused (Brodsky et al., 2001; Fergusson & Mullen,

Submitted 8 December 2008; revised 26 February 2010; accepted 2 March 2010. The authors acknowledge the men and women who took part in this study and the

Centers Against Sexual Assault, Victoria, Australia, that granted access to their data. Address correspondence to Patrick O’Leary, School of Social Sciences, University of

Southampton, Southampton SO17 1BJ, United Kingdom. E-mail: p.o’[email protected]

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1999; Joiner et al., 2007; Molnar, Buka, & Kessler, 2001; Nurcombe, 2000). However, the long-term effects of childhood sexual abuse on adults’ men- tal health vary considerably, raising important questions about why some sexually abused children develop mental health problems during adulthood while others do not. To explain variability among adults who were sexually abused as children, researchers have turned their attention from establish- ing a relationship between sexual abuse and mental health to, for example, examining the relationship between severity of abuse and mental health (Banyard, Williams, & Siegel, 2004) and between disclosure and mental health.

The purpose of this study was to build on this literature by (a) investi- gating the relationship between indicators of severe sexual abuse and mental health symptoms during adulthood and (b) determining whether telling someone the abuse occurred and discussing it in more depth during child- hood moderates the relationship between severe abuse and mental health symptoms. In the following section we describe the relationships between characteristics of childhood sexual abuse, disclosure, and mental health.

LITERATURE

Abuse Characteristics

An important challenge for researchers is to explain why some but not all sexually abused children experience mental health symptoms during adult- hood. Characteristics of the sexual abuse, including its severity, may explain variability in mental health among adults who were abused as children. For example, children who were younger at the time they were first abused were more likely to report anxiety (Banyard et al., 2004) and to attempt suicide (Boudewyn & Liem, 1995) during adulthood. Yet, not all researchers found that younger age at the time of the sexual abuse was related to more severe psychological distress (Ruggiero, McLeer, & Dixon, 2000), leading to some ambiguity as to the role that age plays in the long-term effects of child sexual abuse (Kendall-Tackett, Williams, & Finkelhor, 1993).

Researchers have also reported that the severity of sexual abuse may influence mental health during childhood and adulthood (Merrill, Thomsen, Sinclair, Gold, & Milner, 2001). For instance, the intrusiveness of the sexual act (e.g., penetration), injury, and physical violence were related to mental health problems in both children and adults in several studies (Banyard et al., 2004; Collings, 1995; Heath, Bean, & Feinauer, 1996; Kendall-Tackett et al., 1993; Kendler et al., 2000; Whiffen & Clark, 1997; Windle, Windle, Scheidt, & Miller, 1995).

Whether the adult survivor was close to the abuser (e.g., biologically related) may also be an indicator of severity of sexual abuse and affect his or her mental health. Kendall-Tackett and colleagues (1993), for example,

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found that children who were closely related to their abuser (e.g., son, stepson) were more adversely affected than children who were not close to their abuser. Abuse by a parent, in particular, can be especially damaging because the child relies on his or her parent for care and protection. Sexual abuse by a parent may result in confusion, a sense of betrayal, and harm the child’s capacity for trust, intimacy, and self-agency during adulthood.

Researchers have used frequency and duration of sexual abuse as indi- cators of severity and found that more frequent abuse and/or abuse that occurred over a longer period of time were related to more mental health symptoms in adulthood (Banyard et al., 2004; Boudewyn & Liem, 1995; Kendall-Tackett et al., 1993; Paris, Zweig-Frank, & Guzder, 1994). For exam- ple, in a study of 117 women and men who reported being sexually abused in childhood, longer duration of abuse was related to psychopathology (Rodriguez, Ryan, Rowan, & Foy, 1996). In addition to frequency and dura- tion, the number of people that abused the child may also contribute to poorer mental health outcomes in adulthood. In an early study by Briere and Runtz (1988), the number of sexual abusers was related to mental health symptoms in a nonclinical sample of women. Although subsequent studies have demonstrated an association between the number of abusers and more mental health symptoms (Heath et al., 1996; Sacco & Farber, 1999), Kendall- Tackett and colleagues (1993) did not find a clear relationship between number of abusers and mental health.

Disclosure and Response

Many children do not disclose the abuse at the time it occurs; some children never tell. For many children, there is a significant delay before they tell anyone about their abuse (Bell & Belicki, 1998; Finkelhor, Hotaling, Lewis, & Smith, 1990; Hunter, Goodwin, & Wilson, 1992; O’Leary & Barber, 2008; Weingarten & Cobb, 1995). Shame, fear, and confusion may surround the sexual abuse experience and explain why some children do not tell. These feelings may be intensified by the abuser’s threats and actions to silence the child (Paine & Hansen, 2002).

It is often assumed that children will benefit by telling someone about their abuse (Alaggia & Kirshenbaum, 2005). However, the effect of telling on the child may depend on the adequacy of the response he or she receives from others. A disclosure that is met with a dismissive, disbelieving, nonsup- portive, hostile, or nonprotective response can be traumatic in itself and lead to long-term mental health symptoms (Feiring, Taska, & Lewis, 2002). Feiring and colleagues (2002), for example, found that adolescents who disclosed their sexual abuse reported greater psychological distress than adolescents who did not disclose their abuse. Adolescents who disclosed their abuse tended to feel less supported, to perceive others’ reactions as negative, and to blame themselves for the abuse.

278 P. O’Leary et al.

Who children tell may also influence their mental health. Ruggiero and colleagues (2000) found that disclosure to someone (other than one’s mother) predicted poorer mental health among children. However, a nega- tive response to disclosure, particularly by mothers, may be related to more mental health symptoms (Browne & Finkelhor, 1986). Consistent with these findings, several researchers found that mothers who believed their children and who supported them had children with fewer mental health symptoms (Luster & Small, 1997; Merrill et al., 2001).

From a developmental perspective, a child’s sense of security and con- trol is essential to his or her well-being (Bowlby, 1982). Conversely, feeling out of control may adversely impact a child’s social and psychological func- tioning, leading to long-term mental health symptoms (Mullen & Fleming, 1998). If a child discloses the abuse and his or her confidant tells some- one else about the abuse without the child’s permission, this response may further add to the child’s perceived loss of control, shame, and sense of betrayal, which may lead to mental health symptoms during adulthood (Gold, 1986).

Researchers have infrequently examined the impact of wanting to tell someone about the abuse but feeling unable to tell. This unfulfilled desire to tell may contribute to children feeling guilt, regret, and powerlessness and, consequentially, more mental health symptoms during adulthood (Gold, 2000). Research also suggests that the sooner the abuse is discussed, ver- sus simply told to someone else, the better the mental health outcome (Lamb & Edgar-Smith, 1994; Paine & Hansen, 2002). Timely discussion of the abuse, not just telling someone it occurred, may help the child to pro- cess the experience before the effects of the sexual abuse accumulate and result in adverse long-term problems. However, because we could not iden- tify any study that simultaneously examined both telling someone about the abuse when it occurred and discussing the abuse over time, it is difficult to draw conclusions about how disclosure affects long-term mental health symptoms.

The Present Study

The literature raises important questions about the relationship among severe sexual abuse, disclosure, and long-term mental health symptoms. Only a few studies examined the relationship between disclosure and mental health symptoms among adults. In this study, we examine the relationship among indicators of severe sexual abuse, disclosure, and the number of mental health symptoms reported by adults who were sexually abused as children. First, we hypothesize that indicators of severe child sexual abuse— longer duration, greater frequency, multiple abusers, assault, injury, and incest—will be related to more mental health symptoms. We include multiple

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indicators of severity to determine whether some indicators are more impor- tant than other indicators. Second, we hypothesize that telling alone will not be related to fewer mental health symptoms but that discussing the abuse relatively soon after the abuse occurs will be related to fewer men- tal health symptoms. Finally, we hypothesize that among respondents who were severely sexually abused, discussing the abuse with someone relatively soon after the abuse occurred will moderate the effect of severe abuse on the number of mental health symptoms.

METHODS

Design and Sample

The hypotheses were tested using data collected in a phone survey on the needs of victims of sexual violence living in Victoria, Australia. The survey was designed to understand “common experiences” of survivors, “support needs” of survivors, and the effects of sexual abuse on survivors’ health. The Centers Against Sexual Assault (CASA) recruited respondents from the com- munity through advertisements placed in newspapers; posted at community organizations, including human service agencies, schools, restaurants, and shops; and broadcasted on community radio. Two hundred and seventy-six (276) adults who were sexually abused as children responded to the ads. Of these respondents, 96 people reported they were also sexually assaulted as adults. For some interview questions, we could not be certain whether they were responding to their sexual abuse as a child or to their sexual abuse as an adult. Therefore, we excluded respondents who were both sexually abused as children and as adults. Because the item used to measure age was categorical (e.g., 17–19, 20–24), we excluded respondents who were under the age of 20. This decision allowed us to draw conclusions about the relationship between disclosure and mental health among adults only.

The final sample consisted of 172 adults who were sexually abused as children only. The majority of respondents were female (80.2%; male = 19.8%), were unemployed (64%), and completed high school or fewer years of education (60.5%). The sample was roughly divided into respondents who were in their 20s, 30s, 40s, and 50s or older. Most of the respondents lived in metropolitan Melbourne or the Regional Centre; 47.1% lived in rural Victoria.

Measures

This study received human subject approval from the Flinders University of South Australia Human Research Ethics Committee and from the local participating organizations. Trained counselors and volunteers interviewed the respondents over the telephone.

280 P. O’Leary et al.

MENTAL HEALTH SYMPTOMS CHECKLIST

We used a self-report measure of mental health: the respondents’ perception of their mental health. The interviewers asked the respondents to report whether, yes or no, they had experienced guilt, sadness, or grief, a sense of helplessness, emotional numbness, depression, anxiety, panic attacks, fears or phobias, dissociation, and a sense of vulnerability since the sexual abuse. To create a mental health symptoms index, we added the variables together (theoretical range = 0–10).

CHARACTERISTICS OF THE SEXUAL ABUSE

To measure frequency, respondents were asked the number of times they were abused. To measure duration, respondents were asked how old they were when the abuse started and how old they were when the abuse ended. Age at first abuse was subtracted from age at last abuse. Because these variables were highly skewed, we recoded frequency (more than once = 1; once = 0) and duration (five years or less = 0; more than five years = 1). If respondents reported they were physically assaulted by their abuser(s), they received a score of 1 (were not physically assaulted = 0). Similarly, if they reported they were injured when they were sexually abused, they received a score of 1 (were not injured = 0). The respondents reported four types of injuries: to the skin (abrasions, scratches, or bruises), bones, muscles, and internal or external genitals or rectum. If they were sexually abused by more than one abuser, they received a score of 1 (one abuser only = 0). Finally, if the respondents knew their abuser or abusers, then they were asked about their relationship to each abuser (e.g., parent, step-parent, sibling, neighbor) and whether they considered their abuse to be incest. If they said the abuse was incest, then they received a score of 1 (not incest = 0).

RESPONSE TO THE SEXUAL ABUSE

The interviewers asked the respondents whether they told anyone about the abuse at the time it occurred. If the respondents said they, at the time, told someone about the abuse, then they received a score of 1 (did not tell = 0). If they told someone, then they were asked who they told. The interview included nine role-types, including family member, friend, doc- tor, other health care professional, CASA (court appointed special advocate), other counselor, lawyer, police officer, and other. The respondents could add additional roles that were not included on the list. They added priest and teacher. If they told someone at the time of the abuse, the interviewers asked them whether that person told someone else without their permis- sion. Regardless of whether they told someone about their abuse, they were asked whether they wanted but were unable to tell someone else (wanted to tell = 1; didn’t want to tell = 0). If they wanted to tell, they were asked who

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they wanted to tell. The respondents reported several types of people includ- ing parent, other family member, friend, health care professional, teacher, police, offender’s family member, trusted person, nonjudging person, and anybody. In a separate question respondents were asked whether they ever discussed their abusive experience with anyone. If the respondent talked to someone about their experience (not just told someone it occurred), then they were asked how long it was before they discussed the abuse. Their responses ranged from immediately to more than 50 years. Because the dis- tribution was skewed, we recoded how long it took to discuss the abuse into two categories (within one year = 1; more than one year = 0). By using a one-year interval, we also know all respondents were still children when they discussed the abuse.

Data Analysis

The analyses proceeded in three steps. First, we examined whether the demographic variables were related to the dependent variable, the num- ber of mental health symptoms. Only the respondents’ age was related to mental health. Second, we examined the bivariate correlations among the number of mental health symptoms and the independent variables (charac- teristics of abuse and disclosure and response to the sexual abuse). Third, the bivariate relationships that were statistically significant at the p < .05 level were included in the multivariate analyses. We entered the variables into the hierarchical regression model in four steps: (a) the demographic variable age, (b) characteristics of the abuse, (c) disclosure and response to the sexual abuse, and (d) interactions.

RESULTS

Table 1 shows the intercorrelation among indicators of severity, disclosure and response, and mental health. All of the indicators were related to the number of mental health symptoms reported by adults sexually abused as children. The younger the respondent was at the time he or she was first sexually abused, the greater the number of mental health symptoms the respondent reported as an adult. If the abuse occurred more than once, then the respondents tended to report more mental health symptoms as adults. Similar to other studies, sexual abuse that occurred over a longer period of time was related to more mental health symptoms.

If the abuser physically assaulted the respondent as a child, then the respondent was more likely to report more mental health symptoms. Similarly, adults who reported they were injured by the abusers were more likely than adults who did not report an injury to have a greater number of symptoms. The most common injuries were scratches and bruises (16.3% of

282 P. O’Leary et al.

TABLE 1 Bivariate Correlations Among Potential Predictors and Number of Mental Health Symptoms (n = 172)

1 2 3 4 5 6 7 8 9 10 11

1. Mental Health Symptoms

— −.18∗∗ .14∗ .16∗ .16∗ .28∗∗ .29∗∗ .30∗∗ .29∗∗ .14∗ −.13∗

2. Age at First Abuse

— −.34∗∗ −.40∗∗ −.09 −.16∗ −.24∗∗ −.28∗∗ −.09 −.19∗∗ .19∗∗

3. Frequency of Abuse

— .38∗∗ .16∗ .17∗ .18∗∗ .20∗∗ .06 −.00 −.37∗∗

4. Duration of Abuse

— .03 .11 .12 .26∗∗ .16∗ .02 .00

5. Abuser Assaulted Child

— .31∗∗ .35∗∗ .00 .06 .02 .05

6. Abuser Injured Child

— .24∗∗ .23∗∗ .13∗ .10 .06

7. Number of Abusers

— .08 .13 .23∗∗ −.07 8. Abuse Was

Incest — .06 .13∗ −.06

9. At the Time, Child Told

— .23∗∗ .12

10. Confidant Told

— .19∗∗

11. Child Discussed

—

Phi and Pearson correlations: ∗p < .05, ∗∗p < .01.

the total sample) and injuries to the genitalia or rectum (10%). Five respon- dents reported that the abusers broke their bones. The respondents who were sexually abused by more than one person tended to report more men- tal health symptoms than the respondents who were abused by one person. Finally, if the respondent reported that the sexual abuser was a biologi- cal relative, then he or she was more likely to report more mental health symptoms.

We included several variables to examine disclosure of abuse and how others responded to it. The respondents who told someone about the abuse at the time that the abuse occurred reported more mental health symp- toms. The respondents were most likely to tell family members (35.5%), followed by CASAs and other counselors (31.4%), friends (26.7%), doctors (12.8%), and other health professionals (4.1%). A substantial percentage of children (39%) never told anyone about the abuse during childhood. Almost 27% of the respondents said they had told someone about their abuse during childhood, and that person told someone else without their per- mission. Telling someone without the respondent’s permission was related to a greater number of mental health symptoms as an adult.

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The majority (61%) of the respondents wanted—but were unable—to tell someone or someone other than whom they told. When asked who they wanted to tell, the respondents were most likely to say they wished they would have told a parent (40.1%) or another family member (15.1%). Almost 30% of the respondents said they did not want to tell anyone or anyone other than whom they told. Because of missing data, we did not test the bivariate relationship between wanting to tell but being unable to tell and the number of mental health symptoms.

Finally, we examined whether the respondents discussed the abuse with someone, not just told someone about their sexual abuse. Almost all of the respondents (98%) had discussed their abuse sometime during their life- time. We were interested in whether the respondents who discussed their abuse within a relatively short amount of time after the abuse would have fewer mental health symptoms. Only a small percentage of the respondents (10.5%) had discussed their abuse within a year of the abuse; however, discussing the abuse within one year was related to fewer mental health symptoms.

Table 2 shows the results for the hierarchical regression analysis. Age was originally coded as a categorical variable: 20–24, 25–29, 30–39, 40–49 and 50 and older. To avoid a small cell problem, we recoded age into three categories (20–29, 30–49, and 50 and older). We found that the respondents in their 20s and the respondents in their 50s and older had significantly fewer symptoms than the respondents in their 30s and 40s. To simplify the model, we recoded age into two categories (30–49 and other). Because the results were similar when we included the three-category variable and when we substituted the two-category variable, we reported the results for the model with the two-category variable.

Six additional variables made an independent contribution to the model explaining mental health symptoms. Frequency, duration, and whether the respondent had been physically assaulted by the abuser were not significant; however, being injured during the abuse was significant. If the abuser had injured the child during the sexual abuse, then the respondent was more likely to report more mental health symptoms. Being abused by more than one person and being abused by a biological relative were also related to a greater number of symptoms.

Table 2 also shows that telling at the time the abuse occurred was related to a greater number of mental health symptoms; however, discussing the abuse within a year of the abuse was related to fewer symptoms. Whether the respondents said they had told someone about their abuse and that person told someone else without their permission was not significant in the model. Overall, the model explained 25% of the adjusted variance in number of mental health symptoms.

Finally, we examined whether discussing the abuse within one year moderated the relationship between an injury and mental health, between

284 P. O’Leary et al.

TABLE 2 Hierarchical Regression Model Predicting Mental Health Symptoms as a Function of Characteristics of and Response to the Sexual Abuse (n = 168)

Standardized B Adjusted �R2

Step 1: Control Variable .05∗∗∗

Age (30–49)a .24∗∗ .24∗∗∗ .21∗∗

Step 2: Characteristics of the Abuse

.16∗∗∗

Younger at first abuse −.04 −.05 Abuse occurred more than once −.02 −.07 Abuse lasted more than five

years .05 .06

Abuser assaulted child .03 .05 Abuser injured child .18∗ .17∗

More than one abuser .21∗∗ .17∗

Abuse was incest .21∗∗ .20∗

Step 3: Response to the Abuse .04∗∗∗

Told someone about the abuse at the time

.21∗∗

Told someone else without the child’s permission

.04

Child discussed the abuse within one year

−.15∗

aReference group: Less than 30 and 50 and older. ∗p < .05, ∗∗p < .01, ∗∗∗p < .001.

more than one abuser and mental health, and between incest and mental health. For example, we hypothesized that, among respondents who were injured, those that discussed the abuse within one year would have fewer mental health symptoms. None of these hypotheses were supported; how- ever, the lack of significance could have been due to a small cell problem. Accordingly, these results should be interpreted with caution.

DISCUSSION

The results suggest disclosure of child sexual abuse during childhood may be important in understanding mental health symptoms during adulthood. We found that telling someone about the sexual abuse was related to a greater number of mental health symptoms. However, discussing the sexual abuse within a year was related to fewer mental health symptoms. It seems likely that the relationship between telling someone about the abuse at the time it occurred and more mental health symptoms may be attributed, in part, to an inadequate response by parents and others. This study did not examine the adequacy of responses to disclosure. However, researchers have found that many children do not receive an adequate response (Feiring et al., 2002; Paine & Hansen, 2002), and adequacy of response to disclosure has been cited as a key factor in adult functioning (Jonzon & Lindblad, 2005). Finally, we examined only whether the abuse was discussed within one year; we

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do not know what was discussed. Future research is needed to understand how respondents concluded they had had an in-depth discussion and to understand whether and how the content of these discussions affects mental health.

Regardless of whether the respondent told someone about the abuse or discussed it, three indicators of abuse severity were associated with more mental health symptoms: being injured, being abused by more than one person, and being abused by a biological relative. These results are consis- tent with a number of studies. Researchers, for example, have found that injury and incest were related to more mental health symptoms in adult- hood (Banyard et al., 2004; Heath et al., 1996; Kendall-Tackett et al., 1993; Whiffen & Clark, 1997; Windle et al., 1995). Other indicators of severity such as frequency and duration—which have been widely reported in the liter- ature as correlates of mental health symptoms—were related to number of mental health symptoms in the bivariate analysis; however, when they were added to the multivariate model, they were no longer statistically significant. Similar to findings by Kendall-Tackett and colleagues (1993) and Ruggiero and colleagues (2000), we did not find a relationship between age at onset of child sexual abuse and mental health symptoms.

The results from this study showed that adults in their 30s and 40s were more likely than younger adults to report mental health symptoms. Adults in their 20s may be more likely to deny, repress, or minimize their sexual abuse than older adults. There is evidence to suggest that some victims may forget the abuse occurred and recall it in middle life. Several authors write that, for some survivors, memories of child sexual abuse are triggered by specific events or by therapy (Alpert, Brown, & Courtois, 1998). It is also possible that the younger adults in this sample may have benefited from greater community awareness and improved professional responses to child sexual abuse (Finkelhor & Jones, 2006).

Adults in their 30s and 40s were also more likely than older adults (50 or older) to report mental health symptoms. It is possible that men- tal health symptoms for survivors may worsen during middle life and then somewhat dissipate in later life. Additionally, sampling bias may have influ- enced the results. For instance, older adults who responded to the request to be interviewed may have been physically and emotionally healthier than older adults who did not participate in the study. Our explanations for this unexpected finding—that stage of life may be related to more mental health symptoms among adults who were sexually abused as children—remain speculative and require further investigation.

Limitations

The usual limitations with retrospective, cross-sectional studies are evident in our study. Although we excluded adults who were sexually assaulted as adults, it is not clear whether other stressors during adulthood, such as

286 P. O’Leary et al.

divorce or substance abuse, contributed to the number of mental health symptoms. Childhood stressors, such as parental substance use, poor family functioning, or other forms of child maltreatment may also have contributed to mental health symptoms in adulthood. For example, parental support has been cited as a potential moderator of severe sexual abuse on mental health (Merrill et al., 2001). Moreover, we relied on respondents’ retrospec- tive reports of childhood events and mental health symptoms. The list of mental health symptoms, which was developed specifically for childhood victims of sexual abuse, has not been independently validated. In addition, we were unable to verify independently other important variables, such as when respondents told someone about the abuse, whether they were injured by the sexual abuser, or the number of sexual abusers.

Practice Implications

To reduce the likelihood of ongoing sexual abuse and the potential for adverse long-term effects, child protection strategies often emphasize that children tell someone about the abuse as soon as possible. However, we found a positive relationship between telling and mental health symptoms in adulthood. This finding may be due to children not receiving an ade- quate response to their disclosure. Children may have received a negative response for two reasons. First, family members and friends are often the preferred confidants, and they may be influenced negatively by the abuser (Faller, 1988; Salt, Myer, Coleman, & Sauzier, 1990). The abuser may con- vince them that he or she is not capable of sexually abusing the child and that the child made up the story (Paine & Hansen, 2002). In other instances, the abuser may hold power over confidants by threatening, for example, violence. Second, confidants may be ill-informed about the nature of child sexual abuse and its effect on children. Their lack of knowledge may con- tribute to a response (e.g., telling others without the child’s permission) that is unsupportive and that negatively affects the child’s well-being.

The potential for an unsupportive response highlights the importance of teaching caregivers and other adults (e.g., counselors, health professionals, police officers, teachers) how to respond supportively when children tell them they were abused. When teaching them how to respond to children’s reports of abuse, educators need to explain that telling alone may compound the trauma of child sexual abuse. The central point here is not to discourage children from telling, but, rather, to avoid promoting the potentially false hope that telling alone will stop the abuse or result in healing.

To stop the abuse, potential confidants can help strengthen children’s protective capacities by encouraging them to keep telling until someone acts to protect them. Moreover, children and adult survivors need to know that, although they may have been unable to tell at the time of the abuse, discussing their experience as soon as they are able may help protect

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them against poor mental health or may lessen mental health symptoms. Caregivers and others also need to act protectively when they discover chil- dren may have been abused. If the abuser believes the caregiver will act protectively, then he or she may be less likely to reabuse the child.

In addition to the role that disclosure may play in reducing mental health symptoms among adults, this study identified several characteristics of abuse that were related to mental health, including injury, the number of abusers, and abuse by a biological relative. Child protection workers should consider including these characteristics in their risk assessment tools. Therapists, too, may explore the effect of these characteristics on their client’s response to the abuse and on their relationships.

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AUTHOR NOTE

Patrick O’Leary, BSW (hons), PhD, is at the School of Social Sciences, University of Southampton, Southampton, United Kingdom.

Carol Coohey, MSW, PhD, is at the School of Social Work, University of Iowa, Iowa City, Iowa.

Scott D. Easton, MSW, is at the School of Social Work, University of Iowa, Iowa City, Iowa.

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