Self-Esteem, Anxiety, and Loneliness in Preadolescent Girls Who Have Experienced Sexual Abuse
Alana D. Grayston Rayleen V. De Luca Debby A. Boyes University of Manitoba
This study sought to clarify and extend existing knowledge of the negative sequelae of sexual abuse by comparing levels of self-esteem, anxiety, and loneliness in abused and nonabused girls. Comparisons indicated that sexually abused children had lower levels of self-esteem than nonabused children, but that levels of anxiety and loneliness did not differ between the groups. These findings empirically confirm one of the sequelae of sexual abuse commonly cited in the clinical literature and point to the need for interventions designed to redress this adverse effect.
ABSTRACT:
KEY WORDS: Sexual abuse; self-esteem; anxiety; loneliness.
Despite the recent proliferation of research and clinical work in the area of sexual abuse, controversy continues regarding its effects on children. Some clinicians contend that negative outcomes of abuse are minimal or nonexistent, or that the effects of abuse on children have been greatly overstated. 1 Other clinicians assert that abuse is a damReceived August 22, 1991; For Revision September 18, 1991; Accepted November 16, 1991. This manuscript is based on a presentation made at the 1990 Annual Convention of the Canadian Psychological Association in Ottawa, Ontario, Canada. Preparation of this article was supported, in part, by Manitoba Health Research Council and Medical Research Council of Canada Graduate Studentships to Alana D. Graysten, by a Manitoba Mental Health Research Foundation Grant to Rayleen V. De Luca, and by a University of Manitoba Graduate Fellowship to Debby A. Boyes. The authors would like to acknowledge and thank Don Sharpe for his valuable statistical assistance, Ratna Das, Susan Larson, and Norah Vincent for their help in scoring questionnaires, and John Adair for his insightful comments on earlier drafts of this paper. The assistance of the St. James-Assiniboia School Division No. 2 is also gratefully acknowledged. Reprint requests should be sent to Rayleen V. De Luca, Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada, R3T-2N2. Child Psychiatry and Human Development, Vol. 22(4), Summer 1992
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aging experience for children, having a wide range of deleterious mental health effectsY Although "almost every study of the impact of sexual abuse has found a substantial group of victims with little or no symptomatology,TM accumulating evidence strongly suggests "that sexual abuse is a serious mental health problem ''5 for many children and adults. There is a paucity of empirical evidence regarding its actual effects,~ but numerous anecdotal accounts suggest that abused children display a range of negative reactions and symptoms of emotional distress, resulting from the traumagenic dynamics (i.e., stigmatization, powerlessness, betrayal, and traumatic sexualization)6 comprising their abuse. Low self-esteem,3'7 high levels of anxiety,s'9 and feelings of loneliness and isolation 10.~ are among the short- and long-term symptoms most commonly described.
Self-Esteem
Self-esteem, according to Coopersmith, 12 is a person's customary evaluation of herself or himself. It "is an expression of approval or disapproval, indicating the extent to which a person believes him- or herself competent, successful, significant, and worthy. ''12 People with high self-esteem have self-respect and consider themselves of worth, whereas people with low self-esteem perceive themselves as inadequate and unworthy. 13 Self-esteem is believed to be a central feature of social-emotional adjustment, TM crucially affecting many aspects of an individual's life (e.g., interpersonal relationships, academic achievement).~'16Low selfesteem, for example, is often linked with a host of other problems, including poor mental health (e.g., attention deficit disorder, avoidant disorder), TM self-destructive behavior, ~7 and feelings of anxiety TM and loneliness. TM Higher levels of the construct are associated with creativity, independence, and academic achievement,TM and may help children cope effectively with problems in their lives. 14 Low self-esteem is often cited as an aftereffect of abuse, 3'7 and is purported to result from the stigmatization that accompanies the sexual abuse2 Although many anecdotal reports suggest that both children and adults feel damaged, worthless, or 'bad' following experiences of sexual abuse, 3'7 such effects have not been consistently observed in empirical research. 5 Investigators examining long-term effects of sexual abuse have generally found low self-esteem in survivors of childhood
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abuse, 2~ but researchers working with children have obtained conflicting results. While some investigators have found that sexually abused adolescents have lower self-esteem than normative female samples, 2~ researchers examining the effects of abuse on children have often failed to detect significant differences between abused children and normative samples, or other comparison groups. 2426 These conflicting findings may be due, in large part, to the particular measures employed. Most investigators working with abused children have used self-concept scales in their studies, rather than measures of self-esteem. Self-concept and self-esteem, though intimately related, may actually represent two different entities. 14 Selfconcept may be viewed as "the totality of the individual's thoughts and feelings, ''13 whereas self-esteem may be viewed as a small portion of this larger whole. ~7 Self-concept scales may simply be too broad to accurately assess this small self-evaluative component. Scales specifically designed to measure self-esteem may yield more reliable results. Given the perceived centrality of self-esteem in social-emotional adjustment, TM it seems essential to clarify the relationship between abuse and self-esteem. Anxiety Anxiety, according to Berliner and Wheeler, 2s is a complex blend of responses characterized by apprehension, autonomic arousal, and behavioral attempts to cope with the stimuli that elicit these negative reactions. High levels of the construct are frequently associated with loneliness 19and low self- esteem. 18 High anxiety is often cited as a consequence of sexual abuse. 8,9Elevations are purported to result from children's realizations that they are powerless, and are frequently expressed in the form of fears, sleep disturbances, and psychosomatic complaints2 Although clinical and anecdotal accounts suggest that abused children and adult survivors of abuse exhibit high levels of anxiety} ,9 several researchers have failed to empirically confirm this particular effect, finding no significant differences in anxiety between abused children and test norms. ~4 Other investigators, however, have found that abused children display more symptoms of anxiety than nonabused, normal, or clinical controls in childhood, or later, in adulthood. 29-3'Additional research is clearly required to provide a more conclusive interpretation of the relationship between anxiety and abuse in girls who have been sexually abused.
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Loneliness
Loneliness is a distressing and unpleasant sensation resulting from deficiencies or disruptions in an individual's social relationships. TM High levels are often associated with anxiety and depression, as well as low self-esteem. TM Loneliness and isolation are frequently cited as sequelae of sexual abuse. ~~ Stigmatization and betrayal m a y be largely responsible for the alienation that occurs. 6 Because abused children feel 'different' or 'branded, '11 as well as mistrustful of others, 6 many m a y tend to isolate themselves from people in their lives. Alienation m a y also be produced by the ambiguity of the abuse experience and the child's efforts to cope with it. ~1 "When an abnormal and externally imposed event must be understood and lived with in the absence of a clear framework, ''~1 alienation from oneself and others can commonly result. ~ Feelings of isolation m a y be compounded by negative societal reactions, and, in m a n y cases, by children's removal from their family homes. ~2 Although clinical accounts linking alienation and sexual abuse have been empirically confirmed in adult survivors of abuse, 29 these accounts have not yet been confirmed in empirical studies of abused children. Additional research is clearly required to provide more information about the relationship between loneliness and sexual abuse. The purpose of the present study was to clarify the equivocal findings in the sexual abuse literature regarding self-esteem, anxiety, and loneliness and fill existing gaps in our knowledge of the effects of sexual abuse. Given the consensus among researchers "that experiences with close family members are potentially more traumatic than those with acquaintances or strangers, ''33 and that the victim ratio for reported familial abuse is nine times greater for girls than boys, ~ only girls who had experienced intrafamilial sexual abuse were included in the investigation. It was hypothesized that abused children would obtain lower self-esteem, higher anxiety, and higher loneliness scores than children who had not been abused. Method
Subjects Seventy girls, ranging in age from 7 to 12, participated in the study. Half of the girls had: (a) disclosed at least one incident of intrafamilial sexual abuse
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(which had been investigated and verified by child protection authorities and/ or local police); (b) been referred to a group therapy program ~5~8at the University of Manitoba's Psychological Service Center (PSC); and (c) received parental permission to be evaluated and treated at the PSC. Children were of lower socioeconomic status (SES) and had been abused by a wide range of family members, including fathers, brothers, grandfathers, uncles, and various father-figures (e.g., step-fathers, mothers' cohabitees). At least five girls had been abused by more than one family member. One child had experienced ritualistic cult abuse, and at least nine other children were confirmed or suspected survivors of physical abuse and/or neglect. Thirty-five girls with no known history of sexual abuse served as nonclinical controls. They were selected from a local elementary school in a low- to middle-income district and matched with abused children on the variable of SES. Permission for each girl to participate in the study was solicited from her parent(s) or guardian(s), school principal, and school division head. For purposes of the present study, intrafamilial sexual abuse was defined as any consensual or nonconsensual exploitation of a child for the sexual satisfaction of a parent, ~9or other family member (e.g., brother, uncle, grandfather), or person serving in a family member's role (e.g., step-brother, foster, adoptive, or step-parent, parent's cohabitant). Acts of sexual abuse ranged from genital fondling to intercourse. Instrumentation
Three standardized self-report scales were administered to children to assess levels of self-esteem, anxiety, and loneliness. Self-Esteem. The Self-Esteem Inventory (SEI) 12was used to measure children's self-evaluations in the spheres of social, family, academic, and personal experience. It consists of 58 declarative statements (e.g., "I'm a lot of fun to be with"), to which a child responds like me or unlike me. The scale yields an overall self-esteem score (Total Self), and scores on four subscales (General Self, Social Self-Peers, Home-Parents, and School-Academic). In all cases, higher scores reflect greater self-esteemJ 2 Anxiety. The Revised Children's Manifest Anxiety Scale/What I Think and Feel Questionnaire (CMAS) 4~was used to assess levels of anxiety. The scale consists of 37 declarative statements (e.g., "I am nervous"), to which a child responds yes or no. Higher scores on the CMAS reflect higher levels of anxiety. 4 0 Loneliness. The Children's Loneliness Questionnaire (CLQ) 41 was used to measure feelings of loneliness and isolation. The scale consists of 16 declarative statements, focusing on subjective estimations of status and feelings of loneliness and social inadequacy (e.g., "I'm lonely at school"). An additional eight items, dealing with hobbies and preferred activities (e.g., "I like to read"), are included as filler items, and are not used in the computation of children's loneliness scores. Children respond to each statement on a 5-point Likert-type scale (ranging from that's always true about me to that's not true at all about me). Higher scores on the CLQ reflect greater loneliness in children. 41
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Table 1
Means and Standard Deviations for Abused and Nonabused Girls on the Self-Esteem Inventory, Revised Children's Manifest Anxiety Scale, and Children's Loneliness Questionnaire Abused Scale
Self-Esteem Anxiety Loneliness
Nonabused
M
SD
M
SD
F
56.46 15.40 32.00
17.01 6.77 11.07
69.60 14.57 30.74
14.94 7.27 10.77
11.80* 0.24 0.23
Note: df for the Self-Esteem Inventory and the Revised Children's Manifest Anxiety
Scale = 1, 68; dffor the Children's Loneliness Questionnaire = 1, 67. *p < .ool
Procedure
Prior to testing, participants were told that the investigators were interested in finding out how children think and feel. Children were assured that all responses would be confidential and that there were no right or wrong answers to any of the items. Questionnaires were individually administered to participants by female graduate students in Social Work and Clinical Psychology. Children who had been abused were interviewed at the PSC, as part of an intake and assessment procedure, while children in the control group were tested at their school. Questionnaire items were read aloud to each child to control for differences in reading ability.
Results C o m p l e t e d a t a w e r e o b t a i n e d for 34 a b u s e d a n d 35 n o n a b u s e d girls. A n a s s e s s m e n t of loneliness was u n a v a i l a b l e for one girl who h a d b e e n abused. M e a s u r e s w e r e scored u s i n g s t a n d a r d i n s t r u c t i o n s provided w i t h e a c h of t h e scales. G r o u p m e a n s were c o m p u t e d for each m e a s u r e a n d c o m p a r e d in a series of a n a l y s e s of variance. R e s u l t s of t h e s e a n a l y s e s are p r e s e n t e d in T a b l e 1. F i n d i n g s indicated a significant r e l a t i o n s h i p b e t w e e n s e x u a l abuse a n d total selfesteem. C h i l d r e n who h a d b e e n s e x u a l l y abused, as predicted, obtained significantly lower self-esteem scores t h a n nonabused children. C o n t r a r y to predictions, however, r e s u l t s did not s u p p o r t a relationship b e t w e e n a n x i e t y a n d s e x u a l a b u s e (see T a b l e 1). Scores on t h e CMAS w e r e n e a r l y identical for a b u s e d a n d n o n a b u s e d girls, a n d gene r a l l y fell w i t h i n t h e n o r m a t i v e r a n g e for t h e a n x i e t y scale.
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Sexual abuse also appeared to have no effect on children's loneliness scores (see Table 1). Girls who had been sexually abused reported levels of loneliness comparable to those of girls with no history of abuse.
Discussion
The present study sought to clarify and extend existing knowledge of the sequelae of sexual abuse by comparing levels of self-esteem, anxiety, and loneliness in abused and nonabused girls. Comparisons indicated that abused children had lower levels of self-esteem than nonabused children, and that levels of anxiety and loneliness did not differ between the groups.
Self-Esteem The findings for the self-esteem scale provide support for the multitude of reports in the literature 3.7 that cite impairments in selfesteem as common sequelae of sexual abuse. Moreover, given the perceived centrality of self-esteem in social-emotional adjustment, 14 the findings underscore the need for practitioners and others dealing with children who have been sexually abused (e.g., parents, social workers, teachers, police officers, legal personnel) to be sensitive to self-esteem issues and to take direct steps, whenever possible, to enhance children's self-esteem. A number of simple techniques may be considered in order to improve children's self-perceptions. These include praising children for their efforts and accomplishments,TM helping children focus on their abilities and strengths, TM and assisting children in the development of self-control, problem-solving, and social/communication skills. 14More formalized techniques, including group therapy programs, can also be used to promote positive self-esteem? ~,37,42Concerted efforts to enhance self-esteem in sexually abused children, using these or other modalities, seem essential, given the importance of self-esteem and the finding that abused children have poorer self-perceptions than children who have not been sexually abused.
Anxiety The findings for the anxiety scale fail to confirm clinical impressions that abused children are highly anxious. The absence of sig-
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nificant differences in anxiety between the groups is particularly striking, in view of the fact that clinical and nonclinical populations were compared. Several factors may account for the discrepancy observed between empirical and clinical results. First, the present study employed a 'generic' measure of anxiety, which may not have been appropriate for assessing the effects of sexual abuse on children. Outcome "instruments designed specifically to measure the aftereffects noted by clinicians might be more successful at showing the true extent of pathology related to the experience of sexual abuse. ''5 Another possibility is that abused children were not experiencing problems with anxiety at the time of evaluation. It may be that children were manifesting a delayed reaction to their abuse, such that their symptoms would not appear until a later date, in response to environmental stressors (e.g., court appearance). 4 Alternatively, the absence of significant differences between abused and nonabused groups might also reflect the diversity of scores observed within each group of children. Loneliness
The findings for the loneliness scale fail to confirm clinical accounts linking abuse and alienation. The absence of significant differences in loneliness between abused and nonabused girls is, again, particularly striking, given that clinical and nonclinical groups of children were compared. As with anxiety, several factors may account for the discrepancy observed between empirical and clinical findings. First, we employed a measure of loneliness which specifically assessed children's feelings of isolation and loneliness at school. This measure may have been too specific and school-focused to accurately assess the isolation linked to abuse. Alternatively, the abuse suffered by children may have been relatively free of the traumagenic dynamics (e.g., betrayal) ~ linked with loneliness and isolation, thus having a minimal impact on children's reported loneliness scores. The results obtained for the self-esteem scale extend current knowledge of the sequelae of child sexual abuse. Nevertheless, they are preliminary findings, in need of replication. Additional research efforts, addressing the limitations of the current design (e.g., minimal matching of participants, use of small samples), and exploring other factors (e.g., gender effects), are essential if clinicians are to develop and implement treatment programs that effectively meet the needs of girls and boys who have been sexually abused.
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Summary Low self-esteem,3,7 high levels of anxiety,8'9 and feelings of loneliness and isolation 19.11are cited by many clinicians as common effects of child sexual abuse. The present study attempted to empirically confirm these specific abuse sequelae by comparing abused and nonabused girls on several self-report scales. Results indicated that abused girls had lower self-esteem than nonabused girls, and that anxiety and loneliness scores did not differ between the groups. These findings support numerous anecdotal accounts that cite impaired selfesteem as one of the sequelae of sexual abuse, and point to the need for interventions designed to redress this particular effect. Additional studies, avoiding the limitations of the current design and exploring other factors, are essential to further clarify the effects of sexual abuse on children.
References 1. Henderson J: Is incest harmful? Can J Psychiatry 28: 34-40, 1983. 2. Forward S, Buck C: Betrayal of Innocence: Incest and its Devastation. New York: Penguin Books, 1978. 3. Porter FS, Blick LC, Sgroi SM: Treatment of the sexually abused child. In Handbook of Clinical Intervention in Child Sexual Abuse, ed. Sgroi SM. Lexington, MA: Lexington Books, 1982. 4. Finkelhor D: Early and long-term effects of child sexual abuse: An update. Profess Psychol: Res Pract 21: 325-330, 1990. 5. Browne A, Finkelhor D: Impact of child sexual abuse: A review of the research. Psychol Bull 99: 66-77, 1986. 6. Finkelhor D, Browne A: The traumatic impact of child sexual abuse: A conceptualization. A m J Orthopsychiatry 55: 530-541, 1985. 7. Courtois CA: Healing the Incest Wound: Adult Survivors in Therapy. New York: Norton, 1988. 8. Gelinas DJ: The persisting negative effects of incest. Psychiatry 46: 312-332, 1983. 9. Porter R: Child Sexual Abuse within the Family. London: Tavistock, 1984. 10. Bergart AM: Isolation to intimacy: Incest survivors in group therapy. Soc Casework: J Contemp Soc Work 67: 266-275, 1986. 11. Berliner L, Ernst E: Group work with preadolescent sexual assault victims. In Victims of Sexual Aggression: Treatment of Children, Women, and Men, ed. Stuart IR, Greer JG. New York: Van Nostrand Reinhold, 1984. 12. Coopersmith S: SEI: Self-Esteem Inventories. Palo Alto, CA: Consulting Psychologists Press, 1981. 13. Rosenberg M: Conceiving the Self. New York: Basic Books, 1979. 14. Pope AW, McHale SM, Craighead WE: Self-Esteem Enhancement with Children and Adolescents. New York: Pergamon, 1988. 15. Branden N: How to Raise Your Self-Esteem. Toronto: Bantam, 1987. 16. Phillips D, Bernstein FA: How to Give Your Child a Great Self-Image. New York: Plume, 1989.
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17. Dawson R: Therapeutic intervention with sexually abused children. J Child Care 1: 29-35, 1984. 18. Coopersmith S: The Antecedents of Self-Esteem. San Francisco: Freeman, 1967. 19. Peplau LA, Perlman D: Perspectives on loneliness. In Loneliness: A Sourcebook of Current Theory, Research and Therapy, ed. Peplau LA, Perlman D. New York: Wiley, 1982. 20. Gold ER: Long-term effects of sexual victimization in childhood: An attributional approach. J Consult Clin Psychol 54: 471-475, 1986. 21. Jackson JL, Calhoun KS, Amick AE, Maddever HM, Habif VL: Young adult women who report childhood intrafamilial sexual abuse: Subsequent adjustment. Arch Sex Behav 19: 211-221, 1990. 22. Rew L: Childhood sexual exploitation: Long-term effects among a group of nursing students. Issues Ment Heal Nurs 10: 181-191, 1989. 23. German DE, Habenicht DJ, Futcher WG: Psychological profile of the female adolescent incest victim. Child Abuse Negl 14: 429-438, 1990. 24. Cohen JA, Mannarino AP: Psychological symptoms in sexually abused girls. Child Abuse Negl 12: 571-577, 1988. 25. EUiott DJ, Tarnowski KJ: Depressive characteristics of sexually abused children. Child Psychiat Hum Develpm 21: 37-48, 1990. 26. Tufts New England Medical Center, Division of Child Psychiatry: Sexually Exploited Children: Service and Research Project. Final Report for the Office of Juvenile Justice and Delinquency Prevention. Washington, DC: U.S. Department of Justice, 1984. 27. Marshall HH: The development of self-concept. Young Children 44: 44-51, 1989. 28. Berliner L, Wheeler JR: Treating the effects of sexual abuse on children. J Interpers Viol 2: 415-434, 1987. 29. Briere J, Runtz M: Post sexual abuse trauma: Data and implications for clinical practice. J Interpers Violence 2: 367-379, 1987. 30. Briere J, Runtz M: Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 12: 51-59, 1988. 31. Mannarino AP, Cohen JA, Gregor M: Emotional and behavioral difficulties in sexually abused girls. J Interpers Viol 4: 437-451, 1989. 32. Haugaard JJ, Reppucci ND: The Sexual Abuse of Children: A Comprehensive Guide to Current Knowledge and Intervention Strategies. San Francisco: JosseyBass, 1988. 33. Finkelhor D: Sexually Victimized Children. New York: Free Press, 1979. 34. Westerlund E: Counseling women with histories of incest. Women & Therapy 2: 17-31, 1983. 35. De Luca RV, Boyes DA, Cairns SL, Gilman DA, Grayston AD: Group treatment for children who have been sexually abused. Canad Psychol 32: 366, 1991. 36. De Luca RV, Boyes DA, Furer P, Grayston AD, Hiebert-Murphy D: Group treatment for child sexual abuse. Canad Psychol, in press. 37. De Luca RV, Hazen A, Cutler J: Evaluation of a Group Counseling Program for Preadolescent Female Victims of Incest. Elem Sch Guid Couns, in press. 38. Hiebert-Murphy D, De Luca RV, Runtz M: Group treatment for sexually abused girls: Evaluating outcome. Faro in Society 73: 205-213, 1992. 39. Government of Manitoba: Manitoba Guidelines on Identifying and Reporting Child Abuse. Winnipeg: Queen's Printer, 1988. 40. Reynolds CR, Richmond BO: What I think and feel: A revised measure of children's manifest anxiety. J Abnorm Child Psychol 6: 271-280, 1978. 41. Asher SR, Wheeler VA: Children's loneliness: A comparison of rejected and neglected peer status. J Consult Clin Psychol 53: 500-505, 1985. 42. Hack TF, Osachuk TAG, De Luca RV: Group treatment for preadolescent boys who have been sexually abused: Follow-up data. Canad Psychol 32: 311, 1991.
Alana D. Grayston Rayleen V. De Luca Debby A. Boyes University of Manitoba
This study sought to clarify and extend existing knowledge of the negative sequelae of sexual abuse by comparing levels of self-esteem, anxiety, and loneliness in abused and nonabused girls. Comparisons indicated that sexually abused children had lower levels of self-esteem than nonabused children, but that levels of anxiety and loneliness did not differ between the groups. These findings empirically confirm one of the sequelae of sexual abuse commonly cited in the clinical literature and point to the need for interventions designed to redress this adverse effect.
ABSTRACT:
KEY WORDS: Sexual abuse; self-esteem; anxiety; loneliness.
Despite the recent proliferation of research and clinical work in the area of sexual abuse, controversy continues regarding its effects on children. Some clinicians contend that negative outcomes of abuse are minimal or nonexistent, or that the effects of abuse on children have been greatly overstated. 1 Other clinicians assert that abuse is a damReceived August 22, 1991; For Revision September 18, 1991; Accepted November 16, 1991. This manuscript is based on a presentation made at the 1990 Annual Convention of the Canadian Psychological Association in Ottawa, Ontario, Canada. Preparation of this article was supported, in part, by Manitoba Health Research Council and Medical Research Council of Canada Graduate Studentships to Alana D. Graysten, by a Manitoba Mental Health Research Foundation Grant to Rayleen V. De Luca, and by a University of Manitoba Graduate Fellowship to Debby A. Boyes. The authors would like to acknowledge and thank Don Sharpe for his valuable statistical assistance, Ratna Das, Susan Larson, and Norah Vincent for their help in scoring questionnaires, and John Adair for his insightful comments on earlier drafts of this paper. The assistance of the St. James-Assiniboia School Division No. 2 is also gratefully acknowledged. Reprint requests should be sent to Rayleen V. De Luca, Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada, R3T-2N2. Child Psychiatry and Human Development, Vol. 22(4), Summer 1992
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aging experience for children, having a wide range of deleterious mental health effectsY Although "almost every study of the impact of sexual abuse has found a substantial group of victims with little or no symptomatology,TM accumulating evidence strongly suggests "that sexual abuse is a serious mental health problem ''5 for many children and adults. There is a paucity of empirical evidence regarding its actual effects,~ but numerous anecdotal accounts suggest that abused children display a range of negative reactions and symptoms of emotional distress, resulting from the traumagenic dynamics (i.e., stigmatization, powerlessness, betrayal, and traumatic sexualization)6 comprising their abuse. Low self-esteem,3'7 high levels of anxiety,s'9 and feelings of loneliness and isolation 10.~ are among the short- and long-term symptoms most commonly described.
Self-Esteem
Self-esteem, according to Coopersmith, 12 is a person's customary evaluation of herself or himself. It "is an expression of approval or disapproval, indicating the extent to which a person believes him- or herself competent, successful, significant, and worthy. ''12 People with high self-esteem have self-respect and consider themselves of worth, whereas people with low self-esteem perceive themselves as inadequate and unworthy. 13 Self-esteem is believed to be a central feature of social-emotional adjustment, TM crucially affecting many aspects of an individual's life (e.g., interpersonal relationships, academic achievement).~'16Low selfesteem, for example, is often linked with a host of other problems, including poor mental health (e.g., attention deficit disorder, avoidant disorder), TM self-destructive behavior, ~7 and feelings of anxiety TM and loneliness. TM Higher levels of the construct are associated with creativity, independence, and academic achievement,TM and may help children cope effectively with problems in their lives. 14 Low self-esteem is often cited as an aftereffect of abuse, 3'7 and is purported to result from the stigmatization that accompanies the sexual abuse2 Although many anecdotal reports suggest that both children and adults feel damaged, worthless, or 'bad' following experiences of sexual abuse, 3'7 such effects have not been consistently observed in empirical research. 5 Investigators examining long-term effects of sexual abuse have generally found low self-esteem in survivors of childhood
Alana D. Grayston et al.
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abuse, 2~ but researchers working with children have obtained conflicting results. While some investigators have found that sexually abused adolescents have lower self-esteem than normative female samples, 2~ researchers examining the effects of abuse on children have often failed to detect significant differences between abused children and normative samples, or other comparison groups. 2426 These conflicting findings may be due, in large part, to the particular measures employed. Most investigators working with abused children have used self-concept scales in their studies, rather than measures of self-esteem. Self-concept and self-esteem, though intimately related, may actually represent two different entities. 14 Selfconcept may be viewed as "the totality of the individual's thoughts and feelings, ''13 whereas self-esteem may be viewed as a small portion of this larger whole. ~7 Self-concept scales may simply be too broad to accurately assess this small self-evaluative component. Scales specifically designed to measure self-esteem may yield more reliable results. Given the perceived centrality of self-esteem in social-emotional adjustment, TM it seems essential to clarify the relationship between abuse and self-esteem. Anxiety Anxiety, according to Berliner and Wheeler, 2s is a complex blend of responses characterized by apprehension, autonomic arousal, and behavioral attempts to cope with the stimuli that elicit these negative reactions. High levels of the construct are frequently associated with loneliness 19and low self- esteem. 18 High anxiety is often cited as a consequence of sexual abuse. 8,9Elevations are purported to result from children's realizations that they are powerless, and are frequently expressed in the form of fears, sleep disturbances, and psychosomatic complaints2 Although clinical and anecdotal accounts suggest that abused children and adult survivors of abuse exhibit high levels of anxiety} ,9 several researchers have failed to empirically confirm this particular effect, finding no significant differences in anxiety between abused children and test norms. ~4 Other investigators, however, have found that abused children display more symptoms of anxiety than nonabused, normal, or clinical controls in childhood, or later, in adulthood. 29-3'Additional research is clearly required to provide a more conclusive interpretation of the relationship between anxiety and abuse in girls who have been sexually abused.
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Loneliness
Loneliness is a distressing and unpleasant sensation resulting from deficiencies or disruptions in an individual's social relationships. TM High levels are often associated with anxiety and depression, as well as low self-esteem. TM Loneliness and isolation are frequently cited as sequelae of sexual abuse. ~~ Stigmatization and betrayal m a y be largely responsible for the alienation that occurs. 6 Because abused children feel 'different' or 'branded, '11 as well as mistrustful of others, 6 many m a y tend to isolate themselves from people in their lives. Alienation m a y also be produced by the ambiguity of the abuse experience and the child's efforts to cope with it. ~1 "When an abnormal and externally imposed event must be understood and lived with in the absence of a clear framework, ''~1 alienation from oneself and others can commonly result. ~ Feelings of isolation m a y be compounded by negative societal reactions, and, in m a n y cases, by children's removal from their family homes. ~2 Although clinical accounts linking alienation and sexual abuse have been empirically confirmed in adult survivors of abuse, 29 these accounts have not yet been confirmed in empirical studies of abused children. Additional research is clearly required to provide more information about the relationship between loneliness and sexual abuse. The purpose of the present study was to clarify the equivocal findings in the sexual abuse literature regarding self-esteem, anxiety, and loneliness and fill existing gaps in our knowledge of the effects of sexual abuse. Given the consensus among researchers "that experiences with close family members are potentially more traumatic than those with acquaintances or strangers, ''33 and that the victim ratio for reported familial abuse is nine times greater for girls than boys, ~ only girls who had experienced intrafamilial sexual abuse were included in the investigation. It was hypothesized that abused children would obtain lower self-esteem, higher anxiety, and higher loneliness scores than children who had not been abused. Method
Subjects Seventy girls, ranging in age from 7 to 12, participated in the study. Half of the girls had: (a) disclosed at least one incident of intrafamilial sexual abuse
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(which had been investigated and verified by child protection authorities and/ or local police); (b) been referred to a group therapy program ~5~8at the University of Manitoba's Psychological Service Center (PSC); and (c) received parental permission to be evaluated and treated at the PSC. Children were of lower socioeconomic status (SES) and had been abused by a wide range of family members, including fathers, brothers, grandfathers, uncles, and various father-figures (e.g., step-fathers, mothers' cohabitees). At least five girls had been abused by more than one family member. One child had experienced ritualistic cult abuse, and at least nine other children were confirmed or suspected survivors of physical abuse and/or neglect. Thirty-five girls with no known history of sexual abuse served as nonclinical controls. They were selected from a local elementary school in a low- to middle-income district and matched with abused children on the variable of SES. Permission for each girl to participate in the study was solicited from her parent(s) or guardian(s), school principal, and school division head. For purposes of the present study, intrafamilial sexual abuse was defined as any consensual or nonconsensual exploitation of a child for the sexual satisfaction of a parent, ~9or other family member (e.g., brother, uncle, grandfather), or person serving in a family member's role (e.g., step-brother, foster, adoptive, or step-parent, parent's cohabitant). Acts of sexual abuse ranged from genital fondling to intercourse. Instrumentation
Three standardized self-report scales were administered to children to assess levels of self-esteem, anxiety, and loneliness. Self-Esteem. The Self-Esteem Inventory (SEI) 12was used to measure children's self-evaluations in the spheres of social, family, academic, and personal experience. It consists of 58 declarative statements (e.g., "I'm a lot of fun to be with"), to which a child responds like me or unlike me. The scale yields an overall self-esteem score (Total Self), and scores on four subscales (General Self, Social Self-Peers, Home-Parents, and School-Academic). In all cases, higher scores reflect greater self-esteemJ 2 Anxiety. The Revised Children's Manifest Anxiety Scale/What I Think and Feel Questionnaire (CMAS) 4~was used to assess levels of anxiety. The scale consists of 37 declarative statements (e.g., "I am nervous"), to which a child responds yes or no. Higher scores on the CMAS reflect higher levels of anxiety. 4 0 Loneliness. The Children's Loneliness Questionnaire (CLQ) 41 was used to measure feelings of loneliness and isolation. The scale consists of 16 declarative statements, focusing on subjective estimations of status and feelings of loneliness and social inadequacy (e.g., "I'm lonely at school"). An additional eight items, dealing with hobbies and preferred activities (e.g., "I like to read"), are included as filler items, and are not used in the computation of children's loneliness scores. Children respond to each statement on a 5-point Likert-type scale (ranging from that's always true about me to that's not true at all about me). Higher scores on the CLQ reflect greater loneliness in children. 41
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Table 1
Means and Standard Deviations for Abused and Nonabused Girls on the Self-Esteem Inventory, Revised Children's Manifest Anxiety Scale, and Children's Loneliness Questionnaire Abused Scale
Self-Esteem Anxiety Loneliness
Nonabused
M
SD
M
SD
F
56.46 15.40 32.00
17.01 6.77 11.07
69.60 14.57 30.74
14.94 7.27 10.77
11.80* 0.24 0.23
Note: df for the Self-Esteem Inventory and the Revised Children's Manifest Anxiety
Scale = 1, 68; dffor the Children's Loneliness Questionnaire = 1, 67. *p < .ool
Procedure
Prior to testing, participants were told that the investigators were interested in finding out how children think and feel. Children were assured that all responses would be confidential and that there were no right or wrong answers to any of the items. Questionnaires were individually administered to participants by female graduate students in Social Work and Clinical Psychology. Children who had been abused were interviewed at the PSC, as part of an intake and assessment procedure, while children in the control group were tested at their school. Questionnaire items were read aloud to each child to control for differences in reading ability.
Results C o m p l e t e d a t a w e r e o b t a i n e d for 34 a b u s e d a n d 35 n o n a b u s e d girls. A n a s s e s s m e n t of loneliness was u n a v a i l a b l e for one girl who h a d b e e n abused. M e a s u r e s w e r e scored u s i n g s t a n d a r d i n s t r u c t i o n s provided w i t h e a c h of t h e scales. G r o u p m e a n s were c o m p u t e d for each m e a s u r e a n d c o m p a r e d in a series of a n a l y s e s of variance. R e s u l t s of t h e s e a n a l y s e s are p r e s e n t e d in T a b l e 1. F i n d i n g s indicated a significant r e l a t i o n s h i p b e t w e e n s e x u a l abuse a n d total selfesteem. C h i l d r e n who h a d b e e n s e x u a l l y abused, as predicted, obtained significantly lower self-esteem scores t h a n nonabused children. C o n t r a r y to predictions, however, r e s u l t s did not s u p p o r t a relationship b e t w e e n a n x i e t y a n d s e x u a l a b u s e (see T a b l e 1). Scores on t h e CMAS w e r e n e a r l y identical for a b u s e d a n d n o n a b u s e d girls, a n d gene r a l l y fell w i t h i n t h e n o r m a t i v e r a n g e for t h e a n x i e t y scale.
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Sexual abuse also appeared to have no effect on children's loneliness scores (see Table 1). Girls who had been sexually abused reported levels of loneliness comparable to those of girls with no history of abuse.
Discussion
The present study sought to clarify and extend existing knowledge of the sequelae of sexual abuse by comparing levels of self-esteem, anxiety, and loneliness in abused and nonabused girls. Comparisons indicated that abused children had lower levels of self-esteem than nonabused children, and that levels of anxiety and loneliness did not differ between the groups.
Self-Esteem The findings for the self-esteem scale provide support for the multitude of reports in the literature 3.7 that cite impairments in selfesteem as common sequelae of sexual abuse. Moreover, given the perceived centrality of self-esteem in social-emotional adjustment, 14 the findings underscore the need for practitioners and others dealing with children who have been sexually abused (e.g., parents, social workers, teachers, police officers, legal personnel) to be sensitive to self-esteem issues and to take direct steps, whenever possible, to enhance children's self-esteem. A number of simple techniques may be considered in order to improve children's self-perceptions. These include praising children for their efforts and accomplishments,TM helping children focus on their abilities and strengths, TM and assisting children in the development of self-control, problem-solving, and social/communication skills. 14More formalized techniques, including group therapy programs, can also be used to promote positive self-esteem? ~,37,42Concerted efforts to enhance self-esteem in sexually abused children, using these or other modalities, seem essential, given the importance of self-esteem and the finding that abused children have poorer self-perceptions than children who have not been sexually abused.
Anxiety The findings for the anxiety scale fail to confirm clinical impressions that abused children are highly anxious. The absence of sig-
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nificant differences in anxiety between the groups is particularly striking, in view of the fact that clinical and nonclinical populations were compared. Several factors may account for the discrepancy observed between empirical and clinical results. First, the present study employed a 'generic' measure of anxiety, which may not have been appropriate for assessing the effects of sexual abuse on children. Outcome "instruments designed specifically to measure the aftereffects noted by clinicians might be more successful at showing the true extent of pathology related to the experience of sexual abuse. ''5 Another possibility is that abused children were not experiencing problems with anxiety at the time of evaluation. It may be that children were manifesting a delayed reaction to their abuse, such that their symptoms would not appear until a later date, in response to environmental stressors (e.g., court appearance). 4 Alternatively, the absence of significant differences between abused and nonabused groups might also reflect the diversity of scores observed within each group of children. Loneliness
The findings for the loneliness scale fail to confirm clinical accounts linking abuse and alienation. The absence of significant differences in loneliness between abused and nonabused girls is, again, particularly striking, given that clinical and nonclinical groups of children were compared. As with anxiety, several factors may account for the discrepancy observed between empirical and clinical findings. First, we employed a measure of loneliness which specifically assessed children's feelings of isolation and loneliness at school. This measure may have been too specific and school-focused to accurately assess the isolation linked to abuse. Alternatively, the abuse suffered by children may have been relatively free of the traumagenic dynamics (e.g., betrayal) ~ linked with loneliness and isolation, thus having a minimal impact on children's reported loneliness scores. The results obtained for the self-esteem scale extend current knowledge of the sequelae of child sexual abuse. Nevertheless, they are preliminary findings, in need of replication. Additional research efforts, addressing the limitations of the current design (e.g., minimal matching of participants, use of small samples), and exploring other factors (e.g., gender effects), are essential if clinicians are to develop and implement treatment programs that effectively meet the needs of girls and boys who have been sexually abused.
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Summary Low self-esteem,3,7 high levels of anxiety,8'9 and feelings of loneliness and isolation 19.11are cited by many clinicians as common effects of child sexual abuse. The present study attempted to empirically confirm these specific abuse sequelae by comparing abused and nonabused girls on several self-report scales. Results indicated that abused girls had lower self-esteem than nonabused girls, and that anxiety and loneliness scores did not differ between the groups. These findings support numerous anecdotal accounts that cite impaired selfesteem as one of the sequelae of sexual abuse, and point to the need for interventions designed to redress this particular effect. Additional studies, avoiding the limitations of the current design and exploring other factors, are essential to further clarify the effects of sexual abuse on children.
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