A strong link between childhood sexual abuse and posttraumatic stress disorder (PTSD) has been documented by a spate of retrospective studies conducted in adults.

Fewer studies, however, have explored PTSD outcomes in sexually abused children. And even fewer have examined sexually abused children to see whether specific factors pertinent to their trauma, or psychological states experienced right after their trauma, set the stage for PTSD. So Julie Kaplow, Ph.D., and colleagues at the Center for Child and Family Health at Duke University conducted such a study.

They have found that sexually abused youngsters who are anxious, avoid coping with their trauma, and above all dissociate are at high risk of developing PTSD.

There is a special facility at Duke to assist children who have been sexually abused. In addition to being medically examined and videotaped for forensic purposes, they are interviewed to determine their psychological states. For instance, the Trauma Symptom Checklist for Children is used. Certain factors possibly pertinent to their abuse—age at time of sexual abuse or previous life stress, for example—are also noted.

Kaplow and her co-workers recruited 156 children from this facility for their study. The group comprised 129 girls and 11 boys, with an average age of 11 years. Written informed consent to participate in the study was obtained from the parents of the subjects, and informed assents to participate were obtained from the subjects themselves.

In addition to reviewing the psychological reports for each of the subjects at the time of sexual abuse, Kaplow and her team interviewed each of the subjects to determine whether they had developed PTSD symptoms since their abuse. Nearly all (97 percent) had, they determined. They then evaluated whether certain factors possibly pertinent to the youngsters' abuse or their psychological states right after being abused could be linked to the later development of PTSD symptoms.

Some variables that did not predict the development of PTSD symptoms included the severity, duration, and frequency of abuse and whether the perpetrator was a family member.

In contrast, anxiety, avoidance of coping with the trauma, and above all dissociation strongly predicted the later development of PTSD symptoms.

Recently, Israeli researchers reported that, in traffic-accident victims with mild head injury, forgetting seemed to protect against PTSD (Psychiatric News, June 3). Yet Kaplow and her colleagues have found that dissociation is a strong risk factor for PTSD. Kaplow, who is now an assistant professor of psychiatry at the University of Medicine and Dentistry of New Jersey, told Psychiatric News that she could not explain this apparent contradiction, but said that the Israelis were undoubtedly measuring" forgetting," whereas she and her colleagues were measuring" dissociation," and while forgetting is part of dissociation, dissociation is a lot more. It includes such reactions, she noted, as pretending to be someone else, feeling as though you are outside of your body, emotional numbing, and daydreaming, for example. Dissociation, in short, seems to be a primitive mechanism for coping with danger to which people resort only when their fight-or-flight arousal systems have been overwhelmed.

Sexual-abuse survivors may also deploy dissociation because it gives them a sense of protection against more abuse, David Wright, M.D., believes. Wright is the staff psychiatrist for Canada's only inpatient treatment program for PTSD—the Program for Traumatic Stress Recovery at Homewood Health Center in Guelph, Ontario (Psychiatric News, March 19, 2004).

Psychiatric News asked Kaplow what kinds of treatments she would recommend for sexually abused children to minimize the risk that they will develop PTSD.

"It is clear," she replied, "at least in our sample, that avoidance and dissociation can be extremely detrimental in terms of children's longer-term functioning following sexual abuse, so treatments that help children to not only discuss the facts regarding the abuse itself, but also their feelings before, during, and after the event would likely be useful."

Two treatments that she would recommend for this purpose, she added, are trauma-focused cognitive-behavioral therapy and trauma systems therapy.

"Both of these treatments," she said, "involve the use of relaxation techniques, coping skills, and trauma narratives, which allow children to tell their `stories' and process their emotions via creative means including books, plays, videos, or songs."

The study was funded by the North Carolina Governor's Institute on Alcohol and Substance Abuse. Study results were published in the July American Journal of Psychiatry.

"Pathways to PTSD, Part II: Sexually Abused Children" is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/162/7/1305?>.▪

Am J Psychiatry  20051621305