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Section 17
Abuse - Somatic Complaints and Sleep Disturbances

Question 17 | Test | Table of Contents

Somatic Complaints and Bodily Concerns
Therapists generally agree that boys are more likely to experience somatic complaints following sexual abuse. This may reflect social acceptability of bodily complaints versus emotional and psychological ones. Headaches, stomach aches, sore throats, and fatigue are the most frequently reported somatic complaints, sore throats and stomach aches often being linked with the child having been forced to perform oral sex.

Sexually abused children frequently have tremendous concerns about their bodies which they may feel have been damaged; this can be particularly true if the sexual abuse was painful and involved force. Older children might worry about contracting sexually transmitted diseases and AIDS. Some children are encopretic or enuretic. Some young children fear that people know about their abuse just by looking at them. They may view their bodies as 'different' and permanently 'damaged'. They may feel increased shame and self-consciousness and project these feelings onto others.

Treatment Implications
Ensure that the child has had a thorough medical examination to exclude, or get treatment for, physical problems and infections. In order to come to terms with what has happened to them, children need to express their feelings and concerns about their bodies. They often respond to encouragement, as they may feel embarrassed about how their bodies work. This is particularly relevant with younger children, but older children frequently are confused and have misinformation about bodily functions. Most children desire and need accurate information about how their bodies work. Encourage children to ask questions about bodily functions, changes, or possible ill effects of the abuse. The therapist can help children to express their concerns by speaking about what some other children's worries might be.

If appropriate, help the child to understand the correlation between the somatic complaint and the abuse. Usually children are unaware of the link. Normalize the child's symptoms, give reassurance, and let the child know that the complaints will lessen and go away with time. AIDS, infection, or physical damage need assessment, treatment and the prognosis verified. The child should have suitable factual information and support, with encouragement to express feelings about the abuse, the abuser, and future concerns.

Reassure the child who believes that 'everyone knows' about the abuse that this is not so. Inform the child that it is impossible to tell if someone has been sexually abused simply by looking at them. Groups can be effective in helping children to realize that victimization is not physically visible.

At one level sexual abuse is experienced as a physical trauma. Children up to the age of about four encode memories in the basal brain and are likely to act out physically or emotionally; older children may revert to bodily symptoms under stress, but have greater access to language and emotion (van der Kolk, 1996). Children may experience disgust towards their bodies and attempt to disown them. Many adult survivors dissociate from their bodily experience as a result of sexual abuse as children. Focusing on taking care of, and enjoying, the body can help prevent disowning and dissociative tendencies from developing. Encourage children to participate in physical activity and to have a positive awareness of their body. Warm, fragrant baths and attractive clean clothes are part of the process of helping children feel better about themselves.

If children experienced physiological pleasure as a result of the sexual activity, they may feel that they were betrayed by their own body. Educating and normalizing physiological and pleasurable response to the abuse will help the child accept the physiological response as a normal and natural reaction.

Sleep Disturbances
Sleep disturbances are common. Children may experience a fear of sleep or an inability to fall asleep; this may be particularly true if the abuse occurred at night. Children often complain of disturbed sleep; they may wake up frequently throughout the night and be unable to fall back to sleep. They may think about the abuse at this time, and experience painful emotions or thoughts related to the abuse. Some children engage in excessive masturbation. Children may have difficulty waking up in the morning due to the poor quality of sleep, and may be fatigued throughout the day.

Children frequently have frightening dreams and nightmares. Some dreams involve the actual abuse experience or a variation on what happened. Other common themes reported by children are monsters, wild animals, or situations in which the child, or those close to the child, is/are in danger. The child may be reluctant to go to sleep for fear of bad dreams.

Treatment Implications
Theoretical analysis of dream content has focused on the adaptive work of the ego and on the problem-solving nature of dreams. Dreams help to process internal and external experience. For example, in a nightmare or dream children may achieve mastery by taking control of a situation in which they were previously powerless. Dreams can provide useful diagnostic information about the issues and conflicts the child is currently facing, and can indicate the child's ego strength and functioning.

Dreams or nightmares can be used as a tool to facilitate drawings, acting out, poetry, or discussion. The therapist can help the child to understand the meaning and importance of dreams. Dreams, like play and art therapy, can provide a safe distance for exploration. The feelings and experiences of the child, related to dreams, can be discussed, leading to greater understanding for the child.

Encourage the child to bring dream material to sessions. Have the child work on the dream and what it means. What feelings do the dream images bring up in the child? Normalize the feelings and help the child to see the connection, if applicable, to the abuse situation.

There are several ways of working on the dreams. They can be talked about, or the child may wish to make a dream journal. Writing dreams down as soon as they occurred 'seemed to get them out of Kenny's head, to distance and diminish their power' (Carolin and Mimer, 1999: 27-8). They can be acted out, made into pictures or paintings, written as stories, or tape recorded. Children can be encouraged to change the dream or ending of the dream in any way they desire. James suggests that children can be empowered to reduce the frightening elements by making them smaller, twitching their noses at them, picking them up or some such ploy (1989: 198). Using a gestalt technique, older children can name the objects or feelings in the dream, the child talking as if she were each of those things with the therapist reflecting inferences and making links.
- Wickham, Randall, & Janet West, Therapeutic Work with Sexually Abused Children, Sage Publications: London. 2002.

Personal Reflection Exercise #10
The preceding section contained information about somatic complaints and sleep disturbances in sexually abused children. Write three case study examples regarding how you might use the content of this section in your practice.

Who is most likely to experience somatic complaints following sexual abuse? To select and enter your answer go to Test.

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