Introduction
It has been established that sexual abuse against children is a widespread global problem (Stoltenborgh et al. 2011). Some scholars have reported that child abuse, including sexual abuse among children is high in Africa, as well as other continents (Filkelhor et al. 2013; Hillis et al. 2016). Sexual abuse against children is a public health concern due to the fact that its outcomes are detrimental to the health of children, families and society (Madu et al. 2010). Often, mental health problems among children are detected late and identification rates by health professionals are quite low (Grant & Brito, 2010; Ndetei et al. 2009). Research studies indicate that children who experience sexual abuse suffer deleterious physical, psychiatric, psychological, educational and social consequences (Green et al. 2010; Roberts et al. 2009).
The most common psychiatric morbidity is depression, which presents with low levels of self-esteem, poor body image, guilt, social withdrawal and little or no display of emotions (Perlman et al. 2008; Roberts et al. 2008). Feelings of guilt and shame among the sexually abused children reduce their likelihood of making a disclosure regarding their experiences with their perpetrators (Azad & Leander, 2015; Schonbucher et al. 2012). Besides, cultural practices may hinder the families of children exposed to sexual abuse from reporting such incidents to law enforcement agencies (Bridgewater, 2016; Fontes & Plummer, 2010). Thus, children often disclose these abuses during forensic interviews when psychosocial support is provided (Lippert et al. 2009). Also cognitive alterations often occur due to sexual abuse against children and could continue into adolescence and adulthood (Ayoub et al. 2006; Nolin & Ethier, 2007).
Furthermore, sexual abuse against children psychologically robs them of their childhood and leisure in their formative years (Omondi, 2014). This deprivation leaves psychological, psychiatric, social and educational scars that may take many years to heal among the children (Whitehead, 2010). Also, chronic sexual abuse against children could result in negative brain changes that may lead to anxiety, which manifests itself alongside emotional instability (Mizenberg et al. 2008; Tomoda et al. 2009). With regard to interpersonal relationships and functioning, sexual abuse survivors experience problems related to trust and security (De prince et al. 2008; Isley et al. 2008). In consequence, affected children lose trust, particularly among adults and may become vulnerable to further exploitation (Maniglio, 2009). Moreover, children who experience incest suffer most from low levels of self-esteem because the abuse was perpetrated by people the children loved and trusted (Guelzow et al. 2002; Lalor et al. 2010).
Review of Related Literature
Empirical studies have been conducted in different countries regarding the prevalence of abuse among children. Hillis et al. (2016) and Filkelhor et al. (2013) reported that abuse among children aged 2-17 years was highest (80%) in Africa and Asia, and even among other continents, it was high, ranging from 60.0% in North and Latin America to 70.0% in Europe. However, China had a lower prevalence of 15.3 % (Ji et al. 2013) and penetrative sexual abuse against children also stood at a low prevalence of 1.0%. Similarly, India registered a lower prevalence rate of sexual abuse against children at 16.7% (Mishra et al. 2016). The global prevalence of sexual abuse among girls was (19.7%), which was more than double that of boys (7.9%) (Pereda et al. 2009). This finding is in tandem with a study conducted in Ethiopia by Girgira et al. (2014), which found that girls (75.7%) were three times more likely to be sexually abused than boys (24.3%). Likewise, other studies have reported that more girls experienced sexual abuse than boys. In Uganda, it was found that the majority of girls experienced sexual abuse as compared to boys (X2 (1,407) = 12.44; p < 0.0005) (Mandrup et al. 2014) and in Kenya, Sumner et al. (2015) found that sexual abuse was 11.8% and 3.6% among girls and boys respectively in their study over a five- year period from 2007-2013.
In a review paper on African countries in 2014, it was reported that the odds for girls experiencing sexual abuse was (OR 1.85-3.85 and p<0.01), implying that African girls were at risk of sexual abuse (Meinck et al. 2015). Low self-esteem has been found to be the cause of feelings of guilt and shame among the sexually abused children because perpetrators manipulated the children to believe that it was their fault to be abused (Dorahy & Clearwater, 2012; Jonas et al. 2011). Oslen et al. (2008) found out that sexually abused children made assumptions about themselves, others, the environment and the future based on their childhood experiences. Thus, it is important to note that there is a connection between physical consequences and psychological outcomes (Young et al. 2011). In addition, a study on the sequelae of serial or repeated sexual abuse against children showed that these types of victimization placed children and adolescents at risk of chronic and severe coexisting problems with emotional regulation, attention, cognition, dissociation, interpersonal relationships and low self-esteem (Ford & Courtois, 2009).
A study was conducted by Wondie et al. (2011) among 318 sexual abuse survivors in Ethiopia, using the Rosenberg self-esteem scale and the findings indicated that the abused children had a lower degree of self-worth compared to non-abused children. Also Burack et al. (2006) found that maltreated children had lower self-worth and depression than their peers, which led to self-harm, risk taking behaviors and poor performance in school. Similarly, Valentino et al. (2008) found that abused children were more likely to recall false-negative information about themselves. Besides, Daigneault et al. (2006) reported that poor self-esteem among maltreated children was a risk factor for adolescent psychopathology. In a 5-year follow-up assessment among children, Tebbutt et al. (1997) reported that sexually abused children continued to have lower self-esteem than their non-abused peers. Another study found that sexually abused children were unhappy or depressed and they had low level of self-esteem (Swanston et al. 2003; Cicchetti, 2006).
Overall, the reviewed studies pointed to the fact that sexual abuse against children had several detrimental health outcomes that negatively impacted on the overall development and well-being of children. Moreover, sexual abuse against children affected the victims even later in their adult life. This suggests the need for a better understanding of sexually abused children’s self-esteem, as well as the provision of psychosocial services for them. Piaget’s (1965) developmental theory proposed that sexual abuse against children affected victims in the psychological (self-esteem) functioning and sexual abuse against children was most harmful during the concrete operational period. Despite the growing magnitude of sexual abuse against children, which translates into psychosocial outcomes, such as low self-esteem, not much has been done in Kenya to curb the problem as perpetrators of such heinous crimes are left unpunished or not apprehended and prosecuted in courts of law. This is likely to result in repeated sexual abuse against children and perpetuation of negative psychosocial outcomes. Hence, this study sought to determine the incidence of self-esteem among children who had experienced sexual abuse in Kenya.
Methodology
This was a longitudinal study that employed quantitative methods, which lasted for one year from June 2015 to July 2016 and data was collected at four-month intervals at the two specialized Gender Based Violence Recovery Centres (GBVRC) in Nairobi: (a) the Kenyatta National Teaching and Referral Hospital (government) and (b) the Nairobi Women’s Hospital (private) in Kenya. The study was conducted with approval from the Ethical and Research Committee (ERC) of the Kenyatta National Hospital, University of Nairobi. The study population comprised children who did not have severe learning disabilities. Also, included in the study were children who had experienced sexual abuse, assented to participate and their parents/legal guardians consented to participate in the study and follow up. Children whose parents did not consent to participate in the study were excluded from the study. A sample size of 191 with an assumed attrition rate of 20% was used to estimate the incidence rate within a relative precision of 15% and 95% confidence levels. The ages of participants ranged between seven and seventeen years in conformity with the age requirements of the Piers-Harries Children’s Self Concept Scale, 2nd Edition (Piers & Herzberg, 2002).
The Piers-Harris Children’s Self Concept Scale was used in this study because it was designed for children at risk of sexual abuse. The scale was developed for children 7 to 18 years of age and it had high internal consistency with Cronbach’s alpha value, of 0.87 to 0.94. The scale had been successfully utilized with many populations, including Americans, Australians and Africans, specifically Kenyans (Kasomo, 2012). It is a self-reporting questionnaire, in which higher scores mean higher self-esteem. It is composed of 60 items covering six subscales: physical appearance and attributes, intellectual and school status, happiness and satisfaction, freedom from anxiety, behavioral adjustment and popularity. Test items are simple descriptive statements, written at a second-grade reading level. Children indicate whether each item apply to them by selecting “yes” or “no” responses, which require 10 to 15 minutes to complete. Also, it provides a total score that reflects the overall self-concept, in addition to subscale scores that permit more detailed interpretation (Piers & Herzberg, 2002).
For this study, a simple random sampling technique was used to recruit the parents/legal guardians of the children from the children’s files one month after the sexual abuse incidence. By the time of recruitment, the children had been put on medical and psychosocial care in the hospitals and or referred to legal service providers; a standard prophylactic and therapeutic treatment provided at the GBVR centres in both hospitals. The study participants whose clinical results after examination indicated the need for treatment were referred to physicians at the two centres. The objective of the study was fully explained to the participants by the researchers. The participants’ autonomy, beneficence and justice, as well as possible harms were explained to participants before written voluntary consents were sought.
Once informed consent was obtained from the parents and assent from the children, a locally designed questionnaire that aimed to capture the socio-demographic characteristics and sexual abuse profiles were administered to the children and their parents or legal guardians by the researchers. Information on school performance was obtained from the end of term school reports of each child. Completed questionnaires were safely and securely stored prior to entry into computer excel sheets for analysis. Descriptive and inferential statistics were conducted using SPSS Version 21. Self-esteem index score was calculated for each child and the raw scores were converted to standardized t-scores: 29-39T was low, 40-55 average and >55 and above was high. The level of statistical significance was set at 0.05 (p<0.05) with a 95% confidence level. Bivariate and multivariate logistic regression analysis were done to determine associations among variables.
Findings
Socio-demographics of study participants
One hundred and ninety-one participants were recruited for the study of whom 23 (12%) were males and 168 (88%) were females (male-female ratio of 1:7). The mean age of participants was13 years. The youngest child included in the study was seven years and the oldest was seventeen years. Over two-thirds of the participants 67(35.1%) were between the ages 13-15 years, 47(24.6%) were aged between 16-17 years, 44(23%) were aged between 10-12 years and 33 (17.3%) were aged between 7-9 years. Over three quarters of the study participants 144(75.4%) had both parents alive, 33(17.3%) had only mothers, 8 (4.2%) had only fathers alive and 6(3.1%) were orphans. The majority of the parents 138 (72.2%) were married, 33(17.3%) separated, 4(2.1%) divorced, 16(8.4%) single. Fifty-eight (30.4%) of the parents/legal guardians earned less than Ksh100 a day, 71(37.2%) earned Ksh100 a day, 56(29.3%) earned more than Ksh100 a day while 6(3.1%) earned more than ksh200 a day, implying that many of them earned no more than $1 per day for their livelihoods.
Levels of Self- Esteem on Pier-Harris Self-concept scale: June 2015 – July 2016
As indicated in table 1, majority of the children 144(75.4%) had average self-esteem at baseline, 35(18.3%) had high self-esteem and 12(6.3%) had low self-esteem. At follow up one, 162(92.6%) had average self-esteem, 11(6.3%) had low self-esteem while 2(1.1%) had high self-esteem. At follow up two, one hundred and fifty-six (92.8%) had average self-esteem, 4(2.5%) had low self-esteem and 8(4.7%) had high self-esteem. At follow up three, 158(98.1%) had average self-esteem and 2(1.9%) had low self-esteem. There were no participants with high self-esteem at follow up three.
Table 1.
| Baseline | Follow up 1 | Follow up 2 | Follow up 3 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | N | % | ||
| Self-esteem | Low self-esteem | 12 | 6.3 | 11 | 6.3 | 4 | 2.5 | 2 | 1.9 |
| Average self-esteem | 144 | 75.4 | 162 | 92.6 | 156 | 92.8 | 158 | 98.1 | |
| High self-esteem | 35 | 18.3 | 2 | 1.1 | 8 | 4.7 | 0 | 0 | |
| Total | 191 | 100 | 175 | 100 | 168 | 100 | 160 | 100 | |
Self- esteem in relation to socio demographic characteristics of the children
Table 2 shows no association between socio-demographics of the children and self-esteem.
Table 2.
| Self-esteem | ||||||
|---|---|---|---|---|---|---|
|
| ||||||
| Low-Average self-esteem | High self-esteem | |||||
| N=156 | N=35 | |||||
| N | (%) | N | (%) | p-value | ||
| Gender | ||||||
| Male | 20 | (87.0) | 3 | (13.0) | 0.485 | |
| Female | 136 | (81.0) | 32 | (19.0) | ||
| Age group | ||||||
| 7–9 | 27 | (81.8) | 6 | (18.2) | 0.914 | |
| 10–12 | 37 | (84.1) | 7 | (15.9) | ||
| 13–15 | 53 | (79.1) | 14 | (20.9) | ||
| 16–17 | 39 | (83.0) | 8 | (17.0) | ||
| Schooled | ||||||
| Yes | 152 | (82.2) | 33 | (17.8) | 0.712 | |
| No | 4 | (75.0) | 2 | (25.0) | ||
| Educational levels | ||||||
| Primary | 138 | (83.6) | 27 | (16.4) | 0.278 | |
| Secondary | 18 | (73.7) | 8 | (26.3) | ||
| Parental care | ||||||
| Both | 121 | (84.6) | 22 | (15.4) | 0.064 | |
| Mother only | 23 | (69.7) | 0 | (30.3) | ||
| Father only | 5 | (62.5) | 3 | (37.5) | ||
| None | 6 | (100.0) | 0 | (.0) | ||
| Parental marital status | ||||||
| Married | 112 | (82.4) | 24 | (17.6) | 0.168 | |
| Separated | 28 | (84.8) | 5 | (15.2) | ||
| Divorced | 6 | (100.0) | 0 | (.0) | ||
| Single | 10 | (62.5) | 6 | (37.5) | ||
| Caretaker | ||||||
| Good Samaritan | 5 | (50.0) | 1 | (50.0) | 0.461 | |
| Care Giver | 129 | (80.1) | 32 | (19.9) | ||
| Guardian | 22 | (91.7) | 2 | (8.3) | ||
Self- esteem in children in relation to socio demographic characteristics of parents
As indicated in table 3, self-esteem of sexually abused children was significantly associated with the income of their parents (p=0.005).
Table 3.
| Self-esteem | |||||
|---|---|---|---|---|---|
| Low-Average self-esteem | High self-esteem | ||||
| N=156 | N=35 | ||||
| N | % | N | % | p-value | |
| Gender of parent | |||||
| Male | 15 | (73.7) | 6 | (26.3) | 0.319 |
| Female | 141 | (82.9) | 29 | (17.1) | |
| Level of Education of Father | |||||
| Primary | 84 | (86.5) | 14 | (13.5) | 0.115 |
| Secondary | 60 | (82.2) | 13 | (17.8) | |
| College | 12 | (64.3) | 8 | (35.7) | |
| Level of Education of Mother | |||||
| Primary | 32 | (86.5) | 5 | (13.5) | 0.376 |
| Secondary | 72 | (84.7) | 13 | (15.3) | |
| College | 24 | (75.0) | 8 | (25.0) | |
| Income | |||||
| Less than Sh. 100 per day | 55 | (89.7) | 6 | (10.3) | 0.005 |
| Sh. 100 per day | 63 | (85.9) | 11 | (14.1) | |
| More than Sh. 100 per day | 38 | (67.9) | 18 | (32.1) | |
Self-esteem in relation to sexual abuse profile
As shown in table 4(a), low and average self-esteem of sexually abused children were associated with the frequency of abuse (p<0.001) and how long ago the abuse had taken place (p=0.005). Also, table 4(b) shows that low and average self-esteem were associated with how long it took to receive medical attention (p<0.001), school success (p<0.0001) and the use of school to escape abuse (p=0.01).
Table 4.
| (a)
| ||||||
|---|---|---|---|---|---|---|
| Self-esteem | ||||||
| Low-Average self-esteem N=156 |
High self-esteem N=35 |
|||||
| N | (%) | N (%) | p-value | |||
| Relationship to Perpetrator | ||||||
| Stranger | 59 | (77.6) | 17 | (22.4) | 0.652 | |
| Acquaintance | 86 | (84.2) | 16 | (15.8) | ||
| Non Parental care giver | 2 | (66.7) | 1 | (33.3) | ||
| Biological Parent | 9 | (88.9) | 1 | (11.1) | ||
| Perpetrators Acts | ||||||
| Vagina Anal Penetration | 140 | (82.4) | 30 | (17.6) | 0.812 | |
| Touching the Genitals | 8 | (72.7) | 3 | (27.3) | ||
| What perpetrator made victim to do | ||||||
| Nothing | 10 | (66.7) | 5 | (33.3) | 0.365 | |
| Touching Genitals | 143 | (83.1) | 29 | (16.9) | ||
| Oral Copulation | 3 | (66.7) | 1 | (33.3) | ||
| Frequency of abuse | ||||||
| Once | 68 | (73.9) | 24 | (26.1) | 0.001 | |
| Twice | 33 | (86.8) | 5 | (13.2) | ||
| Three Times | 30 | (100.0) | 0 | (.0) | ||
| Four Times | 16 | (100.0) | 0 | (.0) | ||
| More than Four times | 9 | (60.0) | 6 | (40.0) | ||
| How long ago did the abuse take place | ||||||
| Days | 28 | (66.7) | 14 | (33.3) | 0.005 | |
| Weeks | 4 | (100.0) | 0 | (.0) | ||
| Months | 110 | (85.3) | 19 | (14.7) | ||
| Years | 14 | (86.7) | 2 | (13.3) | ||
| First person to tell of Abuse | ||||||
| Mother | 116 | (82.9) | 24 | (17.1) | 0.538 | |
| Father | 5 | (71.4) | 2 | (28.6) | ||
| Guardian | 8 | (100.0) | 0 | (.0) | ||
| Friend | 7 | (70.0) | 3 | (30.0) | ||
| Teacher | 10 | (83.3) | 2 | (16.7) | ||
| None | 1 | (50.0) | 1 | (50.0) | ||
| (b): Self- esteem in relation to sexual abuse against children profile
| |||||
|---|---|---|---|---|---|
| Self-esteem | |||||
| Low-Average self-esteem N=156 |
High self-esteem N=35 |
||||
| N | (%) | N | (%) | p-value | |
| How long before Sharing | |||||
| Same Day of Abuse | 91 | (84.3) | 17 | (15.7) | 0.772 |
| One Day after the Abuse | 36 | (78.3) | 10 | (21.7) | |
| One Week after the Abuse | 6 | (75.0) | 2 | (25.0) | |
| One Month after the Abuse | 23 | (77.8) | 6 | (22.2) | |
| First place to be taken | |||||
| Hospital | 130 | (82.3) | 28 | (17.7) | 0.526 |
| Chief’s Camp | 1 | (50.0) | 1 | (50.0) | |
| Police Station | 22 | (78.6) | 6 | (21.4) | |
| How long before receiving medical attention | |||||
| Within 1 Hour | 109 | (87.2) | 16 | (12.8) | 0.001 |
| Within 2 Hours | 13 | (100.0) | 0 | (.0) | |
| Within 12 Hours | 21 | (72.4) | 8 | (27.6) | |
| Within 48 Hours | 2 | (40.0) | 3 | 60.0 | |
| Within 72 Hours | 2 | (66.7) | 1 | (33.3) | |
| After 72 hours | 9 | (56.3) | 7 | (43.8) | |
| How did you cope with school work | |||||
| Finishing Homework | 110 | (82.7) | 23 | (17.3) | 0.621 |
| Not Finishing Homework | 46 | (79.6) | 12 | (20.4) | |
| School success | |||||
| Yes | 146 | (85.4) | 25 | (14.6) | <0.0001 |
| No | 10 | (43.8) | 10 | (56.3) | |
| Used school to escape from abuse | |||||
| Yes | 143 | (83.6) | 28 | (16.4) | 0.01 |
| No | 13 | (58.8) | 7 | (41.2) | |
Predictors of Low and average Self-esteem
As shown in table 5, the factor that was associated with prediction of low and average self-esteem was poor school performance (p<0.05).
Table 5.
| B | S.E. | p-value | OR | 95% C.I. for OR | ||
|---|---|---|---|---|---|---|
| Lower | Upper | |||||
| Frequency of Abuse | −.377 | .230 | .102 | .686 | .437 | 1.077 |
| How long ago the Abuse taken place | .129 | .292 | .659 | 1.137 | .642 | 2.014 |
| How long before receiving medical attention | .309 | .180 | .085 | 1.362 | .958 | 1.937 |
| School success | 1.603 | .799 | .05 | 4.967 | 1.038 | 23.758 |
| Used school to escape from abuse | −.498 | .898 | .579 | .608 | .104 | 3.534 |
| Income | .594 | .310 | .055 | 1.812 | .987 | 3.327 |
| Substance Use | .485 | .524 | .355 | 1.623 | .581 | 4.535 |
| How Family disagreements are sorted out | .812 | .536 | .130 | 2.251 | .788 | 6.433 |
Discussion
This study examined self-esteem among children exposed to sexual abuse in Kenya. It found that sexual abuse against children was associated with low and average self-esteem in children. Over (75%) of the participants had average scores of self-esteem while (6.3%) had low self-esteem scores at baseline. The findings are consistent with Wondie et al.’s (2011) study among sexually abused child survivors in Ethiopia, which found that sexually abused children had a lower degree of self-worth. Similarly, the findings of the current study are consistent with a study done in India among rural adolescent girls who had average and low self-esteem (Nagar et al. 2008). Also, Pullmann and Allik (2008) found that Estonian students had low and average scores of self-esteem. Besides, Kim and Cicchetti (2006) found that abuse of children predicted initial levels of self-esteem. In addition, Dyer et al. (2013) found that girls who had experienced sexual abuse had negative appraisals of themselves and had developed post-traumatic stress disorder.
The mean age (13) years in the current study was comparable to other studies done in Kenya by Ombok et al. (2013) and Syengo et al. (2008) where the mean ages were 11.1 and 14.8 years respectively. In Kenya, students completed primary school education by the age of 13 years, implying, according to this study, that sexual abuse was directed at children of tender age predominantly and pre-adolescent children all of whom had under-developed bodies and minds. It was therefore conceivable that the level of stress experienced by these young children in the hands of the perpetrators was immense. This was consistent with Piaget’s (1965) developmental theory, which noted that sexual abuse against children affected victims in their psychological (self-esteem) functioning, and the abuse was most harmful during the concrete operational period.
The gender differences among victims of sexual abuse in Kenya showed that girls (88%) were seven (7) times more at risk of sexual abuse than boys (12%). This study therefore, demonstrated that gender was no comparable factor but predisposition and vulnerability of girls turned to be the real factor behind the large number of girls being abused in Kenya. The findings support previous studies on sexual abuse in Kenya (Ombok et al. 2013 and Syengo et al. 2008) as well as International studies (Brown et al. 2009; Finkelhor et al. 2013; and Pereda et al. 2009). Also, majority (67.6%) of parents in the current study earned less than two dollars a day, an indication that they had low socio-economic status. This finding corroborates studies done by Cancian et al. (2010) and Sedlak et al. (2010).
Furthermore, some scholars have argued that children who had not been exposed to any abuse demonstrated significantly higher self-esteem and lower symptoms of trauma (Ismayilova et al. 2016). This is an indication that exposure to abuse among children could determine their self-esteem. Also, sexual abuse against children is associated with school disruption and could have a profound impact on the ability of children to concentrate in school. In this current study, it was found that majority of the children had low school success due to the sexual abuse they experienced. A study among girls aged 13-16 years in Finland by Wiens et al. (2014) found that the girls considered good health to mean both physical health and having a good self-esteem. Additionally, good health, included doing well in school, feeling good and being carefree as a whole and these led to self-realization (Wiens et al. 2014). Similar findings were reported by Fry et al. (2016) and Holt et al. (2007) who found that youth in the US who had experienced sexual abuse emerged as the group with the most significant academic problems.
The findings of this current study reflects and adds to the body of knowledge on the levels of self-esteem among sexually abused children. It also highlights the factors that affect self-esteem during childhood to adolescent years. Self-esteem is built over the years during childhood and adolescence depending mainly on prevailing circumstances. Thus, considering the findings obtained, parents should be encouraged and motivated to provide their children with support after the incidence of traumatic events in order to raise their children’s self-esteem and lessen the likelihood that the children will exhibit antisocial behaviours as it is well established in extant research studies that depression, suicide and dropping out of school, are associated with low self-esteem.
Limitation of the study
The reported results should be interpreted while considering the possible limitations of this study. Firstly, the study did not have a comparison group, hence conclusions can be made based on the study population. Secondly, there were few boys compared to girls. Thirdly, there was a potential influence of other covariates in the study, such as teacher-based interventions or time spent with parents/legal guardians.
Conclusion and Recommendations
The study concludes that sexually abused children included in this study had mental health problems as measured by Pier Harris Self-Concept Scale. Girls were more at risk of experiencing sexual abuse than boys. The findings of this study suggest the need for psychosocial support for children who sought services at the Nairobi Women’s and Kenyatta National Hospitals, as well as other children. The provision of a comprehensive health care by a multi-disciplinary team, including psychiatrists and social workers is warranted. Also, further studies need to be done among boys who experience sexual abuse. Moreover, there is the need to (a) enhance parenting protective skills and (b) minimize risk factors that could lead to poor mental health outcomes among children after the incidence of sexual abuse.
Acknowledgments
Funding
This study was carried out and funded within the “Mental Health Research for Better Outcomes,” a project funded from the National Institute of Mental Health (NIMH) through award no 4R34MH09913. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health. The University of Washington, provided oversight and resources around child mental health and quantitative research.
Footnotes
Compliance with Ethical standards
Conflict of Interest
On behalf of all the authors, the corresponding author states that there is no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. The study was approved by the Ethical and Research Committee (ERC) of the Kenyatta National Hospital/University of Nairobi in Kenya with approval number (P577/09/2014). Informed consent and assent from children were obtained from all the participants.
References
- Ayoub CC, O’connor E, Rappolt-Schlichtmann G, Fischer KW, Rogosch FA, Toth SL, Cicchetti D. Cognitive and emotional differences in young maltreated children: A translational application of dynamic skill theory. Development and Psychopathology. 2006;18(3):679–706. doi: 10.1017/s0954579406060342. [DOI] [PubMed] [Google Scholar]
- Azad A, Leander A. Children’s reporting about sexual versus physical abuse patterns of reporting, avoidance and denial. Psychiatry Psychol Law. 2015;22(6):890–902. doi:1080/13218719.2015.1016392. [Google Scholar]
- Bridgewater G. Physical and sexual violence against children in Kenya within a cultural context. Community Practitioner. 2016;89(2):30–36. [PubMed] [Google Scholar]
- Brown WD, Riley L, Butchart A, Meddings RD, Kann L, Harvey AP. Exposure to physical and sexual violence and adverse health behaviors in African children: Results from the Global school based student health survey. Bull World Health Organization. 2009;87:447–455. doi: 10.2471/BLT.07.047423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Burack JA, Flanagan T, Peled T, Sutton HM, Zygmuntowicz C, Manly JT. Social perspective-taking skills in maltreated children and adolescents. Developmental psychology. 2006;42(2):207–217. doi: 10.1037/0012-1649.42.2.207. [DOI] [PubMed] [Google Scholar]
- Cancian M, Shook Slak K, Yang M. Effect of family income on risk of child maltreatment. Madison, WI: Institute for Research on Poverty; 2010. [Google Scholar]
- Daigneault I, Hébert M, Tourigny M. Attributions and coping in sexually abused adolescents referred for group treatment. Journal of Child Sexual abuse against children. 2006;15(3):35–59. doi: 10.1300/J070v15n03_03. [DOI] [PubMed] [Google Scholar]
- DePrince AP, Chu AT, Combs MD. Trauma-related predictors of deontic reasoning: A pilot study in a community sample of children. Child Abuse & Neglect. 2008;32(7):732–737. doi: 10.1016/j.chiabu.2007.10.006. [DOI] [PubMed] [Google Scholar]
- Dorahy MJ, Clearwater K. Shame and guilt in men exposed to childhood sexual abuse: A qualitative investigation. Journal of Child Sexual Abuse. 2012;21(2):155–175. doi: 10.1080/10538712.2012.659803. [DOI] [PubMed] [Google Scholar]
- Dyer A, Borgmann E, Feldmann RE, Kleindienst N, Priebe K, Bohus M, Vocks S. Body image disturbance in patients with borderline personality disorder: Impact of eating disorder and perceived childhood sexual abuse against children. Body Image. 2013;10(2):220–225. doi: 10.1016/j.bodyim.2012.12.007. [DOI] [PubMed] [Google Scholar]
- Finkelhor D, Turner HA, Shattuck A, Hamby SL. Violence, crime and abuse exposure in a national sample of children and youth: An update. JAMA Pediatr. 2013;167(7):614–621. doi: 10.1001/jamapediatrics.2013.42. [DOI] [PubMed] [Google Scholar]
- Fontes LA, Plummer C. Cultural issues in disclosure of child sexual abuse. Journal of Child Sexual Abuse. 2010;19(5):491–518. doi: 10.1080/10538712.2010.512520. [DOI] [PubMed] [Google Scholar]
- Ford JD, Courtois CA. Defining and understanding complex trauma and complex traumatic stress disorders. In: Courtois CA, Ford JD, editors. Treating complex traumatic stress disorders: An evidence-based guide. New York, NY: Guilford Press; 2009. pp. 13–30. [Google Scholar]
- Fry D, Anderson J, Hidalgo R. Prevalence of violence in childhood and adolescence and the impact on educational outcomes: evidence from the 2013 Peruvian national survey on social relations. International Health. 2016;8:44–52. doi: 10.1093/inthealth/ihv075. [DOI] [PubMed] [Google Scholar]
- Girgira T, Tilahun B, Bacha T. Time to presentation, pattern and immediate health effects of alleged child sexual abuse at two tertiary hospitals in Addis Ababa, Ethiopia. BMC Public Health. 2014;14(1):92–98. doi: 10.1186/1471-2458-14-92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Grant R, Brito A. Chronic illness and school performance: A literature Review. Focusing on Asthma and Mental Health Conditions. A Children’s Health Fund Monograph 2010 [Google Scholar]
- Green J, McLaughlin K, Berglund P, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and adult psychopathology in the stress sensitization in a national sample. National Comorbidity Survey Replication (NCS-R) I: Associations with first onset of DSM-IV disorders. Archives of General Psychiatry. 2010;67(2):113–123. doi: 10.1001/archgenpsychiatry.2009.186. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Guelzow JW, Cornett PF, Dougherty TM. Child sexual abuse victims’ perception of paternal support as a significant predictor of coping style and global self-worth. Journal of Child Sexual Abuse. 2003;11(4):5372. doi: 10.1300/j070v11n04_04. [DOI] [PubMed] [Google Scholar]
- Hillis S, Mercy J, Amobi A, Kress H. Global prevalence of past-year violence against children: a systematic review and minimum estimates. Pediatrics. 2016;137(3):113. doi: 10.1542/peds.2015-4079. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Holt MK, Finkelhor D, Kantor GK. Multiple victimization experiences of urban elementary school students: Associations with psychosocial functioning and academic performance. Child Abuse & Neglect. 2007;31:503–515. doi: 10.1016/j.chiabu.2006.12.006. [DOI] [PubMed] [Google Scholar]
- Ismayilova L, Gaveras E, Blum A, To-Camier A, Nanema R. Maltreatment and mental health outcomes among ultra-poor children in Burkina Faso: A latent class analysis. Plos One. 2016;11(10):e0164790. doi: 10.1371/journal.pone.0164790. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Isely PJ, Isely P, Freiburger J, McMackin R. In their own voices: A qualitative study of men abused as children by Catholic clergy. Journal of Child Sexual Abuse. 2008;17(4):201–215. doi: 10.1080/10538710802329668. [DOI] [PubMed] [Google Scholar]
- Ji K, Finkelhor D, Dunnes M. Child sexual abuse in China: A meta-analysis of 27 studies. Child Abuse & Neglect. 2013;27(9):613–622. doi: 10.1016/j.chiabu.2013.03.008. [DOI] [PubMed] [Google Scholar]
- Jonas S, Bebbington S, McManus S, Meltzer H, Jenkins R, Kuipers E. Sexual abuse against children and psychiatric disorder in England: Results from the 2007 Adult Psychiatric Morbidity Survey. Psychological Medicine. 2011;41(4):709–719. doi: 10.1017/S003329171000111X. doi:org/10.1017/S003329171000111X. [DOI] [PubMed] [Google Scholar]
- Kim J, Cicchetti D. Longitudinal trajectories of self-esteem processes and depressive symptoms among maltreated and non-maltreated children. Child Development. 2006;77(3):624–639. doi: 10.1111/j.1467-8624.2006.00894.x. doi:1111/j.1467-8624.2006.00894X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lalor K, McElvaney R. Child sexual abuse, Links to later sexual exploitation high risk sexual behavior, and prevention/treatment programs. Journal of Trauma, Violence & Abuse. 2010;11(4):159–177. doi: 10.1177/1524838010378299. [DOI] [PubMed] [Google Scholar]
- Lippert T, Cross T, Jones L, Walsh W. Telling interviewers about child sexual abuse: Predictors of child disclosure at forensic interviews. Child Maltreatment. 2009;14(1):100–113. doi: 10.1177/1077559508318398. [DOI] [PubMed] [Google Scholar]
- Madu SN, Ndom RE, Ramashia CL. Depression among female survivors of domestic violence in Thohoyandou, South Africa. Gender & Behaviour. 2010;8(1):2871–2885. doi: 10.4314/gab.v8i1.54706. [DOI] [Google Scholar]
- Maniglio R. Severe mental illness and criminal victimization: A systematic review. Acta Psychiatrica Scandinavia. 2009;119(3):180–191. doi: 10.1111/j.1600-0447.2008.01300.x. [DOI] [PubMed] [Google Scholar]
- Meinck F, Cluver L, Boyes M, Mhlongo E. Risk and protective factors for physical and sexual abuse of children and adolescents in Africa: A review and implications for practice. Trauma, Violence & Abuse. 2015;16(1):81–107. doi: 10.1177/1524838014523336. doi:1177/1524838014523336. [DOI] [PubMed] [Google Scholar]
- Minzenberg J, Poole J, Vinogradov S. A neurocognitive model of borderline personality disorder: effects of childhood sexual abuse against children and relationship to adult social attachment disturbance. Development & Psychopathology. 2008;20(1):341–368. doi: 10.1017/S0954579408000163. [DOI] [PubMed] [Google Scholar]
- Mishra K, Ransing R, Khairkar P, Gajanan S. Association between childhood abuse and psychiatric morbidities among hospitalized patients. Indian Journal of Soc Psychiatry. 2016;32(1):50–55. doi: 10.4103/0971.176769. [DOI] [Google Scholar]
- Nagar S, Sharma S, Chopra G. Self- esteem among rural adolescent girls in Kangra district of Himachal Pradesh. Anthropologist. 2008;10(2):151–154. [Google Scholar]
- Ndetei D, Khasakhala L, Mutiso V, Mbwayo A. Recognition of depression in children in general hospital-based pediatric units in Kenya: practice and policy implications. Annals of General Psychiatry. 2009;8(1):25. doi: 10.1186/1744-859X-8-25. doi.org/10.1186/1744-859X-8-25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Nolin P, Ethier L. Using neuropsychological profiles to classify neglected children with or without physical abuse. Child Abuse & Neglect. 2007;31(6):631–643. doi: 10.1016/j.chiabu.2006.12.009. [DOI] [PubMed] [Google Scholar]
- Ombok C, Obondo A, Kangethe R, Atwoli L. The prevalence of Post –Traumatic Stress Disorder among sexually abused children at Kenyatta National Hospital in Nairobi, Kenya. East African Medical Journal. 2013;90(10):332–337. [PubMed] [Google Scholar]
- Omondi S. An evaluation of child sexual abuse trial procedures in Kenya. Journal in Humanities and Social Science. 2014;2(4):11–63. [Google Scholar]
- Olsen JM, Breckler SJ, Wiggins EC. Social Psychology Alive. 1st. Canada: Nelson; 2008. [Google Scholar]
- Perlman SB, Kalish CW, Pollak D. The role of maltreatment experience in children’s understanding of the antecedents of emotion. Journal of Cognition & Emotion. 2008;22(4):651–670. [Google Scholar]
- Pereda N, Guilera G, Forns M, Gomez-Benito J. The prevalence of child sexual abuse in community and student samples: A meta- analysis. Clinical Psychology Review. 2009;29(4):328–338. doi: 10.1016/j.cpr.2009.02.007. [DOI] [PubMed] [Google Scholar]
- Pier E, Herzberg D. Piers- Harris children self-concept scale. 2nd. western psychological services; Los Angeles, Ca: 2002. [Google Scholar]
- Piaget J. The Moral Judgment of the Child. New York: Free Press; 1965. [Google Scholar]
- Pullmann H, Allik J. Relations of academic and general self-esteem to school achievement. Personality & Individual Differences. 2008;45(6):559–564. doi: 10.1016/j.paid.2008.06.017. [DOI] [Google Scholar]
- Roberts B, Damundu E, Lomoro O, Sondorp E. Post-conflict mental health needs: A cross-sectional survey of trauma, depression and associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009;9(1):7. doi: 10.1186/1471-244X-7-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Roberts B, Ocaka K, Browne J, Oyok T, Sondrop E. Factors associated with post- traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychiatry. 2008;8(1):38. doi: 10.1186/1471-244X-8-38. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Schonbucher V, Maier T, Mohler-kuo M, Schnyder U, Landolt M. Disclosure of child sexual by adolescents: A qualitative in-depth study. Journal of Interpersonal Violence. 2012;27(17):3486–3513. doi: 10.1177/0886260512445380. [DOI] [PubMed] [Google Scholar]
- Sedlack A, Mettenburg J, Basena M, Petta L, Mcpherson K, Greene A, Li S. Report to congress. Washington DC: US department of health & human services, administration for children & families; 2010. Fourth National incident study of child abuse & neglect (NIS-4) [Google Scholar]
- Stoltenborgh M, Van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg M. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreatment. 2011;16(2):79–101. doi: 10.1177/1077559511403920. [DOI] [PubMed] [Google Scholar]
- Sumner AS, Mercy AJ, Saul J, Motza-Nzuza N, Kwesigabo G, Buluma R, Hillis SD. Prevalence of sexual violence against children and use of social services-seven countries, 2007-2013. MMWR, Morbidity & Mortality Weekly Report. 2015;64(21):565–569. [PMC free article] [PubMed] [Google Scholar]
- Swanston HY, Plunkett AM, O’Toole B, Shrimpton S, Parkisn P, Oates K. Nine years after (SVAC) Child Abuse & Neglect. 2003;27(8):967–984. doi: 10.1016/s0145-2134(03)00143-1. [DOI] [PubMed] [Google Scholar]
- Syengo M, Kathuku M, Ndetei M. Psychiatric morbidity among sexually abused children and adolescents. East African Medical Journal. 2008;85(2):85–91. doi: 10.4314/eamj.v85i2.9611. [DOI] [PubMed] [Google Scholar]
- Tebbutt J, Swanston H, Oates R, O’ Toole B. Five years after (SVAC): Persisting dysfunction and problems of prediction. Journal of American Academy of Child Adolescent Psychiatry. 1997;36(3):330–339. doi: 10.1097/00004583-199703000-00011. doi.org/10.1097/00004583-199703000. [DOI] [PubMed] [Google Scholar]
- Tomoda A, Navalta CP, Polcari A, Sadato N, Teicher MH. Childhood sexual abuse against children is associated with reduced gray matter volume in visual cortex of young women. Biological psychiatry. 2009;66(7):642–648. doi: 10.1016/j.biopsych.2009.04.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Valentino K, Cicchetti D, Rogosch FA, Toth SL. True and false recall and dissociation among maltreated children: The role of self-schema. Development & Psychopathology. 2008;20(1):213–232. doi: 10.1017/S0954579408000102. [DOI] [PubMed] [Google Scholar]
- Wiens V, Kyngäs H, Pölkki T. A descriptive qualitative study of adolescent girls’ well-being in Northern Finland. International Journal of Circumpolar Health. 2014;73 doi: 10.3402/ijch.v73.24792. doi.103402/ijch.v73.24792. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wondie Y, Zemene W, Tafesse B, Reschke K, Schroder H. The psychosocial consequences of child sexual abuse against children in Ethiopia: A case-control comparative analysis. Journal of Interpersonal Violence. 2011;26(10):2025–2041. doi: 10.1177/0886260510372937. [DOI] [PubMed] [Google Scholar]
- Young T, Riggs M, Robinson JL. Childhood sexual abuse and severity reconsidered: A factor structure of CSA characteristics. Journal of Child Sexual Abuse. 2011;20(4):373–395. doi: 10.1080/10538712.2011.590124. [DOI] [PubMed] [Google Scholar]