Topic:

Parental acceptance- rejection, behavioral problems and nightmare distress in

children with sexual and physical abuse
ABSTRACT

The current study has been conducted to explore the relationship of parental acceptance-

rejection with behavioral problems and nightmare in adolescents with sexual and physical

abuse. The following hypotheses are formulated based on previous literature. 1-paternal

rejection(coldness/lack of affection, hostility/aggression, indifference, neglect and

undifferentiated rejection) would positively predict behavioral problems in adolescents with

sexual and physical abuse, 2-paternal acceptance would negatively predict behavioral

problems in adolescent with sexual and physical abuse 3-maternal rejection (coldness/ lack

of affection, hostility/aggression, indifference, neglect and undifferentiated rejection) would

positively predict behavioral problems in adolescent with sexual and physical abuse.4-

maternal acceptance would negatively predict behavioral problems in adolescents with

sexual and physical abuse, 5- paternal rejection would positively predict nightmare in

adolescent with sexual and physical abuse. 6- paternal acceptance would negatively predict

nightmare in adolescent with sexual and physical abuse. 7- maternal rejection would

positively predict nightmare in adolescent with sexual and physical abuse. 8- maternal

acceptance would negatively predict nightmare in adolescent with sexual and physical

abuse. 9- There would be a difference in adolescents with sexual and physical abuse on the

variable of behavioral problems. 10- There would be a difference in adolescent with sexual

and physical abuse on the variable of nightmare distress. Sample of 200 adolescents(100

with sexual abuse, 100 with physical abuse) was selected; age range of 13-17 years.

Parental acceptance-rejection questionnaire (Rohner,1984) and Strength and difficulties

 questionnaire ( Goodman et al,1998) and Trauma-Related Nightmare Survey (Christopher

C Cranston )were used to assess study variables,

Chapter 1

INTRODUCTION

Childhood sexual and physical abuse is generally defined as physical contact between a child and
another person, significantly older, or someone in a position of power or control over the child,
where the child is used for sexual and physical stimulation of the adult or other people.
According to one Estimates of childhood sexual and physical abuse prevalence range from 8%
to 31% for girls and from 3% to 17% for boys.It has been accordance with this perspective,
abused survivors’ sexual dysfunctions and distress evolve from the traumatic experience of the
abuse. Difficulty trusting sexual partners and experiencing dissociative episodes or flashbacks of
the abuse during sexual activity could lead to shame or guilt about sexual response and feelings
of disgust as well as sexual distress and physical distress. By the same token, various aspects of
abusers, such as its interpersonal nature, the survivor’s age during the abuse, size and power
differences, and the overwhelming, coercive, and invasive nature of sexual and physical abuse,
can also lead to sexual and physical dysfunction and distress.(M~ller, Sicoli and Lemieux2,
2000)

Adolescent is a period of adjustment marked by physical and psychological changes.

Remarkable changes lead to conflicts in interpersonal relationships and many other behavioral,
cognitive , social and personality issues. Adolescent also has faced many challenges and
pressures. These pressures maybe from family members, friends and environment. It includes
violence, poverty and parental problems. Sometimes children are having difficulty to face with
the past traumas which a child experience such as abuse. Adolescent who are abused in their
childhood developed a number of behavioral problems especially when it’s accompanied with
parental rejection.(Gewirtz-Meydan and Lahav, 2020)

The impact of childhood sexual and physical molestation can span months, years and even
decades over the lifetime of a survivor and his or her family. Physical and sexual abuse of
children can devastatingly change lives, disrupt personality development and corrupt
interpersonal relationships throughout one’s entire life. The invisible psychological scars of
childhood sexual abuse and physical abuse can lead to suffering in adolescence, adulthood and
even after survivors become parents themselves. (Anon, n.d.)

Kilmer (2006) identified seven interrelated domains that influence a child’s ability to experience
PTG after experiencing trauma or abuse: (a) child’s pretrauma beliefs, characteristics, and
functioning; (ii) caregiver’s post-trauma responsiveness; (iii) trauma exposure; (iv) relationships
and support; (v) appraisals, ruminations, and cognitive processing; (vi) cognitive resources; and
(vii) self-system functioning.(McElheran et al., 2012)

The associations between giving a history of physical, emotional, and sexual abuse in children
and a range of mental health, interpersonal, and sexual problems in adult life were examined in a
community sample of women. Abuse was defined to establish groups giving histories of
unequivocal victimization. A history of any form of abuse was associated with increased rates of
psychopathology, sexual difficulties, decreased self-esteem, and interpersonal problems. The
similarities between the three forms of abuse in terms of their association with negative adult
outcomes was more apparent than any differences, though there was a trend for sexual abuse to
be particularly associated to sexual problems, emotional abuse to low self-esteem, and physical
abuse to marital breakdown. (Berkowitz, 2017)

higher levels of perceived social support were related to lower scores on all symptom outcome
measures. Abuse involving oral, genital, or anal penetration was related to more insomnia
symptoms. Longer duration of abuse and threatening conducted by the perpetrator were related
to higher nightmare frequency, while threats and abuse involving penetration were related to
higher degrees of distress associated with nightmares. In conclusion, the present study provides
preliminary data indicating that perceived social support may affect the nature of sleep
difficulties in sexual abuse victims. Also, more severe forms of sexual abuse are related to higher
levels of sleep difficulties.(Steine et al., 2011)

According to the attachment theory (Bowlby, 1973), through repeated interaction with
caregivers, children form mental representations (internal working model; attachment cognition)
of themselves, others, and expectations of the relationship -- whether they are lovable, whether
others are trustworthy, and whether other people are likely to be available when needed (Howe,
2005). If the caregiver is consistently available, sensitive and responsive, children form a
representational model of others being accessible and dependable and of themselves being
loveable and worthy. These children are considered securely attached to their caregiver
(Ainsworth et al., 1978). With these representations, children can also generate expectations
regarding whether significant others would satisfy their need or be rejecting.(Wang, 2020)

Janoff-Bulman (1 992) proposed that individuals with negative core assumptions about the self
are more likely to engage in self-blame and make negative attributions in regard to negative life
events. Several theorists have proposed that individuals who engage in characterological self-
blame, attributing the cause of a traumatic experience to some enduring negative character trait
that is invariant, are more vulnerable to the development of posttraumatic stress
symptomatology.(M~ller, Sicoli and Lemieux2, 2000)

sleep disturbances were widespread and more prevalent in sexually abused subjects as compared
to in non-abused samples. Symptoms reported more frequently by sexually abused samples
included nightmare related distress, sleep paralysis, nightly awakenings, restless sleep, and
tiredness. Results were divergent with regards to sleep onset difficulties, nightmare frequency,
nocturnal activity, sleep efficiency, and concerning the proportion of each sample reporting sleep
disturbances as such. Potential sources of these divergences are examined. Several
methodological weaknesses were identified in the included studies. In order to overcome
limitations, future researchers are advised to use standardized and objective measurements of
sleep, follow-up or longitudinal designs, representative population samples, large sample sizes,
adequate comparison groups, as well as comparison groups with other trauma experiences.
(Steine et al., 2012)

Children with documented histories of abuse and neglect and matched controls were followed up
and assessed in young and middle adulthood. Abused and neglected children were more likely to
report experiencing inadequate sleep conditions in childhood, sleep problems in young
adulthood, and higher levels of depression and anxiety later in middle adulthood. Results
revealed significant indirect paths from childhood maltreatment to anxiety and depression in
middle adulthood through inadequate sleep conditions in childhood and sleep problems in young
adulthood. This longitudinal follow-up of children with documented cases of maltreatment
reveals the important role of sleep disturbances in the lives of maltreated children and adults and
sleep disturbances in the development of subsequent anxiety and depression.(Javakhishvili and
Widom, 2021)

LITERATURE REVIEW

An impressive body of research has investigated whether sexual and physical abuse is associated
with sleep disturbances. Across studies there are considerable differences in methods and results.
Thirty-two studies fulfilled the inclusion criteria (reported empirical data, included sexually
abused subjects, employed some form of sleep measurement, English language and published in
peer reviewed journals). Across the studies included, sleep disturbances were widespread and
more prevalent in sexually and physically abused subjects as compared to in non-abused
samples. Symptoms reported more frequently by sexually and physically abused samples
included nightmare related distress, sleep paralysis, nightly awakenings, restless sleep, and
tiredness. Results were divergent with regards to sleep onset difficulties, nightmare frequency,
nocturnal activity, sleep efficiency, and concerning the proportion of each sample reporting sleep
disturbances as such. Potential sources of these divergences are examined. Several
methodological weaknesses were identified in the included studies. In order to overcome
limitations, future researchers are advised to use standardized and objective measurements of
sleep, follow-up or longitudinal designs, representative population samples, large sample sizes,
adequate comparison groups, as well as comparison groups with other trauma experiences.

Adolescent girls ranging in age from 13 to 18 years were recruited from the Wyoming Girls
School in Sheridan, Wyoming (treatment group, n = 9; control group, n = 10). These girls had
previously suffered a high prevalence of unwanted sexual experiences in childhood and
adolescence, and thus many suffered from nightmares, sleep complaints, and posttraumatic stress
symptoms. Imagery rehearsal therapy was provided in a 1-day (6-h) workshop. Imagery
rehearsal consists of three steps, all of which are performed in the waking state: (a) select a
nightmare, (b) “change the nightmare any way you wish,” and (c) rehearse the images of the new
version (“new dream”) 5 to 20 min each day. Control participants received no intervention. At
baseline, these girls had been suffering from nightmares, on average, for 4.5 years, and they
reported experiencing 20 nightmares per month, which occurred at a frequency of at least one
bad dream every other night. At 3 months, self-reported, retrospectively assessed nightmare
frequency measured in nights per month decreased 57% (p = .01, d = 1.4) and measured in
nightmares per month decreased 71% (p = .01, d = 1.7) in the treatment group, compared with no
significant changes in the control group. No significant changes were noted for sleep and
posttraumatic stress disorder measures in either group. Imagery rehearsal therapy was an
effective treatment option for chronic nightmares in this adjudicated adolescent population.

Sexual and physical abuse occurs at epidemic rates worldwide. Prevalence studies report rates
ranging between 8 and 31% for women and 3–17% for men during childhood (Barth, Bermetz,
Heim, Trelle, & Tonia, 2013; Finkelhor, 1994), with comparable prevalence rates reported for
adult sexual assault (Elliott, Mok, & Briere, 2004) and intimate partner sexual violence (Krug,
Dahlberg, Mercy, Zwi, & Lozano, 2002). Moreover, childhood sexual abuse often co-occurs
with other types of childhood maltreatment, such as physical and emotional abuse or neglect
(Clark, Caldwell, Power, & Stansfeld, 2010; Kessler et al., 2010; Turner, Finkelhor, & Ormrod,
2010).

Over the years, a massive and continuously growing body of literature established that being
victimized by sexual abuse increases the risk of a wide range of short- and long-term mental and
somatic negative health outcomes. Among the reported outcomes are increased risk of suicide
and suicide attempts, post-traumatic stress, anxiety, depression, sleep disorders, eating disorders,
substance abuse, sexual problems, social impairment, interpersonal problems (Beichtman,
Zucker, Hood, DaCosta, & Akman, 1991; Beichtman et al., 1992, Chen et al., 2010, Jumper,
1995, Kendler et al., 2000, Maniglio, 2009; Paolucci, Genius, & Violato, 2001; Putnam, 2003),
functional gastrointestinal disorders, obesity, chronic pain conditions (Gilbert et al., 2009,
Leserman, 2005, Maniglio, 2009, Paras et al., 2009), as well as alterations of neurobiology and
stress physiology (Bremner et al., 1997, Dannlowski et al., 2012, Hulme, 2011, Vythilingam et
al., 2002). Moreover, survivors of sexual abuse show high degrees of comorbidity of symptoms
and disorders (i.e., meeting diagnostic criteria for several mental disorders; Trickett, Noll, &
Putnam, 2011).
While sexual abuse is a well-established risk factor for multiple mental and somatic symptoms as
well as social problems, studies also document substantial symptom heterogeneity among those
victimized (see for example Kendall-Tackett, Williams, & Finkelhor, 1993; Paolucci et al., 2001,
Trickett et al., 2011), indicating the presence of factors moderating symptom outcomes. One
factor consistently associated with less severe symptomatology among sexual abuse survivors is
the degree of perceived social support- a protective factor known to have beneficial health effects
both directly (Cohen and Wills, 1985, Uchino, 2006, Umberson and Montez, 2010) and
indirectly (e.g. through stress buffering; Brewin, Andrews, & Valentine, 2000; Cohen, 2004;
Ozer, Best, Lipsey, & Weiss, 2008). Specifically, higher levels of perceived social support were
associated with better health outcomes in both child (Kaufman et al., 2004; Tremblay, Hébert, &
Piché, 1999) and adult (Burgess & Holmstrom, 1978; Hyman, Gold, & Cott, 2003; Lueger-
Schuster et al., 2015, Runtz and Schallow, 1997, Steine et al., 2012) survivors of childhood
sexual abuse, and among survivors of adult sexual abuse (Burgess and Holmstrom, 1978,
Ullman, 1999). The association between perceived support and health outcomes among sexual
abuse survivors is likely to be complex. For example, several representative population studies
showed that childhood sexual abuse itself is a significant predictor of smaller network size and
lower levels of emotional support from friends, family or spouses later in life (Golding,
Wilsnack, & Cooper, 2002). Another construct of potential relevance for differences in symptom
outcomes, is the personality style of hardiness. Hardiness has been described as a constellation
of personality characteristics contributing to stress resilience. It is a multidimensional construct
comprising characteristics from three sub-facets: 1) the degree to which one believes one can
control events happening in one’s life (Control), 2) the degree to which one approaches difficult
situations as opportunities to learn and grow (Challenge), as well as 3) the degree to which a
person is engaged in a variety of life domains (Commitment) (for more elaborate information, see
Eschleman, Bowling, & Alarcon, 2010; Maddi et al., 2002). Hardiness has been shown to play a
role in mental health and stress resilience. Specifically, higher levels of hardiness have been
associated with lower levels of mental health problems, both in general and following stressful
events (Beasley, Thompson, & Davidson, 2003; Eschleman et al., 2010, Pengilly and Dowd,
2000). This has also been found among sexual abuse survivors (Feinauer, 2003, Feinauer et al.,
1996). However, other studies indicate that stress resilience itself may be negatively affected by
exposure to sexual abuse (e.g., increasing the risk of developing depression after sressful events
later in life; Kendler, Kuhn, & Prescott, 2004). Whether this also holds true for hardiness
remains unclear due to a lack of previous studies investigating this, highlighting the need for
studies addressing this question.
Several abuse-related factors have also been associated with differences in short- and long-term
symptom outcomes, including a close relation to the perpetrator (particularly a biological parent),
abuse involving the use of force, and abuse involving oral, anal or genital penetration
(Beichtman et al., 1991, Beichtman et al., 1992; Feehan, Nada-Raja, Martin, & Langley, 2001;
Fergusson, McLeod, & Horwood, 2013; Kendall-Tackett et al., 1993, Kendler et al., 2000,
Leserman, 2005, Tremblay et al., 1999; Trickett, Reiffman, Horowitz, & Putnam, 1997; Tyler,
2002).

In other samples (e.g., national representative samples, national population samples, clinical
samples), several large-scale studies have reported evidence of a “dose-response” relation
between cumulative exposure to different types of childhood adversities and severity of
symptomatology later in life. Specifically, a graded relationship was found between the number
of different types of childhood adversities experienced and the risk of suicide attempts, anxiety
disorders, depression, sleep disturbances, obesity, hallucinations, drug use, antisocial behavior,
as well as with many leading causes of death in adults, including ischemic heart disease and
cancer (Anda et al., 2006, Chapman et al., 2004, Clark et al., 2010, Felitti et al., 1998;
Koskenvuo, Hublin, Partinen, Paunio, & Koskenvuo, 2010; Schilling, Aseltine, & Gore, 2008;
Turner et al., 2010, Walker et al., 1999). Exposure to cumulative childhood adversities also was
associated with an increasing symptom complexity in both child and adult clinical samples
(Cloitre et al., 2009).
Given the interrelatedness of sexual abuse with other types of childhood adversities (Clark et al.,
2010, Kessler et al., 2010, Turner et al., 2010), it seems plausible that heterogeneity in the degree
of exposure to other childhood adversities could contribute to the symptom heterogeneity
observed among sexual abuse survivors. However, to the best of our knowledge no previous
studies have addressed this question in a sexually abused sample specifically. On the other hand,
a few studies have examined the association between cumulative childhood adversities for
symptom complexity in samples where relatively high proportions had experienced sexual abuse.
Cloitre and colleagues demonstrated that symptom complexity (defined as the number of
complex posttraumatic stress disorder symptoms exceeding predefined clinical cut-off scores)
increased with increased exposure to different types of childhood traumatic experiences in their
clinical samples of 582 adults and 152 children with childhood maltreatment histories.
Approximately two thirds of both samples had experienced childhood sexual abuse, and
approximately half of the adult sample had experienced sexual abuse in adulthood (Cloitre et al.,
2009). Similarly, Briere and colleagues reported a linear relationship between the number of
trauma types experienced during childhood and symptom complexity later in life in their sample
of 2453 female university students, of whom 8.3% and 14.7% had experienced rape or other
types of sexual abuse during childhood, respectively (Briere, Kaltman, & Green, 2008).
Building on previous studies reporting a dose-response relation between cumulative childhood
adversities and more severe symptom outcomes later in life, the aim of the present study was to
examine whether a similar dose-response pattern could be identified in a sample comprising
adult survivors of sexual abuse. Specifically, we investigated the role of cumulative childhood
maltreatment (sexual abuse, physical/emotional abuse and neglect) for current symptoms of
posttraumatic stress (PTSS), anxiety, depression, sleep disturbances (insomnia and nightmare-
related distress), eating disorders, pain (physical and emotional), dissociation, relational
problems, self-harm behaviors, as well as with a measure of symptom complexity and a measure
of work functioning. Based on the existing literature documenting a dose-response relation
between cumulative childhood maltreatment and negative health outcomes, we hypothesized that
cumulative childhood maltreatment scores would be positively associated with the symptom
outcome measures and negatively associated with work functioning levels. In addition, we
explored whether cumulative childhood maltreatment showed associations with perceived social
support and hardiness, given the lack of previous studies examining this question. Based on
previous studies reporting lower perceived social support levels among adult survivors of
childhood sexual abuse, we hypothesized that such relation would also be found for a broader
array of childhood maltreatment, and thus that higher cumulative childhood maltreatment scores
would be associated with reporting less perceived social support. No specific hypotheses were
made for the hardiness outcome measure due to the lack of previous studies investigating
hardiness levels as a function of childhood maltreatment exposure. Finally, we explored whether
the relation between cumulative childhood maltreatment and the outcome measures persisted
after controlling for abuse characteristics that have been shown to contribute to differences in
symptom severity in previous studies.
A strong and secure attachment bond with a primary caregiver is the core of developing
resilience and a healthy personality.7,8 It strengthens a child’s ability to cope with stress,
regulates emotions, provides social support, and forms nurturing relationships.9 The world is
experienced as a safe place in which to explore and develop independence. The child finds
comfort and support from his or her caregiver when under stress. When children are
abused, they might display disturbed forms of attachment and abnormal patterns of
emotional response toward their caregivers. This might subsequently lead to a serious
attachment disorder with symptoms such as those shown in Box 1.5-8 The Early Years Study 2
summarized the research on the effects of violence and neglect on early brain devel-
opment.5 Poor caregiver-infant interactions compromise the formation of neural circuits
and pathways. A series of studies spanning 2 decades shows that neglect, abuse, or parenting
compromised by depression or sub-stance abuse influence the development of the child’s
brain and biologic pathways.10Research has shown that the quality of exchanges between
caregiver and infant serves as the foundation for the infant’s signaling system and
influences the child’s subsequent mental and physical health, especially the child’s
capacity to interact with others and the development of neural pathways for language and
higher cognitive functions.7 Children are more likely to have learning and behavior
problems when living with parents who struggle with mental health or substance abuse
problems. Maternal depression is a key determinant of poor early child development; it is
related to and as important as family functioning, parenting style, and engagement. Young
children are highly sensitive to other people’s emotions, particularly those of their family
members. Witnessing scenes of verbal or physical violence and discord has direct negative
effects with long-lasting con-sequences. Similarly, children who experience parental abuse
or neglect are more likely to show negative outcomes that carry forward into adult life,
with ongoing problems with emotional regulation, self-concept, social skills, and academic
motivation, as well as serious learning and adjustment problems, including academic
failure, severe depression, aggressive behavior, peer difficulties, substance abuse, and
delinquency.11-13Types of child abuse. The current literature dis-cusses many kinds of
child abuse, each with implications that have been shown to harm child development. An
abused child often suffers from more than one type of abuse; however, some types of
abuse are more frequently seen than others.1-5Physical abuse: Physical abuse is direct
harm to a child’s body. It might be a single act or repeated acts. The physical injuries might
be external (e.g., a laceration or burn) or internal (e.g., bruised organs). There are different
methods of inflicting physical abuse; for example, strongly shaking an infant, hitting a child,
cutting a child’s skin, or burning the skin with a hot implement. Additionally, in some
social cultures, certain abusive behavior is legitimated by religious beliefs; for example,
badly cauterizing a child or inserting sharp objects into a child’s body in order to heal
disease or to force out evil spirits. Emotional abuse: Emotional abuse is inflicted by ignoring
or dismissing a child’s emotional reaction or by shaming and humiliating a child. It might be
verbal, in the form of derogatory words or hurtful names, or put-ting a child down by
comparison with a sibling or friend. It could also be nonverbal, such as not acknowledging
a child’s needs, ignoring cries for help, or treating the child as unlovable or as a “bad
child.” Neglect: Neglect is the most common type of child abuse. Not providing a child
with adequate food, clothing, or shelter to survive and to grow has important effects on
the child’s future and puts a child at greater risk of disease, infection, retardation, or
even death. Neglect also includes not providing access to health and educational services.
Emotional neglect is also common and can have negative long-term effects on brain
development and future mental health. Sexual abuse: Sexual abuse is identified as engaging in
any sexual act with a child. It can be sexual penetration or acts that are sexually
suggestive, such as inappropriate touching or kissing. Some specific examples of sexual
abuse include inducing or coercing a child to engage in any sexual activity, the use of a
child as a prostitute, or use of children in pornography. Children are generally sexually
abused by people they know, often close relatives. Effect of child abuse on the stages of
behavioral development Infancy: Infancy is a critical period in a child’s development.
During infancy, the brain, which is approximately one-quarter of the size of the adult
brain, is one of the most undeveloped organs and it is highly susceptible to both the
positive and the negative effects of the external environment. For instance, shaken baby
syn-drome, a result of physical abuse,14 damages the brain structure, which can have
severe consequences for the health of an infant—namely mental retardation, hearing
problems, visual problems, learning disabilities, and cognitive dysfunction.11 Some studies
show that physically abused children have structural brain changes, including “smaller
intracranial and cerebral volume,” smaller lateral ventricles, and smaller corpora callosa.15
The consequences of abuse might not manifest clinically until later in life. For example, the
outcomes for infants who suffer brain damage from shaking can range from no apparent
effects to permanent disability, including developmental delay, seizures or paralysis,
blindness, and even death. Survivors might have substantially delayed effects of neurologic
injury resulting in a range of impairments seen over the course of their lives, including
cognitive deficits and behavioral problems. Recent Canadian data on children hospitalized for
shaken baby syndrome showed that 19% died; 59% had neurologic deficits, visual
impairment, or other health effects; and only 22% appeared well at the time of discharge.
Data also indicate that babies who appear well when discharged from hospital might show
evidence of cognitive or behavioral difficulties later on, possibly by school age.14High
cortisol and catecholamine levels, which increase as a response to stress that results from
abuse, have been linked to the destruction of brain cells and the disruption of normal
brain connections, consequently affecting children’s behavioral development. Sleep
disturbances, night terrors, and nightmares can be signs of infant abuse.5Toddler age: By the
second year, a child will usually react to stress with a display of angry and emotional
expression. Stress accompanying any kind of abuse causes children to feel distress and
frustration.16 The excessive anger is displayed in the form of aggressive behavior and
fighting with caregivers or peers. This form of response is intensified more with physical
abuse. Preschool age: At this stage, children have similar reactions to the different types
of abuse as younger children do. However, by ages 4 and 5, children might express
their reaction to abuse through different behavior. Boys tend to externalize their emotion
through expression of anger, aggression, and verbal bullying.17 Girls are more likely to
internalize their behavioral attitudes by being depressed and socially withdrawn, and
having somatic symptoms such as headache and abdominal pain.18Primary school age: At
this age, children develop through peer interaction. Abused children often have difficulties
with school, including poor academic performance, a lack of interest in school, poor
concentration during classes, and limited friendships.9 They are often absent from school.
Adolescence: Adolescents who have experienced abuse might suffer from depression,
anxiety, or social withdrawal. In addition, adolescents who live in violent situations tend
to run away to what they perceive to be safer environments.19,20 They engage in risky
behavior such as smoking, drinking alcohol, early sexual activity, using drugs,
prostitution, homelessness, gang involvement, and carrying guns.17,21,22 Psychiatric
disorders are often seen in adolescents who have been abused.18,23,24 In one long-term
study, 80% of young adults who had been abused met the diagnostic criteria for at least
1 psychiatric disorder by the age of 21.24Common behavioral indicators of abuse. Identifying
indicators of child abuse is usually challenging. Family members and family physicians
should be very watchful of children who have unusual psychosomatic com-plaints or
behavioral changes. In such cases, more in-depth assessment of the child and family
might be indicated.25 It should be noted that not all maladaptive behavior is an indication of
abuse, and the indicators listed in Box 2 are not indicative of abuse only. Physically abused
children might have unusual injuries to particular sites on their bodies that are not
usually subject to injury, such as wounds on the genitals, on the thighs, or around the eyes.
Physical abuse might even manifest as serious trauma without adequate justification, such as
fracture with minimal trauma. In clinical practice, physically abused children might stare at
their parents or caregivers and appear apprehensive, as if they are waiting for the next abusive
event to occur.23 In addition, the way clothing is worn can indicate physical abuse; for
example, a child wearing a long-sleeve dress or clothing that covers parts of the body
that are not normally covered—i.e., hands, legs, and neck—especially in hot weather.
Emotional effects of abuse often stem from insecure relationships with caregivers and affect
child attachment development (Box 3). Such effects might be destructive to their confidence and
self-esteem and to relationships with peers or partners later in life. Emotionally abused
children might also persist with age-inappropriate habits and repetitive behavior such as
rocking and thumb-sucking.18 When emotional abuse is chronic and persistent, it can
result in emotional harm to the child. Under the Child and Family Services Act, a child is
defined as emotionally harmed if he or she demonstrates severe anxiety, depression,
withdrawal, or self-destructive or aggressive behaviour.26The child’s condition and behavior in
general might indicate abuse. The history might reveal multiple emergency admissions and
multiple visits to different physicians. Also, undue delay in obtaining treatment of injury
should raise concern. In the case of neglect, a child might exhibit poor hygiene such as
an unwashed body or hair, or an unpleasant body odor. He or she might live in unhealthy
conditions, be left unsupervised, or be allowed to play in unsafe situations. Such children are
frequently late for or absent from school. Sexual abuse also has serious negative effects
throughout children’s lives, ranging from physical injuries to emotional destruction.17
Indicators of sexual abuse are outlined in Box 5. Sexually abused children might have
trouble walking or sitting because of disabling pain or injuries. Additionally, they might
be afraid to change their clothes in front of other people because they do not want
others seeing their bodies. They might also avoid sitting with peers or engaging in
physical exercises that could lead to being touched. Sometimes, they behave in a
seductive manner, which shows knowledge about sexual relationships. Teen pregnancy
and a history of sexually transmitted dis-eases might be signs of ongoing sexual abuse.

The sexual abuse of children is a problem that was once thought to be rare but has become
recognized as occurring frequently (Russell, 1984). Victims may demonstrate a variety of short-
and long-term effects of this abuse. Yet the empirical literature is sparse and is either marred by
methodological problems or reports contradictory results. Some of the specific methodical
problems involve the use of a variety of definitions of sexual abuse, sampling techniques that
rarely assess the child victim shortly after the abuse, and the lack of standardized outcome
measures. Researchers on the outcome of abuse diverge widely: Some predict little or no harm
and others predict harm only when the child victim grows older and begins to engage in intimate
heterosexual relationships. Others discuss possible short- and long-term effects in children which
include problems in sexual adjustment, interpersonal problems, education problems, and a
variety of other psychological symptoms (Mrazek & Mrazek, 1981). Largely clinical data
suggest that greater trauma to the child is incurred when the perpetrator is more closely related
(Burgess, Groh, Holmstrom, & Sgroi, 1978), the abuse has a longer duration (Burgess et al.,
1978), that force is used (Finkerlhor, 1979), the victim is older and can understand what
happened (Tsai, Feldman-Summers, & Edgar, 1979), and the abuse involves penetration
(Russell, 1984). Mrazek and Mrazek (1981) have suggested that six primary characteristics of
the sexual abuse may be related to subsequent behavioral sequelae. These include the extent of
sexual contact, the age and developmental maturity of the child, the degree of relatedness
between victim and perpetrator, the affective nature of the sexual relationship, the age difference
between the victim and the perpetrator, and the length of the sexual relationship. They
recommend that at least these characteristics be included in studies of behavioral symptoms
subsequent to abuse. The present study was designed to overcome some of the methodological
shortcomings extant in the literature. An initial step in this direction was the choice of a
standardized measurement device, in this case a child behavior checklist. Second, only children
were studied, and these were children who had a documented history of sexual abuse that had
been ongoing no more than 24 months earlier. Finally, by using only those cases where the
offender was at least 18 years old, we eliminated the age difference variable and were able to
focus on measuring those variables identified by Mrazek and Mrazek (1981). One of the only
published studies similar to this had only 28 children in the sample, ranging in age from 3 to 15.
Additionally, the time since abuse varied more widely, and a child behavior checklist without
sufficient items pertaining to sexual behaviors was used (Adams-Tucker, 1982). The
measurement device chosen, the Child Behavior Checklist (CBCL, Achenbach & Edelbrock,
1983), is a widely used, psychometrically sound instrument that is completed by the parent. It
provides measures of social competence in the child and broadband factors for Internalizing and
Externalizing Behavior. These two factors are the result of a factor-analytic studies of children's
behavior problems. Essentially, behavior problems fall generally into one or the other of these
two broad categories of internalizing and externalizing. The former includes behaviors described
as fearful, inhibited, depressed, and overcontrolled, whereas the latter includes aggressive,
antisocial, and under controlled behavior. The CBCL was also chosen specifically for this study
because it contains several items related directly to sexual behavior. Sexualization or increased
sexual behavior has been reported as an outcome of sexual abuse (Kreiger, Rosenfeld, Gordon,
& Bennett, 1980). The CBCL allows the enumeration of these particular sexual behaviors, for
example, masturbation, preoccupation with sex, etc. The study was designed to answer several
questions. Initially, we wanted to determine, using norms for the CBCL, what percentage of the
children in our sample could be described as having a significant elevation on the internalizing or
externalizing scales. Second, we wanted to determine whether any of the abuse characteristics
were related in a significant fashion to internalizing, externalizing, or sexualized behavior. This
was examined using multiple regression analyses.

National statistics demonstrate a dramatic increase in reports from 700,000 cases or 10 per 1,000
children in 1976, to the late 1990s when over 3 million children were reported or 47 per 1,000
children (Faller, 1999). Rates of reports continue to increase each year. In 2014, the most recent
year for which data are available, there were 3.6 million reports representing 6.6 million children
or 48.8 per 1,000 children, referred for all types of child maltreatment (Children’s Bureau, 2016).
As reporting rates have increased, substantiation rates have decreased. In the 1970s and 1980s,
the substantiation rates were 40–50% (Faller, 1999). In the late 1980s, in order to manage the
daunting number of reports, states developed screening criteria (Wells, Fluke, & Brown, 1995).
In 2014, of the 3.6 million reports, 39.3% were screened out, that is, not investigated. Of the
screened-in reports, approximately one-fifth were substantiated, or 702,000 children. Thus, of all
children who were reported to child protective services, a little more than 10% were deemed to
be victims of child maltreatment. Victims are approximately equally likely to be male or female.
In terms of race, the largest number are White (44%), but African American (21.4%), Hispanic
(22.7%), and Native American (1%) children are overrepresented. Child Maltreatment does not
provide separate racial and gender statistics by type of maltreatment (Children’s Bureau, 2016).
(Faller, 2017)

Methodology
Aim and Objectives

1- To investigate the relationship between parenting acceptance- rejection and behavioral

problems in children with sexual and physical abuse.
2- To investigate the relationship between parenting acceptance- rejection and nightmare in
children with sexual and physical abuse.
3- To find out whether parenting acceptance tend to decrease behavioral problems in
children with sexual and physical abuse.
4- To find out whether parenting rejection tend to increase behavioral problems in children
with sexual and physical abuse.
5- To find out whether parenting acceptance tend to decrease nightmare distress in children
with sexual and physical abuse.
6- To find out whether the parental rejection tend to increase nightmare distress in children
with sexual and physical abuse.
7- To examine gender differences among children with sexual and physical abuse.

Hypothesis:
1- Parental acceptance would negatively predict behavioral problems in adolescent with
sexual and physical abuse.
 2- Parental rejection would positively predict behavioral problems in adolescents with
sexual and physical abuse.
3- Parental acceptance would positively predict nightmare in children with sexual and
physical abuse.
4- Parental rejection would negatively predict nightmare in children with sexual and
physical abuse.
5- There would be difference in children with sexual and physical abuse on the variables of
behavioral problems and nightmare.

Sample:

The sample size was comprised of 200 abused adolescents with 100 sexual and 100 physical
abuse. The data was collected from different NGOs and hospitals. The institute located in Punjab
Pakistan. The participant age ranged from 12-18 years.

Inclusion

The participants who can understand the statements and ther can read the statements. Participants
in Punjab province was included.

Exclusion:

Participants with severe comorbid psychological disorders were excluded. Participants other than
Punjab province was also excluded.

Description of measures:

Following standardized instruments were used to access parental acceptance- rejection,

behavioral problems and nightmare distress in adolescent with sexual and physical abuse.

Demographic information form:

Demographic was used to collect the personal information of the participant such as age, gender,
education, siblings, birth order, mother education, mother age, mother occupation, father
education, father age, father occupation. Marital status of parents, time of abuse, type of abuse,
severity of abuse.
Scales:

Parental acceptance -rejection Questionnaire (PARQ)

THE PARENTAL Acceptance-Rejection Questionnaire was developed byRohner(1984). It is

self-report tool which is designed to measure individual perceptions of parental acceptance-
rejection. The scale consisted of two forms for mother and father. It consists of 5 sub scales that
include coldness/lack of affection, hostility/aggression, indifference neglect, undifferentiated,
rejection. It consists of 60 items each of PARQ for the mother and father. PARQ is a 4-point
Likert scale with response category of “ almost always true (4) to never true (1). Items
1,7,21,28,35,42 and 49 are reversed scores. Total score ranges from 60- 240. The higher the
score , more the child perceives his/her parent rejection.

Strength and difficulties questionnaire(SDQ)

The strength and difficulties questionnaire(Goodman) are a behavioral screening tool for 3-17
years old children. It exists innumerous variations to meet the needs of researches, clinicians and
educationalists. All versions of SDQ have 25 attributes, some positive and other are negative.
These 25 items are divided into 5 scales. Emotional symptoms (5 items), conduct problems(5
items), hyperactivity/inattention (5items), peer relationship problems(5 items), prosocial
behavior (5 items). It is a 3-point scale “are not true” , “somewhat true” , and “certainly true”.
Each item is scored as 1,2 or 3 depending on which column is ticked. “ Somewhat true” is
always scored as 1 but the scoring of “not true” and “certainly true” varies with the item. For
each of the category emotional, conduct, hyperactive, peer and prosocial the maximum score is
10.

Trauma-Related Nightmare Survey(TRNS)