Making Their World Safe Again
by Maryann Brinley

Speak to anyone who deals with child sexual abuse — researchers, pediatricians, clinicians, therapists, law enforcement personnel, child advocates — and this is the refrain voiced in reference to so many aspects of this scourge.

Martin A. Finkel, DO, and Esther Deblinger, PhD, have heard it all.

* You can hardly believe that one in three girls and one in seven boys will be sexually abused by age 18. “Of all childhood traumas, sexual abuse may be the most difficult for children to talk about, ” says Deblinger, co-director of the New Jersey Child Abuse Research Education Service (NJ CARES) Institute, formerly known as the Center for Children’s Support at UMDNJ-School of Osteopathic Medicine (SOM).

* It’s hard to believe that these children who were forced to engage in adult-like sexual acts could be so young. “Forty percent of the kids we see for medical exams are under age 6,” explains Finkel, co-director of NJ CARES.

* And, who can believe that the perpetrators aren’t strangers but close relatives, friends, and even fathers? “For these children, it’s difficult and emotionally unsettling to imagine that people they are routinely entrusted to could betray them. As a result, children generalize their feelings, imagine the whole world as unsafe, and wonder who they can trust,” Finkel says.

So much about child sexual victimization brings on a collective gasp of disbelief: How could this be true?

It is true. Child sexual abuse, or CSA, has been “a persistent and widespread problem for thousands of years,” according to Deblinger. Yet, “attempts to raise public awareness have been met with disbelief and public disdain.” Even the young victims sometimes know that silence is more acceptable than the truth. Deblinger once treated a 6-year-old who had been seeing an outside therapist for a year. The little boy was eventually referred to Deblinger because he still
wasn’t doing well behaviorally.

“At our second session, I asked him to tell me about how much he had talked to his previous therapist about the sexual abuse,” she says.

“Oh no, we didn’t talk about that,” the child responded.

Surprised by his answer, Deblinger continued, “Well, why didn’t you talk about it?”

He explained, “Because she (the therapist) wasn’t ready.”

“That happens a lot,” Deblinger says.

Adults, even parents and professionals, sometimes believe that by not discussing it, they are protecting the child from further harm. “It’s just not intuitively obvious how to talk to kids about these kinds of activities,” Finkel says. Deblinger explains, “Your instinct is to protect the child and that usually means not talking about it, not thinking about it, not asking about it. But it turns out that to recover, children need support and encouragement to talk about it, think about it and express in their words what they are feeling.”

What Finkel and Deblinger have learned is that the most valuable evidence is the spoken word. Unfortunately, Finkel says, “Sometimes individuals interviewing these children will begin to listen and it is such a hard thing to comprehend, that the adult will stop prematurely.” In effect, “What they are saying to the child is ‘I’ve heard enough.’ But hearing enough is not enough. We have to hear it all.” By focusing on the trauma and not silencing the child, Deblinger’s therapy allows the child to regain control and self esteem.

“We’ve been a mom and pop operation, like two rats on a treadmill,” Finkel laughs, describing two decades of working with Deblinger to shed light on CSA and to develop treatments with long-term therapeutic value. “Someone once said that in the world of the blind, the one-eyed man is king. In the beginning, I was that one-eyed man.” Even pediatric colleagues warned him to back down. “I say, tongue in cheek of course, that one of medicine’s biggest contributions to child sexual abuse was the discovery in the early 80s that children have genitalia, located beneath the belly button.”

In fact, Finkel’s own awareness of sexual abuse started rather serendipitously back in the spring of 1982.

“I arrived at the University in 1979,” he says. More of a clinician than an academic, he recalls the gentle pressure by the SOM dean. “Do you remember that TV series, The Many Loves of Dobie Gillis? Well, I was being told that in order to advance in the University, faculty had to do research, had to publish, and had to write grants. Like Dobie, I wanted to say, ‘Who, me?’ Send me thousands of patients but don’t ask me to do those things. I can’t write. I can’t do research. I’ve never written a grant.”

When offered an opportunity to attend a conference on child sexual abuse in Washington, DC, in early 1982, Finkel accepted this academic invitation because it was also cherry blossom time. However, after attending Dr. Suzanne Sgroi’s informed, articulate and passionate presentation on child sexual abuse, Finkel was hooked. He had grown up in Ephrata, Pennsylvania, the son of a country doctor and one of four happy siblings. Neither his sheltered background nor his medical training had offered any information about CSA. “I never imagined that people had any interest in engaging children in sexual activity. I had never even seen a reference to it in the medical literature and yet I was a practicing pediatrician with a special interest in child physical abuse. I couldn’t believe what I was hearing.” He also realized that if he was going to make a difference in medicine, it had to be in a field that was relatively unexplored. A college entomology professor had once told him, “If you want to be a world expert in entomology, pick a mosquito in the most remote part of South America and study that mosquito to death.” On that day in Washington, DC, Finkel thought to himself, “This is my mosquito.”

Back in New Jersey, he set out to become an expert. Working with law enforcement agencies and the New Jersey Division of Youth and Family Services (DYFS), he slowly built his experience with patients. Finkel learned to ask the right questions and use a tape recorder so children could speak freely. He was in a league of his own. “I’ll never forget the day when I asked a Camden County prosecutor, ‘How has
medicine assisted you in dealing with these cases of child sexual abuse?’ The head of DYFS was there at the time and they both looked at me as if I were from outer space.” No one from the medical field had ever come forward to help them. Recognizing that CSA was like a puzzle with many pieces, Finkel was determined to use a multidisciplinary approach to intervene, protect and treat kids.

Within the first two years, he had seen more cases than had ever been described in medical literature. “It’s hard,” he admits. Developing emotional distance was especially critical. His secretary would be seen weeping as she typed up his patients’ reports. “You do not want to give children the message that this is worse than they already imagine. No gasping. No running out of the room. Would you want a doctor treating you for a laceration in an emergency room to fall down fainting?” The details Finkel nudges out of his little patients speak volumes. Asking them about their bodies, he’ll listen to little girls worry about icky stuff still inside, getting breast
cancer or becoming pregnant. Little boys suspect that everyone can tell they’ve been mistreated by the way they walk. “When I see kids, I tell them that today is about making sure your body is okay. After today, it’s important for you to see a talking doctor.”

Finkel recruited Deblinger 17 years ago, when it was unusual for medicine and mental healthcare to work together. Deblinger, who holds a doctorate in clinical psychology, says, “I had very little experience.” At first she relied on scientific literature and “discovered that although there was a lot of research on the devastating effects of child sexual abuse, there was absolutely no research on what therapies helped. That was frightening to me.”

Deblinger, the mother of two daughters, ages 12 and 9, is now surrounded by talented experts who are dedicated to helping children overcome the trauma of sexual abuse. While other therapists might follow the client’s lead using a
nondirective approach, her tactic encourages therapists to tackle the trauma head on and in a timely, 12-week fashion that involves the non-offending parent when possible. “What we learned from one study was for the treatment to be effective, it was critical to have a parent involved, particularly if the child was depressed or having behavioral problems.” On the way to recovery, children between ages 2 and 8 can be found singing, reading stories, drawing, or writing poetry. As one child wrote: “Abuse is like a boomerang... If you don’t deal with it... It will come back... To hurt you.”

In collaboration with researchers at Allegheny Hospital in Pittsburgh, Deblinger has
conducted extensive, multi-site testing of her therapeutic module, known formally as Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), and proved that it is superior to other approaches. More than 1,000 children are treated at NJ CARES annually. “We really help them not to feel ashamed and to understand that this is a crime against them, not something they did.” Eighty percent overcome the most significant symptoms, a huge victory considering the fact that children who have experienced sexual abuse can suffer from a wide range of emotional, behavioral and social difficulties including anger, hostility, guilt, shame, depression, post-traumatic stress, sleep disturbances, fears, general behavior problems and age-inappropriate sexual behaviors.

The author of numerous scientific articles, Deblinger has published four books including one for children, Let’s Talk About Taking Care of You: An Educational Book Abut Body Safety. “I found myself getting anxious about discussing this with my own children and here I am, someone who talks about it every single day. That’s why I co-authored that book. Through our school and public education efforts, we hope to break the silence and enhance efforts to talk about these issues with our
children.”

Over the years, financial support for NJ CARES’ evidence-based research has come from sources like the Foundation of UMDNJ, the National Institute of Mental Health, and the National Child Traumatic Stress Network. In fact, TF-CBT is now the standard of care for all children and teenagers who have experienced abuse and trauma.

“I was sitting here in my office in 2001,” Deblinger recalls, “and I got this surprising phone call from the U.S. Department of Health and Human Services saying we had been recognized as a model program. I could have spent the rest of my career just doing research and hoping that others would read my books and articles. Now our evidence based treatment program will reach so many more therapists.” With this federal support, NJ CARES, renamed to reflect its larger, statewide presence, will be instrumental in preparing therapists across the country to be the kind of listeners incapable of saying: “You can’t believe what you are hearing.”