Epidemiology of Sexual Victimization in Early Childhood

Statistically contextualizing the problem and providing figures regarding its extent is especially relevant in childhood sexual victimization (^{Pereda, 2016}). However, the epidemiology of sexual abuse in preschoolers has scarcely been studied.

The pioneering work carried out in Canada by ^{Mian et al. (1986)} presents a review of the hospital records of 125 child victims of sexual violence aged 6 years or younger. The authors show that 1.6% were victims under one year of age, 4.8% were one year old, 14.4% were two years old, 24.8% were three years old, 21.6% were four years old, 20.8% were five years old, and 12% were six years old. Also in Canada, ^{Dubé and Hébert (1988)} evaluated the hospital records of 511 cases of sexual abuse in children under 12 years of age and found that 29.4% involved victims under 5 years of age. In Israel, ^{Hershkowitz et al. (2005)} found, with a sample of 26,408 interviews with victims of sexual and physical abuse aged 3 to 14 years, that 20.1% of the cases involved children between 3 and 6 years of age. In Turkey, ^{Yüksel and Koçtürk (2020)}, through the analysis of 3,429 files of children treated in a center for victims of sexual abuse, indicate that 5.98% were under 7 years of age.

^{Finkelhor et al. (2008)}, using data from the NISMART-2 incidence study in the United States, based on surveys of parents, children, and adolescents, identified a total of 285,400 victims of sexual violence between the ages of 0 and 17 years. Of these, 4% were children aged 0 to 5 years, an age rage that represents an estimated 33% of the child population in the country. The same team (^{Finkelhor et al., 2009}), using telephone surveys of 4,549 children aged 0-17 years, or their parents if they were under 10 years old, found that sexual victimization increased with age, but that there was a small percentage of 1% of child victims aged 2-5 years.

These figures, obtained from case file studies and parent surveys, are lower than those obtained when victims are asked at what age the sexual abuse began. In the study by ^{Gewirtz-Meydan and Finkelhor (2020)} in the United States, with 506 victims of sexual abuse aged 2 to 17 years, 17.2% report that the abuse began between the ages of 0 and 5 years, 28.2% of boys and 13.4% of girls. This percentage is similar to that found in Spain, based on calls to the ANAR Foundation telephone number, which showed that 16% of victims are 5 years old or younger (^{ANAR Foundation, 2020}).

Characteristics of Sexual Victimization in Early Childhood

There are many misconceptions about sexual abuse of preschool children that tend to downplay its importance. However, studies show that the sexual behaviors carried out with preschoolers are often very severe.

^{Cupoli and Sewell (1988)} analyzed the hospital records of 1,059 victims of sexual abuse under 17 years of age in the United States and found that 20.1% of the girls under six years of age had suffered vaginal, oral, or anal penetration, while 27.8% of boys under six years of age had suffered oral or anal penetration. Another study that analyzed the type of abuse suffered by preschool children is that carried out by ^{Mian and collaborators (1996)}. The authors, with a sample of 70 girls aged 3 to 5 years in Canada, found a prevalence of 46% of digital penetration of the vagina or anus, 19% of vaginal intercourse and 7% of anal intercourse. For their part, ^{Fontanella et al. (2000)} analyzed the clinical records of 74 victims of sexual abuse aged 2 to 5 years and found that 64% of the girls and 28% of the boys had suffered penetrative sexual abuse. These percentages are lower in the study by ^{Yüksel and Koçtürk (2020)}, who found 13.7% of penetrative abuse in their sample of preschoolers, 23.3% of boys and 8.3% of girls.

The reaction of parents or primary caregivers with preschool victims has also been little studied and seems to follow exactly the same pattern as with older victims. Thus, studies show the state of shock, uncertainty, and emotional roller coaster in which parents of preschool victims of sexual abuse by outsiders find themselves (^{van Duin et al., 2022}). However, when comparing mothers of intrafamilial and extrafamilial preschool victims, it is observed that mothers in the group of intrafamilial sexual abuse victims significantly blame the child more, are more concerned about the impact of the abuse on their own lives, protect the abuser, are more concerned about other family members, and tend to deny that the abuse occurred or minimize the event (^{Mian et al., 1996}).

Indicators and Consequences of Sexual Victimization in Early Childhood

The impact of trauma at preschool ages is associated with the development of significant long-term negative consequences and it is on this topic that most studies have been published (^{De Young et al., 2011}).

One of the first studies focusing on general symptomatology in preschool victims of child sexual abuse is that of ^{Mian and colleagues (1986)}. The records of the children analyzed indicated physical symptoms (vaginal secretions, bleeding, sexually transmitted diseases, bruises in the genital area, and abdominal pain), behavioral/emotional symptoms (nightmares, disruptive behavior, dependence, fears), and 18% presented sexualized behavior (sexual play with dolls, introduction of objects into the vagina and/or anus, masturbation, seductive behavior, asking for sexual stimulation, and age-inappropriate sexual knowledge). At the time of disclosure, the majority of children presented emotional/behavioral symptoms (30%), followed by physical (24%). Notably, 26% of the children did not present any maladjustment symptoms. In a later study, ^{Mian et al. (1996)} conclude that the main effects linked to sexual abuse in preschoolers are affective and anxiety symptoms and inappropriate sexual behavior. Similarly, ^{Fontanella et al. (2000)} found indicators of sexualized behavior, aggressive behavior, sleep problems, sphincter control problems, sadness, and regressive behaviors in their sample of preschool victims' records.

In the study by ^{Hébert et al. (2013)} with a sample of 59 children aged 4 to 6 years who were victims of sexual abuse and 66 non-victim preschoolers in Canada, the authors, after asking the children's parents, show that 42.9% of sexual abuse victims and only 1.5% of non-victims present clinical levels of internalizing symptoms, i.e., depression, anxiety, post-traumatic symptoms. At the same time, 30.4% of sexual abuse victims and 1.5% of non-victims present clinical levels of externalizing symptoms, i.e., aggressive and disruptive behavior. Sexual abuse in preschoolers, therefore, is accompanied by both internalizing and externalizing symptoms of distress according to the parents of the victims. When directly asking the children themselves, by means of a pictorial instrument adapted for this purpose, the most significant items scored by the victims belonged to the areas of somatization and depression. In this sense, it has been shown that preschool children can adequately report their internalizing symptoms and that they do so even better than their parents or caregivers (^{Luby et al., 2007}).

However, it cannot be overlooked that a difficulty in the assessment of victims at this age is that dissociation-which allows the child to continue with his or her life despite the traumatic experience-is very frequent and may result in the victim's maladjustment going undetected and the symptoms of distress remaining latent (^{Macfie et al., 2001}). Dissociation allows the child to forget or remove from conscious thought those experiences with too high an emotional charge for him or her to integrate them into his or her memories, perceptions, and personal identity at the time (^{Spiegel et al., 2011}), but at the same time it makes detection extremely difficult. The earlier the experience of abuse, the more likely it is that the victim will eventually develop dissociative symptoms (see review by ^{Vonderlin et al., 2018}). The main problem is that these symptoms, which may be considered adaptive at first, end up mediating the relationship between sexual abuse and the psychological problems that the victim may present (^{Ensink et al., 2017}), which are especially serious if they persist over time, given that they are an important component, among others, of the cycle of violence (^{Narang & Contreras, 2000}).

But one of the most serious consequences of sexual abuse at this age is related to the bond established with primary caregivers. Attachment theory is very useful for understanding family dynamics, relational antecedents, and the consequences of child sexual abuse (^{Alexander, 1992)}. Empirical studies such as that of ^{Beaudoin et al. (2013)} in Canada, with a sample of 116 children aged 3-6 years and their parents, show that a disorganized attachment makes a unique contribution to the internalizing and externalizing symptoms of preschool sexual abuse victims, beyond the characteristics of the abuse itself and the psychological distress of the parents or primary caregivers. Thus, and although it is a topic that continues to be studied, the development of an insecure attachment seems to be associated with worse emotional self-regulation (^{Pallini et al., 2018}) which, in turn, has been shown to act as a mediating variable between the experience of sexual abuse and the presence of internalizing and, to a lesser extent, externalizing symptoms, in 127 preschoolers aged 3 to 6 years also in Canada (^{Langevin et al., 2015}). Other similar studies in the same country, such as that of ^{Hébert et al. (2020)}, with a sample of 274 victims of sexual abuse aged 3 to 6 years and their parents, find that disorganized attachment and emotional self-regulation are variables that mediate between the experience of sexual abuse and dissociation, thus alerting of the importance of early intervention in the relationship between the child and his or her caregiver figure to prevent later problems.

In addition to dissociation and bonding problems, we must add sleep problems due to their high frequency. The authors who have analyzed this aspect warn of the serious effects they can have on the appropriate development of the child in these early stages. Significant differences have been observed in the frequency of sleep problems between 224 preschoolers who were victims of sexual abuse and 83 non-victims, such as not wanting to sleep alone, difficulties in falling asleep, nightmares and night terrors, interrupted sleep or sleeping less than other children. These problems do not seem to disappear with the passage of time and are maintained one year after the disclosure of the abuse according to the study (^{Langevin et al., 2017}). In turn, these sleep problems have been associated with dissociative symptoms in a sample of 179 child victims of sexual abuse aged 3 to 6 years and should also be treated because of their influence on other consequences of victimization (^{Hébert et al., 2017}).

The experience of abuse at early ages may compromise essential developmental milestones and be associated with developmental delays. ^{Fontanella et al. (2000)} report that in 32% of their sample of 74 preschool victims, 52% of the boys and 19% of the girls had developmental delays. The review carried out by ^{Cooper (2000)} shows that abuse and maltreatment in childhood affect the child's ability to play, presenting significant delays in his or her abilities that place him or her at greater risk of future learning and social problems.

Childhood-especially the early years-is a critical period in the development of the individual in which the experience of continued stress, as would be the case of a victim of child sexual abuse, can lead to permanent or long-lasting neurobiological changes. Neurobiological maladjustments are observed in these victims, with dysregulation of the hypothalamic-pituitary-adrenal axis or stress coping system (see review by ^{Blanco et al., 2015}), which can end up generating neuroanatomical effects, affecting brain structures such as the hippocampus, which has been found to be a highly sensitive region when sexual abuse occurs at preschool ages (^{Andersen et al., 2008}). In turn, the presence of irregularities in the hippocampus, such as a smaller size found in victims of childhood sexual abuse, has been associated with the diagnosis of psychiatric disorders such as major depression, anxiety, and post-traumatic stress disorder in adults (^{Teicher et al., 2018}). Review studies such as ^{Shrivastava et al. (2017)} provide a broad view of the influence of sexual abuse on the development of psychiatric disorders, taking into account the neurobiological effects of victimization.

It is also important to include studies that have analyzed sexualized behavior or the development of inappropriate sexual behavior in victims of sexual abuse (^{Friedrich, 1993}). Thus, despite the difficulty involved, some authors (^{Friedrich et al., 1998}) have attempted to establish which are the normative sexual behaviors in preschoolers. It should be noted that different studies have found variations in what is considered normative sexual behavior depending on the culture to which the preschool child belongs, so this is a variable that should be taken into account when assessing it (^{Kenny & Wurtele, 2013}).

However, few studies have attempted to establish the sexual behaviors in preschoolers that could constitute what is known as sexualized behavior and that would include behaviors such as age-inappropriate sexual vocabulary, compulsive masturbation without pleasure or hurting oneself, seductive behaviors, or eroticized behaviors with adults, use of objects against one's own genitals/anus or against the genitals/anus of other children, and sexual aggression towards other children, adults, or animals (^{Friedrich et al., 2001}).

It should be noted that current research suggests that the development of sexualized behavior is related to a variety of individual, family, and societal factors and should not be considered a causal effect of the experience of sexual abuse (^{Mesman et al., 2019}). Thus, with a sample of 217 children aged 2-6 years seen for problematic sexual behaviors, Tyler et al. (2019) found that only one-third of the sample had been victims of sexual abuse, although in many there is evidence of other traumatic experiences and interpersonal violence. The importance of other maltreatment experiences in sexualized behavior has also been reported in other studies with victims younger than 8 years (^{Merrick et al., 2008}). In turn, the place where sexualized behavior is assessed should be taken into account, given that ^{Larsson and Svedin's (2002)} study in Sweden, with a sample of 185 preschoolers aged 3 to 6 years, found that preschoolers exhibit significantly more sexualized behavior at home than at school, as assessed by parents and educators. Thus, understanding variation in normative sexual behavior involves including the importance of the family context (^{Thigpen & Dennis Fortenberry, 2009}).

Since, as research has shown, it is not only experiences of sexual abuse that can generate sexualized behavior (^{Kellogg and Committee on Child Abuse and Neglect, 2009}), it is necessary to evaluate the daily routines of the child and his or her family and to make a good assessment of the child's age and the sexual behaviors he or she engages in. The instruments most commonly used to make these assessments are the Child Sexual Behavior Inventory (^{Friedrich et al, 2001}) and the Weekly Behavior Report (^{Cohen & Mannarino, 1996}). However, neither of them has been validated in Spain and they are not exempt from criticism regarding their reliability (^{Vrolijk-Bosschaart et al., 2018}). Another perspective to take into account is that which defends that age-inappropriate sexual knowledge should be assessed, more than behavioral expressions that may not always occur and are not always linked to the experience of sexual abuse (^{Brilleslijper-Kater et al., 2004}).

The reality is that preschool children do not always report their experiences of sexual abuse, as illustrated, for example, by the study of ^{Hershkowitz et al. (2005)}, in which less than half of their sample of 3-6 year old victims (47.5%) made an allegation to this effect. Thus, access to sound knowledge and tools to enable the clinician to detect possible indicators of sexual abuse is an absolute necessity in this age group.

Intervention with Preschool Victims of Sexual Abuse

Early childhood is such an important time in development that the response of the victim's environment and the support he or she receives can change the trajectory of risk resulting from the victimization experience into a trajectory of protection (^{Rutter, 1990}).

One of the few studies that has focused on resilience in preschoolers is that of ^{Hébert and collaborators (2014)} who found that 41.9% of their sample presented low levels of maladjustment symptoms linked to high self-control of their behavior, capacity for initiative and independence, and the establishment of bonds with other children and adults. The non-abusing parents of these resilient children had sought support resources to cope with the distress caused by the sexual abuse, showing the importance of this figure in the victim's recovery.

And although there are multiple perspectives of intervention with child victims, it is important to highlight the importance of working based on models that have specific empirical evidence with preschoolers, such as trauma-focused cognitive behavioral therapy (TF-CBT) (see a complete summary of this therapeutic model in ^{Kanter & Pereda, 2020}).

The effectiveness of this model with child victims has been confirmed in recent systematic reviews (^{Serra-Sutton et al., 2021}). As an example of evidence with preschoolers, the seminal study by ^{Cohen and Mannarino (1996)} with 67 victims of sexual abuse aged 3 to 6 years, shows that, when compared with a non-directive therapy group, TF-CBT results in significant improvements in internalizing and externalizing symptoms, sexualized behavior, posttraumatic symptoms, anxiety, and nightmares reported by the victims' parents. Other studies, such as that of Scheeringa and colleagues (2011), have obtained very similar results when comparing the group of preschoolers treated with TF-CBT with a waiting list group. For their part, ^{Hébert and Daignault (2015)} found a significant improvement in distress symptoms in a sample of 10 boys and 15 girls aged 3 to 6 years who were victims of sexual abuse in Canada, and their non-offending parents, when comparing before the application of TF-CBT, immediately after, and six months later.