Journal of Counseling & Development ■ Fall 2008 ■ Volume 8.docx

Journal of Counseling & Development ■ Fall 2008 ■
Volume 86 429
© 2008 by the American Counseling Association. All rights
reserved.
One of the most important goals of U.S. higher education
is to
encourage the enrollment of international students for
academic,
economic, and cultural purposes. The successful recruitment
of
these students comes with the responsibility to welcome,
serve,
and maintain the well-being of international students, and
also
to create an environment for multicultural interaction with
stu-
dents in the United States (hereinafter referred to as
American
students; Peterson, Briggs, Dreasher, Horner, & Nelson,
1999).
Marion (1986) suggested that international students may
act
as great resources for increasing global understanding and
the
perspectives of American students. Peterson et al. found
that
American students learned about different cultures, their
histo-
ries, and international issues from foreign students. In
addition,
they learned to acknowledge and respect cultural and

individual
differences and broaden their perspectives, thereby
preventing
stereotypical thinking. Marion also suggested that
international
students play an important role in providing technological
knowl-
edge to less developed countries. In the United States,
enrollment
of international students has been encouraged for the
economic
contribution of nearly $13.5 billion every year that they
spend
on tuition, living expenses, and related costs (Institute of
Inter-
national Education, 2007).
The United States has the largest number of international
students who represent many countries. During the academic
year of 2005–2006, there were approximately 600,000 inter-
national students from several nations, with Asian
students
representing 58% of all international students, followed
by
students from Europe (15%), Latin America (11%),
Africa
(6%), the Middle East (4%), and 6% from North America
and
Oceania (Institute of International Education, 2007).
Adjustment to a new educational and social environment
can
be a stressful process. Most college students experience
stress
throughout this process. However, many international
students ex-

perience even more serious stress because of the additional
culture
shock factor (Church, 1982) and various sociocultural
factors that
are involved in the adjustment process of international
students
(Luzio-Lockett, 1998). It is not surprising that international
stu-
dents often face language barriers, immigration difficulties,
culture
shock, social adjustment, and homesickness. During this
period
of adjustment, international students may experience
isolation and
loneliness. Mori (2000) reported that these negative
experiences
can cause the students to feel hopeless, and an intensive
sense of
hopelessness may be the manifestation of depression.
Consider-
ing the cultural differences and misunderstandings of
the new
and diverse experiences, it is likely that international
students will
experience feelings of estrangement, anxiety, and depression
as a
part of their adjustment process (Adler, 1975). Spielberger
(1966)
reported that anxiety is related to stress, and
Furukawa (1997)
reported that people who are exposed to foreign
cultures may
become depressed or anxious and display maladaptive
behaviors
as a result of this acculturative stress.

Understanding the experiences of international students has
important implications for creating and implementing
programs
that provide academic and personal support. Therefore, it is
cru-
cial to increase awareness about international students’
problems
and to recognize the students’ individual perspectives
regarding
the factors that are involved in the adjustment and
adaptation
process (Luzio-Lockett, 1998). Because of these
concerns, a
number of studies have focused on the academic,
psychological
and social effects on international students of studying and
liv-
ing in the United States (Marion, 1986). In one of these
studies,
Kilinc and Granello (2003) found that students who were
less
acculturated experienced significantly more difficulty in
their
academic life, with language, and with medical/physical
health
than did the students with higher levels of acculturation.
A close examination of the literature reveals that although
depression and anxiety are frequently manifested symptoms
of
stress (Arthur, 1998), these symptoms were not studied
among
the international student population in the United States.
Con-
sidering the fact that there is limited research on

depression and
anxiety among international students in the United States,
the
purpose of our study is to contribute further to the
literature
by examining these variables in relation to a set of other
vari-
ables retrieved from the literature: gender, age,
race/ethnicity,
proficiency in English, pattern of social contact,
academic
achievement, social support, and length of stay in the
country.
Predictors of Depression and Anxiety
Among International Students
Seda Sümer, Senel Poyrazli, and Kamini Grahame
The role of gender, age, race/ethnicity, length of stay, social
support, and proficiency in English in the variance in depres-
sion and anxiety among international students revealed that
social support was a significant predictor of depression
and anxiety among international students. Age significantly
contributed to the variance in anxiety, and self-rated English
proficiency uniquely contributed to the variance in both
depression and anxiety. Latino/a students had significantly
higher levels of depression than did Asian students.
Seda Sümer, Department of Counseling and Psychological
Services, Georgia State University; Senel Poyrazli and Kamini
Grahame, School of Behavioral Sciences and Education, Penn
State Capital College. Correspondence concerning this article
should
be addressed to Senel Poyrazli, School of Behavioral Sciences
and Education, Penn State Capital College, 777 West Harrisburg
Pike, W157 Olmstead Building, Middletown, PA 17057 (e-mail:

[email protected]).
Volume 86430
Sümer, Poyrazli, & Grahame
This study also attempted to integrate some of these
variables
in the accurate prediction of depression and anxiety levels
of
international students. In the following sections, a
literature
review that is focused on certain variables (i.e., gender,
age,
race/ethnicity, social support, English proficiency, and
length
of stay) in relation to depression and anxiety and
international
students’ adjustment experiences is presented.
Gender
Literature about gender supported a relation between social
support and American female college students’ anxiety and
depressive symptoms. Swift and Wright (2000) found
that
social support was negatively correlated with female
students’
anxiety and depression levels. Hawkins (1995), on the other
hand, found that female students with higher levels of
social
support experienced lower levels of anxiety and depressive
symptoms, whereas male students’ anxiety levels did not
cor-

relate with social support.
Other studies that examined international students showed
that female students had higher emotional, physiological,
and behavioral reactions to stressors (Misra, Crist, &
Burant,
2003) and also were more likely to feel homesick and
lonely
than were male students (Rajapaksa & Dundes, 2002).
In
contrast, Poyrazli, Arbona, Nora, McPherson, and
Pisecco
(2002) reported that male international students scored
higher
on the UCLA Loneliness Scale than did female international
students. In the same study, there were no differences
among
men and women regarding general adjustment. A reason for
the discrepant findings of these two studies might be that
the
former study used a snowballing technique, whereas the
latter
used a random sample approach. In addition, these
studies
used different scales to measure loneliness.
Furthermore, the gender differences reported in previous
research could be a result of international students’ cultural
background and the socialization process both genders
go
through. Therefore, it is important to study
international
students from different ethnicities to see if gender is
related
to their experiences of anxiety and depression.

Age
Oei and Notowidjojo (1990) studied the impact of life
change
on adjustment of international students and found that
age
was a significant predictor of depressive symptoms. In par-
ticular, older international students in Australia scored
higher
on depressive symptoms than younger students.
However,
Furukawa’s (1997) study with Japanese teenage exchange
stu-
dents, who were enrolled in 1-year placements with
volunteer
host families in various countries, showed that age was not
a predictor of depressive symptoms among this international
student group. The discrepancy between the findings of Oei
and Notowidjojo’s and Furukawa’s studies could be a result
of researchers using a different scale to measure depression
and including students from different educational levels.
Therefore, it is important to conduct additional studies with
international college students to see if age is related to
anxi-
ety and depression levels of students attending college in a
foreign country.
Race/Ethnicity
Research on the effects of race/ethnicity and the adjustment
to
a new culture indicated that the adjustment process
becomes
more stressful as the differences between the two
cultures
increase (Kinoshita & Bowman, 1998; Surdam &
Collins,

1984; Yang & Clum, 1994). Yang and Clum suggested that
for a foreigner, entering into a new culture might cause
stress
if that individual lacks information regarding
appropriate
behavior in that culture.
Tafarodi and Smith (2001) conducted a study that compared
Malaysian and British students at a British university. This
study
addressed individualism-collectivism as a dimension of
cultural
factors that produced differential sensitivity to life events.
The
results of the study showed that Malaysian students
displayed
higher levels of depressive symptoms than did British
students.
For Malaysian students, positive social life events were
inversely
related, and negative social life events were directly
related
to increased levels of depression. On the other hand,
positive
achievement-related events indicated a smaller increase in
de-
pression among British students, but there was no
association
between negative achievement-related events and depression.
Overall, collectivist cultural orientation was associated
with
greater vulnerability to social experiences, whereas
individualist
cultural orientation was associated with greater sensitivity
to
personal achievement-related experiences. Other research

about
the impact of collectivist and individualist cultural
orientations
on international students’ adaptation, satisfaction with life,
and
anxiety levels showed similar results, indicating that
students
from collectivist cultural orientations had lower levels of
adap-
tation and satisfaction with life and higher levels of
anxiety as
compared with students from individualist cultures
(Kinoshita
& Bowman, 1998; Sam, 2001; Surdam & Collins, 1984).
These
studies indicated that when an international student
from a
collectivist culture attends college in an individualist
culture,
he or she might experience higher levels of anxiety because
of
cultural dissimilarities.
Social Support
Huang (1977) suggested that it may be difficult for
inter-
national students to replace the social network of
family,
neighbors, and friends that they had in their home country.
Research in this area has shown that stressful life
situations
might lead individuals to evaluate their social support.
In
those circumstances, individuals with poor support might
pay
more attention to the weakness of their support. Rudd

(1990)
suggested that this might lead to increased hopelessness;
indi-
viduals with poor support may be more sensitive to life
stress
and, therefore, experience higher levels of distress.
Volume 86 431
Predictors of Depression and Anxiety Among International
Students
Several studies (Furukawa, 1997; Jou & Fukada, 1995;
Misra et al., 2003; Rajapaksa & Dundes, 2002; Wethington
&
Kessler, 1986; Yang & Clum, 1994; Yeh & Inose, 2003)
have
shown that social support and related variables such as
social
network satisfaction, perceived social network, and
needed
support are related to international students’ adjustment
levels,
life satisfaction, acculturative stress, reactions to stressors,
and
depressive symptoms. In particular, students with higher
social
support tended to experience higher adjustment levels and
lower
levels of depression and acculturative stress. Results
suggest
that social support might serve as a buffer and help
students

cope more effectively with challenges they encounter.
English Proficiency
Language difficulties, in particular, appear to be a
challenge
for the majority of international students. According to
Mori
(2000), the lack of English language skills is likely to
affect in-
ternational students’ academic and social performances,
which,
in turn, may affect their psychological adjustment to the
new
culture (p. 138). Surdam and Collins (1984) studied the
adapta-
tion of international students upon their arrival in the
United
States in relation to their English language skills. Their
results
showed that the students who believed that their English
was
adequate on arrival were significantly better adapted than
those
who believed that it was inadequate. In support of this
finding,
Yeh and Inose (2003) reported that English language
fluency
was a significant predictor of acculturative stress. In
particular,
participants who reported higher levels of English
fluency,
higher frequency of English use, and higher comfort
level
in communicating in English experienced less
acculturative
stress. Proficiency in English was also found to be

significant
in predicting adjustment among international students
(Poyrazli
et al., 2002). Findings from Poyrazli et al.’s study
suggested
that English proficiency affects international students’
ability
to discuss educational issues and to form social
relationships
with Americans. Therefore, lower levels of English
proficiency
were associated with lower levels of adjustment.
Length of Stay
The relation of length of stay to international
students’ ad-
justment experiences has been the focus of a major
theory
developed by Lysgaard (1955). He indicated that the adjust-
ment processes of international students in a host
culture
follow a U-shaped curve over time. Initially, the adjustment
process starts with excitement about being abroad and
seeing
new things. However, during this period, the person is
not
involved in any special friendship group. After some
time,
the excitement of the first stage loses its attraction when
the
need for more intimate personal contact and interaction
with
friendship groups becomes important. If this need is
not
satisfied, the individual might experience feelings of loneli-
ness and depression. In time, however, foreigners may learn

to resolve the adjustment difficulties they experience in this
“loneliness” stage (Lysgaard, 1955). They may get involved
with other individuals at a more intimate level, make
friends,
and have a satisfactory social life.
Literature about the impact of length of stay on interna-
tional students’ adaptation and depression levels
supported
the U-curve hypothesis (Oei & Notowidjojo, 1990; Surdam
& Collins, 1984). Specifically, international students staying
in another country for more than 1 year were more
depressed
than were native-born students; those with less than 1 year
in another country did not become frustrated as easily
and
were less worried about future misfortunes when compared
with native-born students. Also, international students
who
had been in the United States from 2 to 4 years showed
lower
adaptation than those who had been in the United States
more
than 4 years.
In summary, the literature indicates that several variables
affect adjustment and acculturation levels of
international
students to a new culture. Among these variables,
gender,
age, race/ethnicity, social support, pattern of social
contact
(i.e., with whom do students socialize mostly?),
English
proficiency, and length of stay have been studied in

relation
to students’ general adjustment experiences or level of
accul-
turative stress, but not in relation to depression and
anxiety.
However, there is some evidence in the literature indicating
that gender is related to anxiety and depression among non-
international college students. Therefore, the purpose of this
study was to fill a gap in the literature by
examining these
variables and their relation to the depression and anxiety
levels
of international students. We were specifically interested in
the following research questions.
1. What are the correlations among gender, age, length of
stay, academic achievement, social support, pattern of
social contact, English proficiency, and international
students’ depression and anxiety levels?
2. What are the contributions of gender, age, length of
stay, social support, English proficiency, and race/
ethnicity to the variance in international students’
depression and anxiety levels?
Method
Participants
A total of 440 international students who held either F-1
or J-1
student visas participated in the study. They were studying
at
two different college campuses located in the eastern
portion
of the United States. Fifty-seven percent of the participants
were men and 43% were women. The age of the

students
ranged from 18 to 49 years, with an average of 26.15 (SD
=
4.78). Educational levels represented by the students
were
doctoral (50%), master’s (28%), undergraduate (21%),
and
other (1%). Students’ grade point averages ranged from
1.50
to 4.00 (M = 3.60, SD = .37). Regarding race/ethnicity,
68%
of the participants were Asian, followed by 16% White/non-
Latino/a, 4% Latino/a, 3% Middle Eastern, 2% Black,
and
Volume 86432
7% who identified themselves as “other.” A breakdown
of
Asian students by region was as follows: India, 38%;
China,
28%; Korea, 13%; Taiwan, 8%; Japan, 3%; Singapore, 3%;
Thailand, 2%; 1% each from Malaysia, Nepal, Pakistan, and
Sri Lanka; and less than 1% each from Indonesia,
Philippines,
and students who did not indicate their country of origin.
Only 26% of the participants were married. Among those
who were married, 49% reported residing with their spouse
in the United States. Seventy-three percent of the
participants

were single and 1% were divorced. Participants’ length of
stay
in the United States ranged from 2 months to 10 years,
with
an average of 2.9 years (SD = 1.82).
Variables
Depression. The Goldberg Depression Scale (GDS; Goldberg,
1993; Holm, Holm, & Bech, 2001) was used to measure
depres-
sion. Participants respond to this 18-item measure using a
6-point
Likert-type rating scale; responses range from 0 (not at all)
to
5 (very much). The highest score on this scale, 90,
indicates the
most severe depression, and the lowest score, which is
zero,
indicates the complete absence of depressive symptoms.
Factor
analysis was used to measure the internal validity of this
scale;
one general factor was identified, which explained 50% of
the
variance. The results indicated that the 18 items on the
GDS have
a valid rank order and structure. In addition, external
validity
was measured by comparing the responsiveness of GDS
with
the Hamilton Depression Scale (HAM-D). The correlation
of
the total GDS and HAM-D scores was .74 (p < .001; Holm
et
al., 2001). The internal reliability, measured by Cronbach’s

alpha,
of the scale for the sample used in this study was .93,
indicating
that GDS was a reliable measure for our sample.
Anxiety. The State Anxiety scale (Form Y-1) of the State-
Trait Anxiety Inventory (STAI; Spielberger, 1983) was used
to measure anxiety. This scale is a 20-item, 4-point self-
report
scale. Responses range from 1 (not at all) to 4 (very
much
so). The items on the scale measure a temporary
condition
of anxiety, called state anxiety, which consists of feelings
of
tension, nervousness, and worry that vary in intensity
and
fluctuate over time according to perceived threat
(Spielberger,
Sydeman, Owen, & Marsh, 1999). High scores indicate high
levels of state anxiety. The stability coefficients for the
State
Anxiety scale were low, with a median of .33. However,
Spiel-
berger et al. reported that this lack of stability was
expected
and considered essential because a valid measure of
state
anxiety should reflect the influence of situational factors at
the time of testing. On the other hand, internal consistency
of the State Anxiety scale was .93 (Spielberger et al.,
1999).
Spielberger (1983) reported that the construct validity of
the
State Anxiety scale was demonstrated when college students
were administered the scale following a classroom examina-

tion. Participants’ scores were higher at that time than
when
they were tested during a relatively nonstressful class
period.
Cronbach’s alpha reliability coefficient of this subscale
for
the current sample was .94.
Social support. The Social Provisions Scale (SPS; Cutrona
& Russell, 1987) was used to measure social support. This
scale
consists of 24 questions, 4 for each of the following
variables:
attachment, social integration, reassurance of worth, reliable
alliance, guidance, and opportunity for nurturance. The
items
are rated on a 4-point Likert-type scale, with responses
ranging
from 1 (strongly disagree) to 4 (strongly agree). A high
score
indicates a greater degree of perceived support. Test–retest
reli-
ability coefficients for this scale were reported to range
from
.37 to .66 (Cutrona & Russell, 1987). However,
because the
scale consists of items that measure the individual’s mood,
the
time of testing might have influenced the test–retest
reliability
analysis. On the other hand, internal consistency reliability
for
this scale was reported to be excellent (α = .93). The
convergent
validity of this scale was measured by comparing the
scores

on the Social Integration, Reassurance of Worth, and
Guidance
provisions on the SPS with scores on the UCLA Loneliness
Scale for the same sample. The results of this comparison
in-
dicated that the deficits in the social provisions explained
66%
of the variance in the UCLA Loneliness scores. Cutrona
and
Russell reported that the predictive validity measure of
SPS
indicated that social provisions scores were predictive of
loneli-
ness, depression, and health status among teachers. In
addition,
discriminant validity measure showed that the
intercorrelations
among the six provisions ranged from .10 to .51, with a
mean
intercorrelation of .27. The internal reliability of the
instrument
in the current study was .94.
Demographics. We developed a questionnaire to ascertain
students’ age, gender, race/ethnicity, and length of stay in
the
United States. We added four more questions to the
question-
naire to measure students’ English proficiency. Students
were
asked to rate their skills in the areas of speaking, reading,
under-
standing, and writing; responses ranged from poor to
excellent
on a 4-point Likert-type scale. Another item measured
students’

pattern of social contact by asking them to state with
whom
they socialized most—Americans or non-Americans (i.e.,
other
international students or people from their own country).
Procedure
The participants were recruited from two different campuses
of
a university located in the eastern portion of the United
States.
Approximately 3,000 international students were
contacted via
e-mail through International Student Office representatives.
This
e-mail included information about the purpose of the study
and
the compensation for participation. Students were asked to
go to a
designated Web site address to complete the surveys. Of
the 3,000
students who were e-mailed, we could not determine how
many
actually received the information. However, we received a
total of
440 responses, which represented a return rate of 15%.
Although
this rate is low for a traditional mailed survey, we cannot
determine
what this number represents for a Web-based survey.
Web-based data collection procedures must take into con-
sideration Internet accessibility by the targeted
population

Volume 86 433
Students
(Gosling, Vazire, Srivastava, & John, 2004). However,
because
international students are often frequent users of the
Internet
for communicating with their family and friends in their
home
countries and have easy access to the Internet on their
cam-
puses (e.g., in computer labs, libraries), this concern might
not
be as significant, particularly, for the current sample.
To minimize the effects of repeat responders, we matched
consecutive responses on key demographic characteristics
such as age, gender, degree sought, and race/ethnicity (Gos-
ling et al., 2004). We also compared the set of item
responses
to identify duplicate or near-duplicate entries. When such a
match was detected, we kept only the first entry.
Data Analysis
This project was a cross-sectional, exploratory study in
which
depression and anxiety were measured among international
students. Cronbach’s alpha was calculated to determine the
in-
ternal reliability of the measures for the current sample.
Pear-
son product–moment correlational analyses were performed

to examine the relationship between interval variables.
Gender, age, length of stay, social support, English profi-
ciency, and race/ethnicity were investigated for their
contribu-
tions to both depression and anxiety levels of
international
students. Two hierarchical multiple regression analyses were
used to explore the contributions of these variables. To
en-
ter the race/ethnicity variable into regression analyses,
we
dummy-coded this variable.
Results
Correlational Analyses
Pearson product–moment correlation analyses were per-
formed to look at the relation between the interval
vari-
ables used in the study (see Table 1). The means, standard
deviations, and range of scores for these variables are also
presented in Table 1. Analyses indicated that
depression
was negatively correlated with social support (r = –.57,
p
< .01) and English proficiency (r = –.24, p < .01).
Students
with higher levels of social support and English proficiency
reported lower levels of depression. Similarly, anxiety was
found to be negatively correlated with social support
(r =
–.59, p < .01) and English proficiency (r = –.25, p < .01).
Stu-
dents who had lower levels of social support and

proficiency
in English reported higher levels of anxiety. It was also
found
that depression and anxiety were intercorrelated (r = .76, p
< .01). Students who scored high on the GDS, which was
used to measure depression, also scored high on the State
Anxiety scale, which was used to measure anxiety.
English proficiency was negatively correlated with age (r =
–.24, p < .01) and pattern of social contact (r = –.25, p <
.01), and
positively correlated with social support (r = .29, p < .01).
In other
words, younger students reported higher English proficiency
than
did older students, and students who socialized primarily
with
non-American students reported lower English proficiency
than
did students who socialized primarily with American
students. It
was also found that students with higher levels of social
support
reported higher levels of proficiency in English.
Finally, length of stay correlated with pattern of social
contact (r = –.10, p < .05). As the students’ length of stay
in
the United States increased, so did their level of
socialization
with Americans. The relationship, however, was too low
to
reach any practical significance.
Multiple Regression Analyses

Two hierarchical regression analyses were performed using
the following predictor variables in the first block:
gender,
age, length of stay, social support, and English proficiency.
In
the second block, race/ethnicity was entered as dummy-
coded
variables for European, Middle Eastern, Latino/a, African,
and
Other. The Asian group served as the reference group.
Table 1
bivariate Correlations, Means, Standard Deviations, and Range
of Scores
Variable
1. Gender
2. Age
3. Grade point average
4. Pattern of social
contacta
5. Depression
6. Anxiety
7. Social support
8. English proficiency
9. Length of stay
M
SD
Range
—

9
aStudents’ pattern of social contact was dummy coded and
entered into the correlational anaysis. Thus, means, standard
deviations, and
range of scores are not reported here.
*p < .05. **p < .01.
87654321
–.03
—
26.15
4.78
18–49
–.12*
.32**
—
3.60
0.37
1.50–4.00
.03
.04
.09
—
.02
.05

–.12*
.06
—
14.26
13.47
0–90
–.05
.08
–.06
.09
.76**
—
39.23
12.09
20–80
–.06
.00
.01
–.15**
–.57**
–.59**
—
77.90
11.61

24–96
–.01
–.24**
–.02
–.25**
–.24**
–.25**
.29**
—
13.11
2.75
4–16
–.01
.25**
–.04
–.10*
.03
.01
.09
.05
—
2.90
1.82
.17–10

Volume 86434
Depression. When the first set of variables were regressed
on depression, results indicated that this model accounted
for
35% (R² = .35) of the variance in depression (see Table
2). The
F value for the model in predicting depression was
significant,
F(5, 380) = 40.56, p < .01. However, among the
predictor
variables, only length of stay, social support, and
English
proficiency had significant standardized beta coefficients.
When race/ethnicity variables were added to the model,
R²
increased to .36, F(10, 373) = 21.16, p < .01. Interestingly,
although length of stay significantly contributed to students’
level of depression in the first model, with the addition of
race/
ethnicity variables, the contribution became nonsignificant.
This indicated that race/ethnicity groups differed from each
other based on their length of stay in the United States.
An
examination of means for length of stay showed that
Africans
had been in United States longer than any other group (M
=
3.61), whereas Asians had been here for a shorter time
than
the other groups (M = 2.74 years). The second model

also
indicated that Latino/a students had higher levels of
depression
than Asians. However, these findings are tentative because
of
the small number of Latino/a students in our sample.
Overall,
the findings showed that lower levels of social support
and
English proficiency and being Latino/a were associated with
higher levels of depression.
Anxiety. When the first set of variables were regressed on
anxiety, the R² value of this model was .38, indicating that
the
combination of these variables accounted for 38% of the
vari-
ance in anxiety (see Table 3). It was found that these
variables
significantly predicted anxiety, F(5, 361) = 44.66, p <
.01.
The standardized beta coefficients, however, indicated
that
only age, social support, and English proficiency
significantly
contributed to the variance in anxiety. The signs of the
stan-
dardized beta coefficients showed that higher social support
and better English skills were associated with lower
anxiety,
whereas older age was associated with higher levels of
anxiety.
When race/ethnicity variables were entered into the equation
as the second block, the R² of the model increased
to .39,

F(10, 356) = 22.84, p < .01. Age, social support, and
English
proficiency remained significant. Gender, length of stay,
and
race/ethnicity were not significant in predicting anxiety.
Discussion
In this study, international students were examined in terms
of the depression and anxiety levels they might
experience
as a result of their adjustment to living and studying in
the
United States. We investigated the contribution of a
model
for explaining the variance in depression and anxiety.
Results
showed that social support had a significant contribution to
the model in predicting depression. Students with lower
levels
of social support reported higher levels of depression. This
result is consistent with the results of several studies that
in-
vestigated reactions to stressors, adjustment, and depressive
symptoms of international students (Furukawa, 1997; Jou &
Fukada, 1995; Misra et al., 2003; Wethington & Kessler,
1986;
Yang & Clum, 1994; Yeh & Inose, 2003). Besides
depression,
social support also contributed significantly to the variance
in anxiety. In particular, students with lower levels of
social
support were more likely to have higher levels of
anxiety,
suggesting that higher levels of social support might enable
international students to be more socially active and
interact

with people more often and, as a result, reduce the feelings
of depression and anxiety.
Table 2
Summary of Hierarchical Regression analysis for
Variables Predicting Depression (N = 385)
Variable
Step 1
Gender
Age
Length of stay in U.S.
Social support
English proficiency
Step 2
Gender
Age
Social support
English proficiency
Race/ethnicity
European
Middle Eastern
Latino/a
African
Other
b
–0.95
0.11
0.67
–0.64

–0.50
–0.84
0.10
0.57
–0.66
–0.60
2.33
0.58
6.15
2.30
3.47
1.14
0.13
0.32
0.05
0.22
1.15
0.13
0.32
0.05
0.23
1.68
3.39
2.72
4.03
2.47
–.03
.04
.09*
–.55**

–.10*
–.03
.03
.08
–.57**
–.12**
.06
.01
.10*
.02
.06
SE B
Note. R 2 = .35 for Step 1; DR 2 = .36 for Step 2. Reference
group for
race/ethnicity variables = Asian.
*p < .05. **p < .01.
B
Table 3
Summary of Hierarchical Regression analysis for
Variables Predicting anxiety (N = 366)
Variable
Step 1
Gender
Age
Social support
English proficiency

Step 2
Gender
Age
Social support
English proficiency
Race/ethnicity
European
Middle Eastern
Latino/a
African
Other
b
–1.59
0.28
0.23
–0.60
–0.44
–1.60
0.27
0.23
–0.61
–0.47
5.13
1.63
–2.58
–0.62
2.07
1.03
0.12

0.29
0.05
0.20
1.03
0.12
0.29
0.05
0.21
3.49
2.46
3.55
2.28
1.52
–.06
.10*
.03
–.57**
–.10*
–.06
.10*
.03
–.59**
–.11*
.06
.03
–.03
–.01
.06
SE B

Note. R 2 = .38 for Step 1; DR 2 = .39 for Step 2. Reference
group for
race/ethnicity variables = Asian.
*p < .05. **p < .01.
B
Volume 86 435
Students
The age variable contributed uniquely to the variance in
anxiety. Older students were more likely to report higher
levels
of anxiety. This finding suggests that younger students may
be
more open and flexible to a new culture and to
environmental
differences. This might be due to globalization, which gives
younger students the opportunity to have more exposure
than
older students to American culture through media. As a re-
sult, they may feel more familiar with American culture,
and,
therefore, might experience less anxiety toward the cultural,
educational, and social changes, making their adjustment
easier. However, older students may be more traditional,
more
resistant to change, and have more difficulties in accepting
the host culture’s norms and values and, therefore,
experience
higher levels of anxiety during their adjustment period.

Results showed that students with lower levels of Eng-
lish proficiency reported higher levels of depression
and
anxiety. This finding supports the findings of previous
stud-
ies (Poyrazli et al., 2002; Surdam & Collins, 1984; Yeh &
Inose, 2003) indicating that English proficiency is related
to acculturation, adaptation, and adjustment of international
students. However, this result contradicted the finding of
Furukawa’s (1997) study, in which no relation was found
between English fluency and depressive symptoms among
Japanese high school exchange students. One explanation
for this discrepant finding might be that the experiences of
high school exchange students might be different from the
experiences of international college students. Other results
of the current study showed that English proficiency was
negatively correlated with age and pattern of social con-
tact. Specifically, younger students reported higher levels
of English proficiency, and students with higher levels of
English skills reported socializing mostly with Americans,
not with their conationals or other international students.
These results imply that younger students might have
an
easier time learning another language as compared with
older students; having better English skills might help
students to form relationships with Americans, which in
turn might further improve these students’ English skills.
Another finding indicated that Latino/a students had higher
levels of depression than Asian students. However,
these
findings are tentative because we had a small number
of
Latino/a students in our sample; thus, there is a
strong
likelihood of chance variation.

The results of our study do not support the findings
of
previous studies regarding international students’ length
of
stay in the host culture and their adaptation and depression
levels (Oei & Notowidjojo, 1990; Surdam & Collins, 1984).
Previous literature, which investigated length of stay in
rela-
tion to adjustment and adaptation levels among international
students, found significant differences among groups. On
the
contrary, our findings showed no group differences in terms
of
length of stay for international students’ levels of
depression
and anxiety. There might be two reasons for this discrepant
finding. First, some of the previous studies used samples
that
included only one race/ethnic group and examined
differ-
ences among these students. Second, the remaining
studies
included sufficient numbers of students from different
cultural
and ethnic backgrounds and investigated the impact of
length
of stay for various ethnic groups. However, in our study,
the
percentage of students representing different race/ethnic
groups was not equal.
Unlike the studies that showed significant gender dif-
ferences for anxiety, reactions to stressors, and feelings of
loneliness (Hawkins, 1995; Poyrazli et al., 2002; Rajapaksa

& Dundes, 2002; Swift & Wright, 2000) among
college
students, in this study no relation was found between
gender
and international students’ depression and anxiety
levels.
Research studies examining American college students’
anxi-
ety in relation to their gender (e.g., Hawkins, 1995) found
that social support was related to female students’ anxiety
levels. The reason that we did not find a relation
between
gender and levels of depression and anxiety among
inter-
national students might first reflect the fact that we studied
a non-American sample. Second, even though female
and
male students react differently to stressors or feel different
levels of loneliness (Misra et al., 2003; Rajapaksa &
Dundes,
2002), the level of their depression and anxiety might not
differ because of many other factors that contribute to de-
pression and anxiety.
Implications
In this study, we found that social support was
related to
depression and anxiety; students who scored higher on the
social support measure scored lower on the depression and
anxiety measures. Regarding counseling services that can be
provided, a social support group for international students
might be offered to serve as a buffer against depression
and
anxiety. Students in such a group may be taught to utilize
stress-management techniques to release the tension and
anxiety that they might experience. Counseling centers

might also assign bilingual or international counselors
to
work with students whose English proficiency levels
are
not adequate. This approach may promote more
frequent
and easier use of counseling services among international
students, while helping these students learn how to
cope
with depression or anxiety.
Implementing programs like “host family,” or programs
that match international students with more experienced
international students, can help the students have smoother
adjustments by providing social support upon their arrival
to the United States. Peer programs, in which an American
student is paired up with an international student,
might
also serve as a great resource to promote international
students’ interaction with American students, thus
helping
them expand their social support network. It is important to
have American students become an essential part of these
programs for international students because socializing
Volume 86436
with American students also positively affects English
proficiency of international students.
Limitations and Suggestions for

Further Research
The data for this study were collected online. Although the
current sample represents the total international student
population at the university where the data were
collected,
the return rate was only 15%. As a result of the
policy of
the international student office, we were unable to send out
a reminder e-mail to the international students to participate
in the study, and this might have contributed to not having
a
higher return rate. However, because of a lack of
information
on Internet surveys and return rate, we could not determine
if our return rate was low or normal. Also, most of the
data
were collected just before students began their spring break,
a time when they were possibly stressed, working on class
as-
signments, and taking tests. During that period, the
students’
perceptions of their anxiety levels might have been
higher
than they would normally have been.
The results of this study were correlational in nature and,
as a result, no causal conclusions can be drawn about
depres-
sion and anxiety. We also need to interpret the results of
this
study in light of the average level of depression and
anxiety
students reported. For the depression measure (i.e., the
GDS),
our sample, on average, answered 2 on a 0- to 5-point

scale,
and also responded with 2 on a 4-point scale for anxiety
(i.e.,
STAI State Anxiety Scale). These numbers indicate that
stu-
dents did not experience high levels of depression or
anxiety.
However, this might also indicate that less depressed
students
might be more likely to volunteer for a research project on
the
Internet; it could also be that the students with high
depres-
sion or anxiety might have chosen not to participate.
Although
the internal reliability level for the GDS in the current
study
indicated that this scale was a reliable measure for our
sample,
previous research did not specify the racial/ethnic
background
of the participants studied, making it difficult to show
that
this scale has been used with other cultures
effectively. To
measure anxiety, we used the State Anxiety scale of the
STAI,
which measures a temporary condition of anxiety. The Trait
Anxiety scale was excluded because this scale measures an
individual’s anxiety-proneness, and we were interested
in
measuring temporary anxiety that could be caused by being
in a new culture or unfamiliar environment. However,
future
research could examine trait anxiety before students
leave

their country and examine the effects of this type of
anxiety
on students’ experiences while abroad.
Moreover, the race/ethnicity groups in our sample did
not
have an equal number of students. Therefore, future
research
could include equal numbers of participants in each
category and
examine the group differences in terms of depression and
anxiety.
Further research might also attempt to examine depression
and
anxiety levels of international students in a longitudinal
study.
Measuring the depression and anxiety levels of students
prior
to their arrival in the United States and following them up
with
periodic assessments after their arrival would provide a
better
understanding of the impact of cultural change and the
accultura-
tion process. The small number of married students who
reported
residing with their spouses did not allow us to determine
whether
living with a spouse in the United States contributed to the
levels
of depression and anxiety among international students.
There-
fore, further research could be conducted with married
students
with and without their spouses in the United States to

determine
how these students’ psychological well-being is affected by
the
presence or absence of the spouse.
Although we had a large sample of students, it was
a
highly self-selected group. Future research could replicate
this study or compare the results with another college
sample.
Future research could also examine depression and anxiety
among international students with an ecological perspective
that emphasizes the impact of the interaction between inter-
national students and their environment (Bronfenbrenner,
1979; Kelly, Ryan, Altman, & Stelzner, 2000). This
approach
is based on the assumption that an individual’s behavior
and
psychosocial health are influenced by his or her social and
physical contexts (Kelly, 1990). Therefore, examining the
community context and physical setting of international
students might play an important role in understanding
the environmental factors that contribute to these students’
depression and anxiety levels. The way that
international
students (or foreigners, in general) are welcomed and
treated
in the community and the lack of important resources (e.g.,
transportation, financial support) might be factors in inter-
national students’ depression and anxiety levels. Therefore,
in order to understand underlying factors of depression and
anxiety among international students, it might be useful to
assess attitudes of American students and others in the
local
community toward different cultures and countries and
to

examine the resources provided to this population. Finally,
depression and anxiety might negatively affect academic
achievements of international students. This concern could
be addressed through a longitudinal study that
examined
whether or not depression and anxiety are related to
academic
success among international students.
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Journal of Counseling & Development ■ Winter 2009 ■
Volume 8780
Qualitative Research
© 2009 by the American Counseling Association. All rights
reserved.
A child awakens in the middle of the night, the nightmare
still
fresh in her mind of “him” on top of her. Her breath
comes
in short, quick gasps as she struggles to determine whether
what she has just experienced was real or only a dream.
She
strains to hear if the footsteps coming down the hall are
real or
imagined. She pushes the thoughts out of her head. Perhaps
if
she sleeps under the bed, he will not find her. She wishes
her
mother would come in and comfort her, but she feels
discon-
nected from her family, as if she is a stranger living in
her own
house. No one understands. No one cares. She prays for
the
morning to come so the dreams will stop, but she knows
that
the morning brings nightmares of its own: the looks from
her
sister, the speeches from her teacher about her lack of con-
centration in class. Her day is spent alternately trying to

recall
what happened and trying to forget. She finds no pleasure
in
the activities that she once loved. The night comes again,
and
the cycle continues. The monster that was once in her bed
has
now been replaced by monsters in her head.
There has been a growing body of literature on the subject
of
posttraumatic stress disorder (PTSD) in children. The
literature
consistently points to children’s vulnerability to the
development
of PTSD after severe trauma, particularly child sexual
victimiza-
tion. (Note. In this article, both the terms child sexual
victimiza-
tion and child sexual abuse are used. Child sexual
victimization
refers to the symptomatology experienced by the person
being
victimized. This term assumes the perspective of the victim.
Child
sexual abuse refers to the overall experience and nature of
sexual
abuse, including the criminal component.) When children’s
bod-
ies are used to meet adult needs, there is enormous
potential for
physical and psychological trauma (Monahon, 1993).
Many
clinicians differ on the applicability of a diagnosis of
PTSD for

children who have been sexually victimized. Although
many
authors believe that PTSD is a logical outcome following
child
sexual victimization, others (e.g., Finkelhor, 1990) object to
using the diagnosis of PTSD as a way of always
conceptualiz-
ing the sequence of events and symptoms that children who
are
sexually abused often face after the trauma. This article
does
not seek to resolve this debate, but rather seeks to shed
light on
the controversy. This article examines the nature and scope
of the
problem, proper assessment and diagnosis of PTSD in
children,
treatment strategies known to be effective, and implications
for
counselors treating this population. In the interest of time
and
space, this article only addresses PTSD as it specifically
relates
to child and adolescent survivors of child sexual
victimization,
while acknowledging that adult survivors of child sexual
abuse
may also experience the effects of PTSD.
Nature and Scope of the Problem
PTSD has long been associated with the aftereffects of war
and natural disasters. This disorder was brought to
main-
stream attention with the return of soldiers from the
Vietnam
War. Many of these returning soldiers experienced recurrent

nightmares, suddenly feeling or acting as if the event
were
recurring, restricted range of affect, and hypervigilance (Da-
vidson & Foa, 1993). It is now recognized that PTSD is
not
limited to wartime but may arise from a variety of
traumatic
events that can occur throughout the life cycle of men,
women,
and children. It is estimated that 4 out of 10 Americans
have
experienced major trauma, and the disorder may be present
Stacie E. Putman, Counseling, Educational Psychology, and
Reseach, The University of Memphis. Stacie E. Putman is now
at
Department of Psychology, Tennessee State University. The
author thanks Jeri Lee, Ronnie Priest, and Nancy Nishimura for
their
thoughtful review and comments on earlier versions of this
article. This article is based on research conducted for the
author’s
doctoral residency project at The University of Memphis.
Correspondence concerning this article should be addressed to
Stacie
E. Putman, Department of Psychology, Tennessee State
University, 3500 John A. Merritt Boulevard, Nashville, TN
37209 (e-mail:
[email protected]).
The Monsters in My Head:
Posttraumatic Stress Disorder and the
Child Survivor of Sexual Abuse
Stacie E. Putman
Posttraumatic stress disorder (PTSD) is 1 of several possible

outcomes of child sexual victimization. There is a growing body
of
literature regarding the prevalence of PTSD among children
who have been sexually victimized. Using specific case
examples,
this article looks at the nature and scope of the problem,
diagnostic criteria according to the Diagnostic and Statistical
Manual
of Mental Disorders (4th ed., text rev.; American Psychiatric
Association, 2000) symptomatology of children presenting with
this
disorder, assessment and diagnosis, treatment interventions, and
implications for counselors treating this population.
Volume 87 81
Posttraumatic Stress Disorder and the Child Survivor of Sexual
Abuse
in 9% of the U.S. population (Breslau & Davis,
1987). A
growing number of Americans with PTSD are children who
have been sexually abused. According to the U.S.
Depart-
ment of Health and Human Services (2000), 11.5% of
the
903,000 children who were victimized in 1998 were victims
of sexual abuse. According to Browne and Finkelhor
(1986),
it is estimated that between 46% and 66% of children who
are
sexually abused exhibit significant psychological
impairment.

McLeer, Deblinger, Atkins, Foa, and Ralphe (1988) studied
the prevalence of PTSD in 31 children who were
sexually
abused and found that in 48% of their sample, a diagnosis
of
PTSD was warranted. Many children who did not meet
PTSD
criteria nevertheless experienced PTSD symptoms.
Another study by Briere, Cotman, Harris, and Smiljanich
(as cited in Briere, 1992) found that “both clinical and non
clinical groups of sexual abuse survivors report
intrusive,
avoidant, and arousal symptoms of PTSD” (p. 20).
According
to Briere, survivors of sexual abuse are prone to displaying
PTSD-related intrusive symptoms. Other symptoms survivors
of sexual abuse may experience include mood
disorders,
somatization, sexual difficulties, anger and frustration, self-
injurious behaviors, and a pervasive distrust of others
(Naugle,
Bell, & Polusny, 2003). These symptoms often manifest
themselves in the form of flashbacks, when the
survivor is
flooded with intrusive sensory memories that may
include
visual, auditory, tactile, or olfactory sensations (Briere,
1992).
Many of these flashbacks may be triggered by abuse-related
stimuli or interactions.
I worked with a young girl who became physically ill
when she
encountered the smell of chlorine, particularly prevalent
around

swimming pools. During the course of therapy, it was
discovered
that the client had been repeatedly sexually assaulted one
summer
by one of her older brother’s friends at a local swimming
pool.
The perpetrator would take the client behind the pool’s
storage
shed and repeatedly assault her. The smell of the chlorine
would
inevitably return her to that place, and she would “feel”
his hands
on her. Often, disclosing the abuse experience can be the
only
stimulus needed to trigger flashbacks.
In a survey of six separate studies by McNally
(1993),
which involved the application of PTSD criteria to
cases of
child sexual abuse, four of these studies reported no cases
of
PTSD, whereas the other two studies reported rates of
48%
and 90%, respectively. As McNally noted, “Clearly, there is
no
uniform outcome associated with child sexual abuse” (p.
69).
The clinician working with this population should consider
a
diagnosis of PTSD as a possible outcome of child sexual
abuse
but recognize that such a diagnosis is not always a given
in cases
in which child sexual abuse has been reported.

Symptomatology
It is important for the clinician dealing with survivors of
child
sexual victimization to be aware of how these clients
will
present upon entering counseling. The clinician who
suspects
that a child is experiencing PTSD should be cognizant of
the
signs and symptoms that are possible indicators of
PTSD.
Frequently, fearfulness and anxiety-related symptoms
have
been described as sequelae of sexual abuse. Green
(1985)
described anxiety states, sleep disturbances, nightmares, and
psychosomatic complaints in children who were sexually as-
saulted. Sgroi (1982) observed fear reactions in children
who
had been sexually abused extending to a phobic avoidance
of
all males (when the perpetrator is male). Kiser et al.
(1988)
documented PTSD in 9 out of 10 children between the ages
of 2 and 6 years who were molested in a day-care setting.
The
most frequently observed symptoms were acting as if the
trau-
matic event were reoccurring, avoiding activities reminiscent
of the traumatic event, and intensification of symptoms
on
exposure to events resembling the molestation, all of which
satisfied criteria for a diagnosis of PTSD.
According to Koverola and Foy (1993), one of the ongoing

controversies in the diagnosis of PTSD in children who
have
been sexually victimized lies in the issue of whether
children
manifest PTSD symptoms in the same way that adults do.
As
Koverola and Foy noted, “One way in which PTSD in
children
may differ from PTSD in adults is in the nature of the
traumatic
reexperiencing” (p. 120). It is argued that children are
more
likely to experience nightmares as opposed to the
dissociative
flashbacks that adults experience (Koverola & Foy,
1993).
These nightmares can be classified into two types of PTSD
according to Terr (1989). Type I can be classified as a
graphic
representation of the original trauma and that results from
a
single incident. Type II can be classified as more
symbolic
representation of the event and is often classified by
denial,
dissociation, and numbing. Type I nightmares often
appear
soon after the abuse and usually decrease over time. Type
II
nightmares seem to be both a short- and long-term sequel
of
trauma, often surpassing Type I nightmares as the
survivor
grows older (Terr, 1989).
Dissociation, or an alteration in consciousness resulting

in an impairment of memory or identity, has also been ob-
served in children traumatized by sexual abuse (Kluft,
1985).
Signs of early dissociation in children are “forgetfulness
with
periods of amnesia, excessive fantasizing and daydreaming,
trancelike states, somnabulism, the presence of an imaginary
companion, sleepwalking, and blackouts” (Wilson &
Raphael,
1993, p. 578). There seems to be a close relationship
between
dissociation and PTSD. Liner (1989) found that children
who
were physically and sexually abused who were referred for
outpatient treatment exhibited significantly more dissociation
than did a comparison group of nonabused children who at-
tended a child psychiatry outpatient clinic. Sexual abuse
and
physical abuse are the most frequent background factors in
the
etiology of dissociative identity disorder in adults (Wilson
&
Raphael, 1993). It is quite possible that the child who has
been
sexually victimized who presents with dissociative
symptoms
began the dissociation process during the course of the
trauma
as a way of coping. Just as the dissociation served a
purpose
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Putman
during the trauma, the clinician needs to be ever mindful
of
the purpose that dissociation may serve after the trauma.
An essential feature of PTSD is the avoidance of
situa-
tions and stimuli that are associated with the traumatic
event
(American Psychiatric Association [APA], 2000). Survivors
of child sexual abuse invariably make conscious attempts to
avoid thoughts, feelings, or activities that bring back recol-
lections of the abuse. Cognitive suppression and distraction
are particularly common, as is behavioral avoidance
(Jackson
& March, 1995). Children who use these survival
strate-
gies pay a high price because these strategies
inevitably
spill over into other domains of functioning. According
to
Jackson and March, “children with PTSD often show mark-
edly diminished interest in previously enjoyed activities and
sometimes lose previously acquired skills, leaving them less
verbal or regressed to behaviors such as thumb
sucking or
enuresis” (p. 283).
Child survivors of sexual victimization experiencing PTSD
also may show evidence of restricted affect,
accompanied by
feelings of detachment or estrangement from others (APA,
2000).
Children who have been sexually victimized who begin to
talk

about their experiences may do so with blunted affect and
with a
detached demeanor. The clinician should not take this
restricted
affect as a sign of dishonesty regarding whether the abuse
oc-
curred, but rather as a possible sign that abuse has
occurred.
Children often reexperience or reenact part or all of
the
traumatic event. The traumatic event of sexual abuse can
be
reexperienced in the form of distressing, intrusive thoughts
or memories, dreams, or flashbacks. McNamara (2002)
stated
that reenactment is the rule in children who have been
trauma-
tized. Reexperiencing symptoms set PTSD apart from other
psychiatric syndromes; in no other symptom are portions of
the traumatic event recapitulated (Jackson & March, 1995).
Reexperiencing occurs both spontaneously and in response
to traumatic reminders, as noted earlier.
Traumatic play is often an essential feature of PTSD
in
children who have been sexually victimized. Traumatic play
refers to “the repetitive acting out of specific themes of
the
trauma” (Jackson & March, 1995, p. 282). According to
Py-
noos and Nader (1993), when children incorporate
rescues
that lead to a happy ending, otherwise known as
intervention
fantasies, play may represent an attempt at mastery. The

child
who has been sexually victimized may reenact aspects
of
the abuse in his or her play; however, in the child’s
version,
perhaps the “victim” becomes empowered by a magic wand
and he or she is therefore able to make the abuser
disappear.
According to Jackson and March, “traumatic play is clearly
maladaptive when it interferes with play’s normative uses
or
leads to risky or aggressive behaviors” (p. 282).
Child survivors of sexual victimization are said to develop
a
“sense of foreshortened future” (APA, 2000, p. 468),
believing
that they may never grow up or fulfill other adult tasks
(Terr,
1990). Many survivors often possess a self-image of
“bad-
ness,” implying that they are not worthy of having a future
in
which there is happiness, marriage, and children. According
to Jackson and March (1995), there is little empirical
literature
that supports this element as a necessary element of the
PTSD
symptom picture.
Hyperalertness and hypervigilance are also common fea-
tures of PTSD associated with increased physiological
arousal.
Children with PTSD who have been sexually abused may
show

symptoms of increased arousal, such as sleep disturbances,
ir-
ritability, difficulty concentrating, exaggerated startle
respons-
es, and outbursts of aggression (Friedman, 1991). According
to McNamara (2002), these symptoms persist for more than
a month. A study by Chaffin, Wherry, and Dykman (1997)
looked at the coping strategies used by 84 children, ages 7
to
12 years, who had been sexually abused. These authors
found
that internalized coping strategies used by children who had
been sexually abused were strongly associated with
increased
guilt and PTSD hyperarousal symptoms.
The stress and coping literature generally concludes that
males are more vulnerable than females to the negative
effects
of stress (Hetherington, 1984); however, it is unclear
whether
this gender difference holds for all stressors,
particularly
child sexual abuse. Kempe and Kempe (1978)
concluded
that the impact of sexual abuse was usually more severe
for
males than for females; however, they provided no
empirical
evidence for this conclusion. Do males, then, have a higher
rate of PTSD from sexual abuse than do females? Kiser et
al.
(1988) found gender differences in the PTSD presentations
of ten 2- to 6-year-old children who were sexually abused
in
a day-care setting. The boys in the study initially presented

more clinically significant symptoms than did the girls. A
partial follow-up 1 year later suggested that the girls were
more symptomatic at that time than were the boys. A
similar
study by Burke, Moccia, Borus, and Burns (1986) looked at
the behavioral reactions of boys and girls to a traumatic
event
and found that boys reacted more intensely and their symp-
toms resolved slowly, whereas in girls a recurrence of
symptoms
developed at a later time.
Friedrich and Reams (1987) further found gender differ-
ences among children between the ages of 3 and 12 years
who
had been sexually abused. These authors concluded that
girls
display greater internalization and boys greater
externalization
when dealing with the trauma of child sexual victimization.
It
is clear, however, that there is no consensus on whether
there
is a higher incidence of PTSD in males or females who
have
been sexually victimized; however, the literature seems
to
suggest that girls who are victims of father–daughter incest
frequently become symptomatic and meet the diagnostic
criteria for PTSD (Wilson & Raphael, 1993).
Assessment and Diagnosis
The type, duration, and frequency of trauma determines the
likelihood of PTSD development, and as such PTSD
may
result from a single or repeated traumatic event

exposure
Volume 87 83
Abuse
(Famularo, Fenton, Kinscherff, & Augustyn, 1996). Children
who are sexually abused seem to develop PTSD at a higher
rate than do children who have been physically maltreated
or
who have experienced parental neglect (Famularo,
Fenton,
Kinscherff, 1993). How, then, does the clinician
properly
assess, diagnose, and treat those child survivors of
sexual
victimization experiencing PTSD?
Evaluating children who have been sexually victimized
and assessing their treatment needs requires thoughtful and
purposeful planning. As with any client, it is important that
an
assessment is made of all resources available to the
clinician.
These resources may include reports from outside
sources,
such as physicians, teachers, social workers, family, clergy,
and legal services. Assessment instruments are also helpful
in
diagnosing PTSD in children who have been sexually
victim-
ized. Miller and Veltkamp (1995) researched various

measures
designed to aid the clinician in diagnosing PTSD.
Instruments
such as the Children’s Post-Traumatic Stress Disorder
Inven-
tory (Saigh, 1994), the Childhood PTSD Interview (Fletcher,
1991), When Bad Things Happen (Miller & Veltkamp,
1995),
and the Trauma Symptom Checklist for Children (Wolpaw,
Ford, Newman, Davis, & Briere, 2005) are all designed to
aid
the clinician in properly assessing and diagnosing PTSD in
children who have been sexually victimized.
The role of play and drawing in the assessment and treat-
ment of posttraumatic stress goes beyond the simple idea
that
drawing permits an easy access to children who might
other-
wise find it difficult to speak about their abuse
experiences.
According to Nader and Pynoos (1990), in the
specialized
treatment of children experiencing PTSD, drawing is
more
than just a window into the child’s mental representation of
traumatic material. Nader and Pynoos contended that visual
and other perceptual experiences of the event become
embed-
ded and transformed in a child’s play and drawings. “Thus,
play and drawings serve as an ongoing indicator of both
the
child’s processing and his or her resolution of traumatic
ele-
ments” (Pynoos & Nader, 1993, p. 538).

As with any disorder, the criteria for PTSD in the
Diagnos-
tic and Statistical Manual of Mental Disorders (4th ed., text
rev.; DSM-IV-TR; APA, 2000) must be met before an
accurate
diagnosis can be made. PTSD must often be
differentiated
from other DSM-IV-TR diagnostic categories. According to
Peterson, Prout, and Schwarz (1991), common diagnostic
differentials include anxiety disorders, depressive disorders,
adjustment disorders, antisocial personality disorders, schizo-
phrenia, factitious PTSD, and malingering. Because of a
wide
array of potential clinical symptoms following severe
trauma,
errors in diagnosis, particularly differential diagnosis,
are
common among patients with PTSD.
Children who have been traumatized frequently exhibit
symptoms of disorders other than PTSD, and children with
other disorders not uncommonly have PTSD as an
intercurrent
diagnosis. Famularo et al. (1996) conducted a study in
which
PTSD in children who had been maltreated was found to
be
statistically related to other formal psychiatric
diagnoses.
The results of their study suggest that “children
diagnosed
as PTSD demonstrate concurrent ADHD [attention-deficit/
hyperactivity disorder], anxiety disorders (panic, phobic,
overanxious, simple phobia), and a tendency toward
mood

disorders (major depression, dysthymic)” (Famularo et
al.,
1996, p. 959). Borderline personality disorder has also been
etiologically linked to PTSD (Bemporad, Smith, Hanson, &
Cicchetti, 1982). Famularo et al. (1996) also found a
high
correlation between childhood diagnosis of PTSD and at
least
transient suicidal ideation. These findings suggest that when
a diagnosis of PTSD in children who have been sexually
vic-
timized is made, it is highly probable that another disorder
is
also present, as well as suicidal thoughts, for which a
suicide
risk assessment should be administered.
Treatment Interventions
According to Friedrich (1990), “although the PTSD
diagnosis
seems to be relevant for some sexually abused children, its
greatest utility is probably that it identifies the existence of
specific behaviors that should be addressed in therapy”
(p.
24). Likewise, “assessment for PTSD in children who
are
believed to have been sexually abused can be useful both
for
intervention as well as forensic purposes” (Walker, 1993, p.
131). Walker further stated that the treatment of PTSD
in
children must contain some of the same components as
those
for the treatment of PTSD in adults, which includes
empow-
erment. It is essential that the child becomes empowered to

take back that which has been taken from him or her
through
the violation of sexual abuse. It is important to recognize
that
children have limited control over their surroundings and
over
situations, but by allowing them to make decisions that are
within parental limits, the child can begin to regain
power
over his or her life and future (Walker, 1993).
According to the International Society for Traumatic
Stress Studies, “cognitive-behavioral approaches have the
strongest empirical evidence for efficacy in resolving PTSD
symptoms in children” (Ovaert, Cashell, & Sewell, 2003, p.
294). Peterson et al. (1991) contended that from a
behavioral
perspective, it is the child’s response to memories of
traumatic
events that produces the primary manifestations of PTSD. It
is further assumed that secondary features of the
disorder
are also, directly or indirectly, caused by the child’s
reactions
to his or her memories; therefore, the primary focus of a
be-
haviorally oriented approach to PTSD is the child’s memory
of the original trauma (Meiser-Stedman, 2002; Peterson
et
al., 1991).
For adults or children, almost all therapeutic approaches
to PTSD incorporate some review and reprocessing of
the
traumatic events. The emotional meaning the child attaches
to the abuse, as well as the personal impact, is embedded

in
the details of the experience, and the therapist must be
pre-
pared to hear everything, however horrifying or sad.
Special
Volume 8784
Putman
interview techniques may be necessary to assist children to
explore thoroughly their subjective experiences and to help
them understand the meaning of their responses (Pynoos &
Eth, 1986). By encouraging children’s expression
through
drawing, play, dramatization, and metaphor, the therapist at-
tempts to understand the traumatic links and looks for ways
to
recruit children’s fantasy and play actively into
communication
about their abuse experiences.
One treatment goal is to bolster children’s observing ego
and reality-testing functions, thereby dispelling cognitive
con-
fusions and encouraging active coping with the abuse
experi-
ence. A second goal is to help children anticipate,
understand,
and manage everyday reminders, so that the intensity of
these
reminders and their ability to disrupt daily functioning
recede

over time (Wilson & Raphael, 1993).
Another goal is to assist the child in making
distinctions
among current trauma, ongoing life stresses, and previous
trauma
and to decrease the impact of the recent trauma on present
expe-
rience (Walker, 1993). Helping children recover from the
most
immediate posttraumatic reactions may directly increase
their
ability to address the posttraumatic changes in their lives.
Ovaert et al. (2003) found that group therapy was valuable
in decreasing PTSD symptoms in children. Patients
participat-
ing in the study said that by being able to share their
traumatic
experiences with those who could sympathize with them
was
an important part of their treatment. Being able to
express
feelings verbally helped patients to better able to deal with
emotions elicited by the traumatic experience. According to
Foy, Erickson, and Trice (2001), “it [group therapy]
offers
advantages over individual therapy in providing a safe,
shared
therapeutic environment where children who have survived
terrible experiences can normalize their reactions and
provide
support for each other while processing their traumas”
(p.
250). Group therapy helps children to build trusting
relation-

ships with those involved in therapy. The hope is that
children
will integrate these skills into their everyday lives and
begin to
repair the damage to trust relationships caused by the
sexual
abuse experience.
Psychopharmacology may be indicated in those children
whose PTSD arousal symptoms and/or sleep disturbances
have increased to the extent that additional impairment
in
other areas of functioning is experienced, including altered
self-concept and personality. In cases of severe anxiety
or
depression, psychopharmacology may be necessary to bring
the child to a stable level of functioning before other
treatment
interventions can be used.
A wide range of psychotherapeutic and educational tech-
niques have been proved successful in alleviating the PTSD
symptoms and distress experienced by children who have
been
sexually abused. Individual psychoanalytically oriented play
therapy and psychotherapy have been used effectively with
youngsters who have been sexually abused, as well as
group
therapy, whereas family treatment modalities have been
used
with some families that are dysfunctional and abusive
(Coons,
Bowman, Pellow, & Schneider, 1989). According to
Yule
(1989), group counseling affords the opportunity to

reinforce
the normative nature of the children’s reactions and
recovery,
to share mutual concerns and traumatic reminders, to
address
common fears and avoidant behavior, to increase tolerance
for
disturbing affects, to provide early attention to depressive
reactions, and to aid recovery through age-appropriate
and situation-specific problem solving. Ultimately, the clini-
cian must help the child to see that his or her
pathological
defenses, personality traits, and distorted object
relations
that have served to master the abusive experience and
to
control or ward off further assault are not serving him or
her
in nontraumatic, nonabusive environments. This can only be
accomplished when the counselor helps the child to link
these
PTSD symptoms and defenses back to the original traumatic
experiences, which are uncovered, remembered, reframed,
and assimilated in the safety of the counseling setting.
Family
therapy, when warranted, can also help the family
understand
the manifestations of the symptomatology of PTSD, the
mean-
ing the child has attached to the abuse experience, and
how
to effectively intervene to help the child return to a
healthy
level of functioning.
Case Examples

These case examples serve to help clinicians understand the
etiology and manifestation of PTSD in children who
have
been sexually victimized. Although the diagnostic criteria
remain the same for each case, treatment interventions used
and the implications for counselors treating this population
are as unique as the children who present for
treatment.
Without sufficient understanding in how to treat PTSD
in
these children, counselors will only feed the monsters
that
live inside these children’s heads. The names of the
children
cited have been changed and all identifying information left
out to protect confidentiality.
Andrea
Andrea is a 15-year-old, White female adolescent who
presented to a residential treatment facility for treatment of
behavioral issues related to sexual abuse. Andrea presented
to
treatment with a long history of physical and sexual abuse
at
the hands of her uncle and several of her mother’s
boyfriends.
Andrea’s abuse started at the age of 5 years and continued
until
she was finally removed from her mother’s custody and
placed
in the custody of the Department of Children’s Services at
the
age of 6 years. Andrea meets the diagnostic criteria for
PTSD
in the following ways.

Andrea seems to have regressed to the developmental level
that she was at when the abuse occurred. Andrea sucks on
a
pacifier, insists on drinking out of a sippy cup, and talks
in “baby
talk” when addressed. Andrea often has intense
psychological
distress whenever another child goes into crisis or is
aggressive
or if adults raise their voice around her. Andrea’s response
to
Volume 87 85
Abuse
these external cues include her becoming physically
aggressive,
attempts to flee out of the cottage, and Andrea reliving her
own
abuse experience through the form of flashbacks. Andrea
at-
tempts to avoid all discussion regarding her thoughts,
feelings,
or experiences related to her sexual abuse. Andrea often
creates
crises at bedtime to avoid going to bed because of the
intrusive
nightmares she experiences. She has a profound fear of the
dark.
She has impaired memory regarding her abuse

experience,
including the most recent episodes of abuse. Andrea has
dif-
ficulty concentrating and falling asleep and often has
explosive
fits of anger. She is hypervigilant and possesses an acute
sense
of her surroundings. Andrea often experiences anxiety-
related
symptoms, such as a chronic headache and stomachache
(these
somatic complaints intensify when faced with participating
in
therapy related to discussing her abuse experience). She
shuts
down emotionally and refuses to talk about her abuse.
When
asked about her future, Andrea does not seem to project
much
beyond the next few weeks.
Andrea’s physical appearance resembles that of a 16- or
17-year-old. She is physically mature; however, she is
perpetu-
ally stuck in the world of a 5- to 7-year-old. Andrea’s
tone of
voice is often loud and inappropriate. Further exploration
of
this issue resulted in the discovery that Andrea had a
hearing
loss as a result of the physical abuse that she suffered at
the
hands of her perpetrators.
Andrea has continued problems with interpersonal relation-
ships, often making relationships with staff and her

counselor
(the author) into more intimate relationships than they are
in
reality, often calling some female staff members “Mommy.”
She
has no contact with her biological family, including her
younger
brother, who was adopted by a foster family. Andrea
justifies
the use of the pacifier and sippy cup as being the last
physical
links she has to her younger brother. She attempts to
identify
with him by imitating her brother’s developmental level.
She has
abandonment issues and has a difficult time when people
(even
those she dislikes) move on. Her placement following
treatment
is uncertain, and Andrea experiences a high level of
anxiety
when faced with the possibility of returning to another
foster
home. Andrea lacks impulse control and often says
whatever
comes to mind. In this way, she is refreshingly honest.
Andrea’s treatment interventions have included helping her
to recall aspects of the abuse, normalizing her reactions to
the
abuse, exploring the meaning she has attached to the abuse,
and attempting to have Andrea use developmentally
appropri-
ate coping skills for dealing with her abuse experience.
Ben

Ben is a 13-year-old, White male adolescent who presented
to residential treatment for issues related to sexually
offend-
ing his 2- and 6-year-old nieces. Ben also presented with
his
own sexual abuse history, having been placed in the
custody
of his older brother by his mother a few years
earlier. This
brother had been convicted and served time as an
adolescent
for sexually offending Ben. Ben reciprocated by sexually
of-
fending his brother’s children. Ben was also sexually
abused
by a friend of his brother and, according to Ben, carried
on a
“relationship” with this 35-year-old man. Ben was
diagnosed
with PTSD as a result of his own sexual abuse, as
well as
diagnosed with having sexually abused a child. Ben met the
criteria for PTSD in the following ways.
Ben had experienced repeated sexual abuse at the hands
of one of his brothers, while experiencing physical abuse at
the hands of his other brother. Ben had no contact with his
biological father or mother at the onset of treatment;
however,
5 months into treatment, Ben’s mother began making
contact
by phone and letter, indicating that she wanted to be in
Ben’s
life. His mother never followed through with her promises

of
contact and eventually moved and changed her number, ter-
minating all contact with Ben. Ben felt helpless and
powerless
to change his circumstances, choosing to sexually offend as
a way to “empower” himself.
Ben often experienced flashbacks and visual hallucina-
tions in which he saw men in black trench coats. During
these
episodes, Ben would feel as if the sexual abuse was
recurring.
Ben would tremble, cry, and often crawl into a corner,
pulling
himself up into a ball. Ben experienced physiological
reactions
to external cues, often becoming nauseous or vomiting after
witnessing a peer become angry or aggressive or when
faced
with discussions related to sexual behavior or sexuality. In
the
beginning of therapy, Ben would avoid discussing his
feelings,
thoughts, or experiences related to his own abuse. He was
un-
comfortable discussing his own sexually deviant behaviors
but
was often more comfortable discussing his sexual offenses
than
he was his own sexual abuse. Ben felt detached from his
family
and others, becoming more estranged from his family of
origin
as his treatment progressed. Ben vacillated between wanting
to be with his family and wanting to avoid any contact
with

them, given that they reminded him of his own abuse.
Although
Ben had goals for the future, he often felt as if he would
never
achieve them and viewed himself as a “failure.”
Ben was plagued with nightmares during his stay in
residential treatment. He often had difficulty falling
asleep
and concentrating. Ben’s outbursts of anger and
irritability
seemed to be more acute following individual therapy
ses-
sions in which both his sexual offenses and personal sexual
abuse history were addressed. Ben startled easily and
was
hypervigilant regarding his surroundings.
Treatment interventions focused on addressing Ben’s feel-
ings of helplessness and powerlessness by helping him feel
more empowered and in control without his having power
and
control over others. Other interventions included helping
Ben
address his cognitive distortions related to his own abuse
and
the abuse he perpetrated and teaching him more appropriate
coping skills. Interventions regarding healthy sexual
relation-
ships and impulse control were central to helping Ben suc-
cessfully transition back into his community.
Psychotropic
medication was used to help Ben reduce his anxiety level,
as
well as help him sleep at night.

Volume 8786
Putman
Gerry
Gerry is a 10-year-old, White boy who presented to
residential
treatment with a history of sexual abuse by his older
brother.
Gerry is small in stature, physically resembling a 6- or 7-
year-
old child. Gerry presented with a history of
inappropriate
sexual behaviors directed toward his younger siblings. Gerry
is a quiet child who often blends into the crowd. Gerry
met
the criteria for PTSD in the following ways.
Gerry’s history of sexual abuse by his brother lasted for
over a year. Given his small stature and the fact that
his
brother used threats of physical force to keep Gerry
quiet,
Gerry stated that he often felt powerless to stop his brother
from abusing him. Gerry’s reexperience of the traumatic
event
manifested in his sexualized play with his younger siblings.
Gerry complained of nightmares and became visibly shaken
when discussing his sexual abuse history.
Gerry’s affect was blunt and flat, and he presented to
therapy
with a detachment from his surroundings and his

family.
Gerry lacked the ability to emotionally bond to his
family,
stating that he felt unable to love them. Gerry refused to
talk
about his own abuse and the inappropriate sexualized
play
with his siblings. Gerry initially presented to treatment with
a
diminished interest in activities that he once enjoyed, such
as
organized sports. Gerry preferred to play video games alone
rather than socialize with others.
Gerry had difficulty falling asleep and difficulty concen-
trating in school. He was hypervigilant and became agitated
whenever changes in his environment occurred. Gerry’s
family
presented as highly disorganized, with his father placing
Gerry
in an infant role, while his mother placed him in a
parentified
role. This role confusion contributed to Gerry’s anxiety,
and
he responded by further withdrawing emotionally from
his
family, increasing the estrangement.
Treatment interventions focused on helping Gerry bond
with his family by increasing the amount of therapeutic
one-
to-one time with both his mother and father. Gerry’s
attempt
to control his own feelings of helplessness were re-created
in
his sexualized play with his siblings, in which he attempted

to gain control by placing them in the role of victim.
Inter-
ventions focused on helping Gerry normalize his feelings of
helplessness and powerlessness. Because of Gerry’s
small
stature, other interventions focused on ways that Gerry
could
protect himself from future abuse, given that his perpetrator
would eventually return to the home.
Communication issues were a common theme in both
individual and family therapy. The use of bibliotherapy and
creative expression, such as drawing and writing, helped
Gerry express his feelings about his abuse to his counselor
(the author) and his family. Gerry was placed in a leader-
ship role among his peers to facilitate the development of
feelings of healthy power.
Other interventions focused on Gerry’s inappropriate
sexual behaviors with his siblings. Developing empathy for
his
siblings was crucial in increasing the affective bond
between
Gerry and his family of origin. Gerry’s ability to dissociate
from his surroundings and his family was addressed,
and
alternative coping skills were explored.
Counselor Implications
Counselor implications for working with someone who
presents with issues similar to those of Andrea include
care-
fully considering and accounting for Andrea’s desire to stay
stuck at the developmental level of a 5- to 7-year-old,
while

attempting to facilitate developmentally appropriate coping
skills. Further implications include helping Andrea find ad-
equate support resources, given her lack of familial contact,
as well as working through the issues of abandonment
and
loss regarding her brother. Although Andrea desired to stay
at
the developmental level she was in when she was
victimized,
she also presented as highly sexualized and often
dressed
inappropriately for her age. She often talked
suggestively
toward others, yet when approached by anyone in what
could
be construed as a sexual way, she reacted within her PTSD
diagnosis by having outbursts of anger, crying, and
experienc-
ing memory lapses.
Green (1980) described the tendency of some women
physically abused as girls to reenact their “victim” status
by
ultimately choosing physically abusive mates. This tendency
toward revictimization may be regarded as evidence of
the
PTSD symptom of reenacting the trauma. The future
possibil-
ity of revictimization may increase the child’s
likelihood of
experiencing PTSD as an adult survivor. Furthermore,
Russell
(1986) found that between 33% and 68% of the women
who
were sexually abused as children (depending on the
seriousness

of the abuse they experienced) were subsequently raped,
com-
pared with an incidence of rape in 17% of nonabused
women,
supporting Green’s position that children such as Andrea
may
grow up and seek out sexually abusive partners. Naugle et
al.
(2003) discussed several risk factors, including
situational
factors and personal characteristics of both the victim and
the
perpetrator, that increase the risk that child survivors of
sexual
abuse will be revictimized as adults. Therefore, it is
important
for counselors working with someone like Andrea to
educate her
on developing and maintaining healthy sexual relationships
into
adulthood. The counselor dealing with this population
should
be aware of the risk of revictimization and help to prepare
his
or her child clients in an attempt to lower that risk.
Working with Ben’s presenting issues of PTSD was further
complicated by his sexual offending. This counselor (the
au-
thor) often had to balance having Ben review and reprocess
his own sexual abuse experience with the inevitable sexual
arousal and subsequent deviant sexual fantasies that
would
arise following such a discussion. Responsibility for his
own
offenses versus lack of responsibility for his own abuse

was
often a tightrope this counselor walked. The meaning that
Ben
attached to his own abuse experience was integral to
helping
Ben develop empathy for his victims. Given that Ben’s
fam-
Volume 87 87
Abuse
ily life and subsequent placement following treatment was
so
unstable, much intervention was directed toward helping
Ben
cope with this lack of stability, without sexually
offending
others, and helping him incorporate developmentally appro-
priate coping skills to cope with his own sexual abuse,
while
interrupting his sexual assault cycle. Furthermore, Ben also
manifested psychotic symptomatology when he felt
threat-
ened, either physically or sexually by others. Ben used this
pathological defense as a way to protect himself.
Interventions
focused on helping Ben feel empowered to protect
himself
from future assault using appropriate strategies.
Like Andrea, Ben needed help in understanding the nature

of healthy sexual relationships. Ben viewed his last abuser
as a
“lover” and a partner in a meaningful relationship rather
than
as what he was: a sexual predator. This distorted
perception
of what constitutes a healthy sexual relationship can be
traced
back to Ben’s sexual victimization by his older brother.
Not
only was Ben’s perception of romantic relationships skewed
by his trauma, but his perception of appropriate sibling
rela-
tionships was altered as well. Ben’s PTSD symptomatology,
which included visual and auditory hallucinations (such
as
flashbacks of his own victimization), complicated interven-
tions to help him process his sexual abuse history, given
that
such discussions often triggered these symptoms.
Implications for counselors working with a child who
is
diagnosed with both PTSD and sexually deviant behaviors
face
unique challenges. Reliving the abuse experience in
someone
who has sexually deviant behaviors may send that child
into a
cycle of sexual perpetration, increasing the likelihood that
the
child will seek to feel power over his or her own abuse by
abus-
ing others. Often, it is the child’s own sexual abuse history
that
initially motivates the sexual offending behaviors, as was

Journal of Counseling & Development ■ Fall 2008 ■ Volume 8.docx

Journal of Counseling & Development ■ Fall 2008 ■ Volume 8.docx

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