were significantly lower than the self-reported math sat scores of their non-abused sample. because the abused subjects' verbal sat scores were high, they hypothesized that the low math sat scores could "stem from a defect in hemispheric integration." they also found a strong association between short-term memory impairments for all categories tested (verbal, visual, and global) and the duration of the abuse. incest incest between a child or adolescent and a related adult is known as child incestuous abuse, and has been identified as the most widespread form of child sexual abuse with a highly significant capacity to damage the young person. one researcher stated that more than 70% of abusers are immediate family members or someone very close to the family. another researcher stated that about 30% of all perpetrators of sexual abuse are related to their victim, 60% of the perpetrators are family acquaintances, like a neighbor, babysitter or friend and 10% of the perpetrators in child sexual abuse cases are strangers. a child sexual abuse offense where the perpetrator is related to the child, either by blood or marriage, is a form of incest described as intrafamilial child sexual abuse. the most-often reported form of incest is father–daughter and stepfather–stepdaughter incest, with most of the remaining reports consisting of mother/stepmother–daughter/son incest. father–son incest is reported less often; however, it is not known if the actual prevalence is less or it is under-reported by a greater margin. similarly, some argue that sibling incest may be as common, or more common, than other types of incest: goldman and goldman reported that 57% of incest involved siblings; finkelhor reported that over 90% of nuclear family incest involved siblings; while cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers. prevalence of parental child sexual abuse is difficult to assess due to secrecy and privacy; some estimates state that 20 million americans have been victimized by parental incest as children. types child sexual abuse includes a variety of sexual offenses, including: sexual assault – a term defining offenses in which an adult uses a minor for the purpose of sexual gratification; for example, rape (including sodomy), and sexual penetration with an object. most u.s. states include, in their definitions of sexual assault, any penetrative contact of a minor's body, however slight, if the contact is performed for the purpose of sexual gratification. sexual exploitation – a term defining offenses in which an adult victimizes a minor for advancement, sexual gratification, or profit; for example, prostituting a child, live streaming sexual abuse, and creating or trafficking in child pornography. sexual grooming – a term defining the social conduct of a potential child sex offender who seeks to make a minor more accepting of their advances, for example in an online chat room. commercial sexual exploitation commercial sexual exploitation of children (csec) is defined by the declaration of the first world congress against commercial sexual exploitation of children, held in stockholm in 1996, as "sexual abuse by an adult accompanied by remuneration in cash or in kind to the child or third person(s)." csec usually takes the form of child prostitution or child pornography, and is often facilitated by child sex tourism. csec is particularly a problem in developing countries of asia. in recent years, new innovations in technology have facilitated the trade of internet child pornography. in the united kingdom, the term child sexual exploitation covers any form of sexual abuse which includes an exchange of a resource for sexual activity with a child. prior to 2009, the term commonly used to describe child sexual exploitation was child prostitution. the term child sexual exploitation first appeared in government guidance in 2009 as part of an attempt to promote an understanding that children involved in exploitation were victims of abuse rather than criminals. because early definitions of child sexual exploitation were created to foster a move away from use of the term child prostitution, the concept of exchange, which made child sexual exploitation different from child sexual abuse, referred to financial gain only. however, in the years since the birth of the concept of child sexual exploitation, the notion of exchange has been widened to include other types of gain, including love, acquisition of status and protection from harm. disclosure children who received supportive responses following disclosure had less traumatic symptoms and were abused for a shorter period of time than children who did not receive support. in general, studies have found that children need support and stress-reducing resources after disclosure of sexual abuse. negative social reactions to disclosure have been found to be harmful to the survivor's well-being. one study reported that children who received a bad reaction from the first person they told, especially if the person was a close family member, had worse scores as adults on general trauma symptoms, post traumatic stress disorder symptoms, and dissociation. another study found that in most cases when children did disclose abuse, the person they talked to did not respond effectively, blamed or rejected the child, and took little or no action to stop the abuse. non-validating and otherwise non-supportive responses to disclosure by the child's primary attachment figure may indicate a relational disturbance predating the sexual abuse that may have been a risk factor for the abuse, and which can remain a risk factor for its psychological consequences. the american academy of child and adolescent psychiatry provides guidelines for what to say to the victim and what to do following the disclosure. asa don brown has indicated: "a minimization of the trauma and its effects is commonly injected into the picture by parental caregivers to shelter and calm the child. it has been commonly assumed that focusing on children's issues too long will negatively impact their recovery. therefore, the parental caregiver teaches the child to mask his or her issues." in many jurisdictions, abuse that is suspected, not necessarily proven, requires reporting to child protection agencies, such as the child protection services in the united states. recommendations for healthcare workers, such as primary care providers and nurses, who are often suited to encounter suspected abuse are advised to firstly determine the child's immediate need for safety. a private environment away from suspected abusers is desired for interviewing and examining. leading statements that can distort the story are avoided. as disclosing abuse can be distressing and sometimes even shameful, reassuring the child that he or she has done the right thing by telling and that they are not bad and that the abuse was not their fault helps in disclosing more information. anatomically correct dolls are sometimes used to help explain what happened, although some researchers consider the dolls too explicit and overstimulating, which might contribute to non-abused children behaving with the dolls in one or more ways that suggest they were sexually abused. for the suspected abusers, it is also recommended to use a nonjudgmental, nonthreatening attitude towards them and to withhold expressing shock, in order to help disclose information. treatment the initial approach to treating a person who has been a victim of sexual abuse is dependent upon several important factors: age at the time of presentation circumstances of presentation for treatment co-morbid conditions the goal of treatment is not only to treat current mental health issues, and trauma related symptoms, but also to prevent future ones. children and adolescents children often present for treatment in one of several circumstances, including criminal investigations, custody battles, problematic behaviors, and referrals from child welfare agencies. the three major modalities for therapy with children and adolescents are family therapy, group therapy, and individual therapy. which course is used depends on a variety of factors that must be assessed on a case-by-case basis. for instance, treatment of young children generally requires strong parental involvement and can benefit from family therapy. adolescents tend to be more independent; they can benefit from individual or group therapy. the modality also shifts during the course of treatment; for example, group therapy is rarely used in the initial stages, as the subject matter is very personal and/or embarrassing. in a 2012 systematic review, cognitive behavior therapy showed potential in treating the adverse consequences of child sexual abuse. major factors that affect both the pathology and response to treatment include the type and severity of the sexual act, its frequency, the age at which it occurred, and the child's family of origin. roland c. summit, a medical doctor, defined the different stages the victims of child sexual abuse go through, called child sexual abuse accommodation syndrome. he suggested that children who are victims of sexual abuse display a range of symptoms that include secrecy, helplessness, entrapment, accommodation, delayed and conflicted disclosure and recantation. adults adults who have been sexually abused as children often present for treatment with a secondary mental health issue, which can include substance abuse, eating disorders, personality disorders, depression, and conflict in romantic or interpersonal relationships. generally, the approach is to focus on the present problem, rather than the abuse itself. treatment is highly varied and depends on the person's specific issues. for instance, a person with a history of sexual abuse and severe depression would be treated for depression. however, there is often an emphasis on cognitive restructuring due to the deep-seated nature of the trauma. some newer techniques such as eye movement desensitization and reprocessing (emdr) have been shown to be effective. although there is no known cure for pedophilia, there are a number of treatments for pedophiles and child sexual abusers. some of the treatments focus on attempting to change the sexual preference of pedophiles, while others focus on keeping pedophiles from committing child sexual abuse, or on keeping child sexual abusers from committing child sexual abuse again. cognitive behavioral therapy (cbt), for example, aims to reduce attitudes, beliefs, and behaviors that may increase the likelihood of sexual offenses against children. its content varies widely between therapists, but a typical program might involve training in self-control, social competence and empathy, and use cognitive restructuring to change views on sex with children. the most common form of this therapy is relapse prevention, where the patient is taught to identify and respond to potentially risky situations based on principles used for treating addictions. the evidence for cognitive behavioral therapy is mixed. a 2012 cochrane review of randomized trials found that cbt had no effect on risk of reoffending for contact sex offenders. meta-analyses in 2002 and 2005, which included both randomized and non-randomized studies, concluded that cbt reduced recidivism. there is debate over whether non-randomized studies should be considered informative. more research is needed. sexual abuse is associated with many sub-clinical behavioral issues as well, including re-victimization in the teenage years, a bipolar-like switching between sexual compulsion and shut-down, and distorted thinking on the subject of sexual abuse (for instance, that it is common and happens to everyone). when first presenting for treatment, the patient can be fully aware of their abuse as an event, but their appraisal of it is often distorted, such as believing that the event was unremarkable (a form of isolation). frequently, victims do not make the connection between their abuse and their present pathology. prevention child sexual abuse prevention programmes were developed in the united states of america during the 1970s. some programme are delivered to children and can include one-to-one work and group work. programmes delivered to parents were developed in the 1980s and took the form of one-off meetings, two to three hours long. in the last 15 years, web-based programmes have been developed. school-based education programs were evaluated in 2015 by cochrane that demonstrated improvements in protective behaviors and knowledge among children. the american cdc lists that improving surveillance systems can help monitor and prevent child abuse. offenders demographics offenders are more likely to be relatives or acquaintances of their victim than strangers. a 2006–07 idaho study of 430 cases found that 82% of juvenile sex offenders were known to the victims (acquaintances 46% or relatives 36%). more offenders are male than female, though the percentage varies between studies. the percentage of incidents of sexual abuse by female perpetrators that come to the attention of the legal system is usually reported to be between 1% and 4%. studies of sexual misconduct in us schools with female offenders have shown mixed