Practice Profile: Therapeutic Approaches for Sexually Abused Children and Adolescents

Practice Goals

Therapeutic approaches for sexually abused children and adolescents are designed to reduce the effects of sexual abuse. The effects of sexual abuse can manifest in various ways, such as posttraumatic stress disorder (PTSD), fear, and anxiety. PTSD is the most commonly diagnosed disorder, with estimates suggesting that 37 to 53 percent of sexually abused children eventually develop PTSD (Trask, Walsh, and DiLillo 2011). Traumatic reactions may include re-experiencing the abuse through memories or dreams, or actively attempting to avoid situations or stimuli that remind the child of the abuse. Victims may also engage in externalizing behaviors such as sexual behavioral problems, hyperactivity, and aggression. Alternatively, the effects of sexual abuse can cause children to exhibit internalizing behaviors such as depression and anxiety.

Sexual abuse can be a single occurrence or can occur over a period of time, sometimes even years. The duration of exposure depends on a range of factors, such as the person’s access to the child or young person and the steps taken to secure the victim’s silence, such as threats. Child sexual abuse can be perpetrated within the family, by those known to the children outside of the home, or by strangers. The majority of sexual abuse is committed by people known to the victim, although most are not members of their family. Instead, around one third of them are family members (Macdonald et al. 2012).

Overall, therapeutic approaches for sexually abused children and adolescents aim to reduce the developmental consequences that result from this distinct form of maltreatment.

Target Population

Therapeutic approaches to child sexual abuse target children and adolescents aged 18 and under who have experienced sexual abuse. Although males can also experience child sexual abuse and suffer the same consequences, generally females are more often the victims of this specific type of maltreatment. Estimates suggest that between 20 and 32 percent of females experience sexual abuse, whereas approximately 4 to 8 percent of males are victims (Macdonald et al. 2012).

Practice Components

There are a variety of therapeutic approaches that are designed to treat the negative impacts of child sexual abuse, such as cognitive behavioral therapy (CBT), cognitive behavioral therapy for sexually abused preschoolers, trauma-focused cognitive behavioral therapy, child-centered therapy, eye movement desensitization and reprocessing, imagery rehearsal therapy, a recovering from abuse program, supportive counseling, and stress inoculation training.

CBT is a well-known treatment approach that can be delivered individually to the victim, or in a group setting. For child victims of sexual abuse, CBT focuses on the meaning of the events for children and their nonoffending parents, addressing the maladaptive cognitions (e.g., being “soiled”), misattributions (e.g., feelings of blame), and low self-esteem. Interventions may also try to address overt behaviors such as sexualized behavior, externalizing behaviors, or internalizing behaviors.

CBT is designed to address symptoms such as emotional distress, anxiety, and behavior problems. CBT helps children to cope effectively with their emotional distress by teaching relaxation techniques and various other skills such as emotional expression skills and cognitive coping skills. Further, children and their parents are taught how to label feelings and communicate them to others. To reduce anxiety, CBT teaches children and adolescents to recognize the signs of anxiety and the stimuli that trigger it so that they can gradually replace their maladaptive responses with adaptive ones. Finally, to reduce behavior problems, CBT teaches parents how behavior is triggered, shaped, and possibly maintained by consequences. CBT also teaches parents how to improve their child’s behavior, and about the impact that the sexual abuse had so that they are better able to understand their child’s behavior.

CBT for sexually abused children and adolescents typically includes short-term structured interventions, lasting about 12 sessions; however, sessions can extend up to 40 sessions depending on the individual’s need. Interventions are tailored to the developmental age of the child or adolescent, as well as to their symptoms.

As a type of cognitive behavioral treatment, imagery rehearsal therapy (IRT) can also be used as a therapeutic approach to child sexual abuse. Given that approximately 70 percent of individuals with PTSD experience chronic nightmares, which most often include reliving their traumatic experiences, IRT is used to help alleviate the posttraumatic nightmares (Wittmann, Schredl, and Kramer, 2006). With IRT, children and adolescents are asked to recall their nightmares and, in time, rewrite the nightmares into less threatening content (Rose 2013).

Another therapeutic approach that can be used to treat victims of child sexual abuse is eye movement desensitization and reprocessing (EMDR). The goal of EMDR treatment is to help individuals who have experienced traumatic stress to reprocess and adaptively store traumatic memories. Treatment sessions focus on the past experiences that may have caused PTSD or other psychological disorders; the current circumstances that trigger dysfunctional emotions, beliefs, and sensations; and the positive experiences that can improve future adaptive behaviors and mental health (Scheck, Schaeffer, and Gillette 1998).

Mental Health & Behavioral Health | Trauma/PTSD
Therapeutic approaches to child and adolescent sexual abuse were found to have statistically significant impacts on symptoms of posttraumatic stress disorder (PTSD)/trauma. Aggregating the results of five studies, Harvey and Taylor (2010) found an overall effect size of 0.77, meaning that participants in the treatment groups had lower PTSD/trauma symptoms than comparison group participants. The effect size converts to a 68 percent improvement for children and adolescents who received treatment, compared with a 32 percent improvement for the comparison groups. Similarly, examining six studies, Trask and colleagues (2011) found an overall effect size of 0.63, indicating a medium effect. This means that psychological treatment was effective at reducing PTSD symptoms in the treatment groups, compared with the comparison groups. Finally, Macdonald and colleagues (2012) aggregated the results of six studies and found an overall effect size of 0.44, meaning that participants in the treatment groups experienced greater decreases in PTSD/trauma symptoms as a result of therapy, compared with the comparison groups.

Mental Health & Behavioral Health | Externalizing behavior
Across 15 studies, Harvey and Taylor (2010) found that therapeutic approaches for child sexual behavior significantly reduced measures of externalizing behavior symptoms (effect size=1.39). This converts to an improvement of 78.5 percent for children and adolescents who received therapeutic treatment, compared with 21.5 percent for the comparison groups. Trask and colleagues (2011) aggregated the results of 12 studies and found that therapeutic approaches had a small effect on reducing externalizing problems following childhood sexual abuse (effect size=0.39). However, Macdonald and colleagues (2006) examined the results from five studies and found that therapeutic approaches, specifically cognitive behavioral therapy (CBT), did not significantly affect child problem behaviors.

Mental Health & Behavioral Health | Internalizing behavior
Harvey and Taylor (2010) aggregated the results of 22 studies and found that therapeutic approaches for child sexual behavior had a statistically significant impact on measures of internalizing behaviors (effect size= 0.8). This translates to a 69 percent improvement for children and adolescents who received treatment, compared with a 31 percent improvement for the comparison groups. Similarly, Trask and colleagues (2011) examined 15 studies and found that therapeutic approaches for child sexual behavior had a medium effect on reducing internalizing behaviors (effect size=0.56). Finally, Macdonald and colleagues (2012) looked at the results of five studies and found that CBT had a modest impact on reducing internalizing behaviors (effect size=-1.9). Overall, these results indicate that therapeutic approaches reduce the internalizing symptoms experienced by victims of child sexual abuse.

Meta-Analysis Snapshot
	Literature Coverage Dates	Number of Studies	Number of Study Participants
Meta Analysis 1	1986-2001	5	168
Meta Analysis 2	1987-2009	16	852
Meta Analysis 3	1996-2004	10	847

Meta Analysis 1

Harvey and Taylor (2010) conducted a meta-analysis to examine the impact of therapeutic approaches for children and adolescents who are sexually abused. They reviewed studies that met the definition of therapy, which was defined as “any intervention designed to alleviate psychological distress, reduce maladaptive behavior, or enhance adaptive behavior through counseling, structured or unstructured interaction, a training program, or a predetermined treatment plan” (Weisz, Weiss, Alicke, and Klotz 1987). If the study met the definition criteria set, then the therapy had to have been conducted by trained professionals, professionals in training, and paraprofessionals. Pharmacological treatments, interventions that were designed to increase knowledge, and prevention interventions were not eligible. In addition to the definitional criteria, the following criteria were used to determine inclusion into the meta-analysis: 1) the study examined treatment outcomes with children or adolescents up to 18 years old who had experienced sexual abuse, 2) the results were based on empirical findings, 3) the study was written in English, 4) the study was not a single case study, 5) at least 50 percent of the treated sample had been sexually abused, 6) sufficient data was provided to calculate effect size, and 7) the studies reported independent datasets.

A comprehensive search of bibliographic databases, bibliographies of previous meta-analyses, and literature reviews was conducted. The search yielded 48 eligible reports, some of which were multiple publications from the dataset. Therefore, reports referring to the same study but presenting follow-up data were linked and only coded once, which resulted in a total of 40 eligible studies that were included in the meta-analysis. Of the 40 studies, 5 were independent sample designs, and 35 were repeated measures designs. (For the review of this meta-analysis, only outcomes from the independent samples studies were assessed.) Comparison groups included treatment as usual and supportive counseling, which were considered separate therapeutic approaches, as well as minimal attention, and wait-list control, which were considered control groups. All five of the independent-samples studies used a wait-list control, and four compared one treatment group with the control group, whereas one compared two types of treatment with the control group.

A random-effects mean was used to examine the impact of psychotherapy on children and adolescents exposed to sexual abuse on measures of posttraumatic stress disorder (PTSD)/trauma, internalizing behavior, and externalizing behavior. The five independent-samples studies generated six treatment conditions, which included child cognitive behavioral therapy, family cognitive behavioral therapy, imagery rehearsal therapy, and group therapy. The total number of study participants in all five studies was 168. In terms of age, 50 percent of the sample were between 7 and 12 years old, while the other 50 percent were between 13 and 19 years old. Approximately 17 percent were boys, while 83 percent were girls.

Meta Analysis 2

Trask, Walsh, and DiLillo (2011) conducted a meta-analysis to assess the overall effectiveness of treatments for the negative consequences of child sexual abuse. The authors reviewed studies from between 1960 and 2009, which were written in English. To be eligible for inclusion, studies had to 1) explicitly focus on evaluating the effects of a treatment for child sexual abuse experienced by victims younger than 18; 2) be written in English; 3) assess the effectiveness of an intervention using at least one outcome that could be categorized under PTSD symptoms, externalizing problems, or internalizing problems; 4) allow for the calculation of effect sizes; and 5) include a no-treatment or attention-placebo comparison group. A comprehensive search of bibliographic databases, bibliographies of previous meta-analyses, and literature reviews was conducted. Both published and unpublished reports were included in the search. The search yielded 35 articles or dissertations that met the inclusion criteria.

A coding system was developed to identify and search for variables. Three classes of variables were created: 1) psychological outcomes, which consisted of PTSD, externalizing, and internalizing problems; 2) treatment characteristics, which included the theoretical approach treatment, treatment duration, inclusion of a caregiver, type of control group, and treatment modality; and 3) participant characteristics.

The focus of the review for CrimeSolutions was on the studies that included comparison groups. This included 16 studies, comprising a total of 852 participants that were analyzed using a random-effects model to examine the effectiveness of treatment following child sexual abuse.

Meta Analysis 3

Macdonald and colleagues (2012) conducted a meta-analysis to assess the effectiveness of cognitive behavioral therapy (CBT) in addressing the consequences of child sexual abuse. The criteria for inclusion were 1) studies had to have used random allocation or quasi-random allocation to experimental or control groups; 2) studies must have compared CBT to treatment as usual, with or without placebo control; 3) studies had to have included children and adolescents 18 and under who had experienced sexual abuse; 4) studies had to have analyzed the effectiveness of interventions described by the authors as behavioral or cognitive behavioral; 5) the studies’ outcomes had to have examined the psychological functioning of a child, child behavior problems, further offending behavior, and parental skills and knowledge.

A comprehensive search of bibliographic databases, bibliographies of previous meta-analyses, and literature reviews was conducted at four different time points. Both published and unpublished reports were included in the search. The search yielded 10 randomized trials, involving 847 participants. All studies examined CBT programs provided to children or to children with a nonoffending parent. One study compared CBT with a wait-list control, while the rest compared CBT with treatment as usual, which was usually supportive, unstructured psychotherapy. The primary outcomes were depression, posttraumatic stress disorder, anxiety, and child behavior problems.

A random-effects mean was used to examine the impact of CBT psychotherapy on children and adolescents exposed to sexual abuse.

Practice Profile: Therapeutic Approaches for Sexually Abused Children and Adolescents

Practice Summary

Practice Description

Practice Goals

Target Population

Practice Components

Meta-Analysis Outcomes

Meta-Analysis Methodology

Cost

Evidence-Base (Meta-Analyses Reviewed)

Additional References