Effective Psychosocial Therapeutic Approaches for Child Sexual Abuse: A Literature Review

The Australian Institute of Health and Welfare (AIHW, 2013, p.59) reports that 5,828

Australian children/adolescents (aged 0-17 years) were subjected to substantiated child sexual

abuse (CSA) in 2011-2012. The literature on CSA highlights that this form of trauma occurs

in all races, ethnicities and economic classes (Goldman & Padayachi, 1997; Oates, 1990;

O’Donnell & Craney, 1992). Briere and Scott (2015) report that CSA occurs “at the most

vulnerable point in human development” (p.30), with the majority of onset occurring from

the age of three to eight years of age (Finklehor, 1994). Extensive literature (e.g. Burns,

Kolko, Putnam & Amaya-Jackson, 2008; Polusny & Follette, 1995) outlines the immediate

and long-term effects associated with CSA such as anxiety, depression, posttraumatic stress

disorder (PTSD), substance abuse and various behavioural and trauma-related symptoms.

Perry (2001, 2009) states that it is imperative that children and adolescents exposed to

trauma-related psychopathology be treated as promptly and professionally as possible to

reduce the effects of permanent impairment. The aim of this study was to conduct a review of

the literature to identify best-practice psychosocial therapeutic approaches in reducing the

most common trauma-related symptoms of CSA in children and adolescents (aged 0-17 years

of age). The results provide a summary of the key trauma-informed approaches currently

utilised with children and adolescents, indicating that Trauma-Focused Cognitive Behavioral

Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) has the greatest empirical

evidence for treating children and adolescents traumatised by CSA.

Method

An electronic search strategy was performed using EBSCOhost to search within

PsycARTICLES, Psychology and Behavioral Sciences Collection and PsycINFO. As well as

search engines Google and Google Scholar. The following keywords were used to perform

the search: trauma, child*, adolescents, young people, therapy, child sexual abuse,

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evidence-based, psychosocial treatment, best-practice, systematic review, meta-analysis and

psychological harm. Additionally, the reference lists of all of the articles were searched and

reviewed.

Criteria of Inclusion

The review relates to the inclusion of the following criteria: 1) Children and

adolescents (aged 2-17 years) who have directly experienced CSA; 2) studies within the last

20 years (1994-2014); and 3) evidence-based psychosocial therapeutic approaches which

reduce trauma-related outcomes. Of the studies identified, 21 met the criteria of inclusion and

are included in this review. The bulk of the studies originated from America, with various

treatment approaches used. The majority of participants across all studies were predominately

girls.

Brief Description of Best-Practice Therapeutic Approaches for CSA

The best-practice therapeutic approaches in the reviewed studies are consistent, in that

they all utilise a form of short-term therapy, consisting of between 12 – 20 sessions, and

ranging from 50 minutes to 2 hours in length for group therapy. Peters and Miller (2004) state

that short-term therapy is a collaborative process with clear and focused goals. It is

strengths-based, and therefore, focuses on identifying resources and capabilities, rather than

deficits or problems thus, most of the therapeutic work is said to occur between sessions.

Child Centred Therapy (CCT; Deblinger & Heflin, 1996). CCT is a short-term

(12 weekly sessions, 90 minutes in duration) child/parent centred treatment model focused on

establishing a trusting therapeutic relationship which is self-affirming, empowering and

validating for the parent and child.

Child Cognitive Behavioral Therapy (C-CBT; Stallard, 2002). C-CBT is a

short-term child centred therapy consisting of 20 individual sessions lasting 50 minutes in

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duration. The psychotherapeutic sessions involve psychoeducation, relaxation, cognitive

training, and imaginal exposures such drawings, role plays and writings.

Cognitive Behavioral Therapy (CBT; Beck, 1960). CBT is a short-term

psychotherapeutic approach which assists people to identify and change (with the use of

specific skills) unhelpful or unhealthy thoughts, feelings and behaviours.

Cognitive Behavioral Therapy for Sexually Abused Preschool Children

(CBT-SAP; Cohen & Mannarino, 1993). CBT-SAP is a structured short-term 12 session

treatment model targeting common trauma-related symptoms of preschool children including

sadness, sexualised behaviours, anger and regressive behaviours.

Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1989).

EMDR is an integrative eight-phase short-term treatment approach for children and

adolescents suffering trauma-related symptoms. EMDR can last up to 90 minutes in length

and commonly comprises the use of eye movements or finger taps in young children during

recollection of trauma memory.

Group therapy. Trowell et al., (2002) believe group therapy to be psychoeducational

as well as psychotherapeutic. With Kanas (2005) reporting it to be an effective time-limited

treatment strategy for trauma-related outcomes. Manor (1994) states that the exact nature in

which group therapy is conducted is contingent largely on the aims and goals of the group

and the therapist style.

Nondirective Supportive Therapy (NST). Cohen et al., (2006) describe NST as

consisting of “supportive play for younger children, and nondirective, supportive

client-centred therapy for older children” (p.742). Treatment is short-term and ideally occurs

over 12 sessions, which are 90 minutes in duration, focussing on generating solutions to

trauma-related emotions and behaviours (McKay & Storch, 1999).

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Sexual-Abuse Specific Cognitive Behavioral Therapy (SAS-CBT). Cohen and

Mannarino, (1998) purport that SAS-CBT is like TF-CBT as it consists of several treatment

elements. Pauldi and Denmark (2010) believe that SAS-CBT “emphasises positive thought

processes and the cognitive modification or reframing of the thoughts surrounding the

event(s)” (p.90).

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2006).

TF-CBT was specifically designed for sexual abuse, targeting trauma-related symptoms

(Cohen, et al., 1993; Deblinger et al., 1996). TF-CBT has demonstrated effectiveness in

decreasing PTSS, PTSD, anxiety, depression, externalising and sexualised behaviours, as

well as feelings of shame, self-blame and mistrust. Fundamental elements of TF-CBT include

the acronym “PRACTICE: Parenting skills, psychoeducation, relaxation skills, affective

modulation skills, cognitive processing, trauma narration, in vivo desensitization, conjoint

child-parent sessions, and enhancing safety and future development” (Cohen et al., 2006,

p.741). TF-CBT is a short-term treatment occurring over 12-16 weeks for a duration of 60-90

minutes.

Key Research Studies on CSA

Various psychosocial treatment approaches have been studied in order to provide

recommendations for best-practices for children and adolescents suffering from the

symptoms associated with CSA. Cohen and Mannarino (1996a, 1997) for instance, compared

TF-CBT to NST with sexually abused children, 3-7 years of age, and their non-offending

parents/careers. These studies utilised the CBCL to identify problem behaviours. Both studies

found consistent findings indicating that children in TF-CBT showed significant

improvements in PTSS, externalising behaviours and social competence, as well as

decreasing depression. Whilst parents showed significantly less parental emotional distress.

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Cohen, Deblinger, Mannarino and Steer (2004) addressed sample size limitations of

TF-CBT studies in their multisite randomised trial of 229 participants (8-14 years of age)

comparing TF-CBT to CCT. CCT, in this study, was deemed similar in both duration and

content to CBT-SAP used in Cohen and Mannarino’s (1996b) previous study. Cohen, et al.,

(2004) used the Trauma Symptoms Checklist for Children (TSC-C; Briere, 1995), to assess

PTSS; the Child Depression Inventory (CDI; Kovacs, 1992), to assess depressive symptoms;

the State-Trait Anxiety Inventory for Children (STAIT; Spielberger, 1973), to measure

anxiety; and the CBCL. Results indicated that children in TF-CBT showed statistically

significant improvements in the reduction of depressive symptoms, sexualised behaviours,

shame, anxiety and trauma-related emotional distress. These results were found to be

consistently maintained over time by Deblinger, Mannarino, Cohen & Steer’s (2006) six and

twelve month follow up studies, showing efficacy of TF-CBT with this population.

Furthermore, Deblinger, Mannarino, Cohen, Runyon and Steer (2011) assessed

TF-CBT as an effective treatment of CSA. Their randomised study compared TF-CBT with

and without the trauma narrative (TN) component with 210 children aged 4-11 years. They

utilised the PTSD section of the Schedule for Affective Disorders and Schizophrenia for

School-Age Children (K-SADS; Orvaschel, Puig-Antich, Chambers, Tabrizi &

Johnson,1982); the CDI; the Fear Thermometer, which is contained in the phobia section of

the Anxiety Disorders Interview Schedule for Children (ADIS-C; Silverman & Nelles, 1988),

allowing children to self-rate their sexual abuse-related fear; the Multidimensional Anxiety

Scale for Children (MASC; March, et al., 1997), to measure global anxiety; and the WIST

(WIST; Wurtele, Hughes, & Owens, 1998). Deblinger et al.’s (2011) results found positive

outcomes in both comparison groups in relation to improvements in behaviours and safety

skills. However, the TN component was found to be particularly effective in reducing anxiety

and fear in relation to the trauma. In Deblinger, Mannarino, Cohen, Runyon & Steer’s (2012)

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follow-up study, at six and twelve months, they noted that these positive outcomes were

sustained.

In reviewing TF-CBT, Deblinger et al.’s TF-CBT studies (2011/2012) did not utilise

CBCL as an outcome measure, as it has been utilised in previous studies. Such a measure is

considered the most commonly used questionnaire for trauma-related outcomes resultant

from CSA. The reasoning behind this decision is unknown. Nevertheless, all of the studies

analysed in this review, in relation to TF-CBT, showed moderate to large effect sizes,

suggesting that the use of TF-CBT is efficacious in treating CSA. A further element to note is

the involvement of non-offending parents/careers included in the therapy, or as a supportive

role. Cohen et al., (1998) believe that involving a non-offending parent can lead to enhanced

parenting skills and improved support for the sexually abused child/adolescent.

In addition, Cohen, et al., (1998) and Cohen, Mannarino and Knudesn (2005)

compared NST to SAS-CBT. The outcome measures of CBCL and STAIC were utilised,

demonstrating SAS-CBT to be superior to NST in reducing anxiety, depression, PTSS and

sexual behaviours in sexually abused children and adolescents who ranged in age from 8-14

years. Cohen et al., (1996b) compared NST to CBT-SAP in 67 sexually abused children (2-7

years of age). The outcome measure CBCL; and the Child Sexual Behaviors Inventory

(CSBI; Friederich et al., 1992), designed to assess behaviours in sexually abused or suspected

sexually abused children were used. The results indicated that CBT-SAP demonstrated

greater improvement in terms of reduction of behaviours than did NST.

Similarly, Celano, Hazzard, Webb and McCall (1996) compared NST to CBT in their

randomised study with 32 sexually abused African American girls and their non-offending

parents/careers. Results demonstrated that CBT provided positive changes in parental support

however, did not demonstrate improvements for PTSD symptoms. Thus, suggesting that the

involvement of parents/careers is of value in treating sexually abused children/adolescents. In

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further studies, Deblinger, Stauffer and Steer (2001) investigated the effectiveness of NST to

CBT. The outcome measures for children aged 2-8 years of age included CBCL; K-SADS;

CSBI; and the What If Situations Test (WIST; Wurtele et al., 1998), to assess abilities to

recognise and respond effectively to abusive situations. Whilst several outcome measures

were used to assess non-offending parents/careers in relation to general coping skills, parental

stress and feelings of fear and guilt. These measures found greater improvement in children’s

safety skills and reduced PTSS when using CBT, whilst parents/carers displayed less

negative feelings in respect to their child’s sexual abuse.

King et al.’s (2000) randomised clinical trial compared a wait-list control condition to

parent only CBT and child only CBT for 36 sexually abused Australian children aged 5-17

years, and found no significant differences between the two therapies. The child only CBT

treatment demonstrated improvements in PTSD, PTSS, fear, anxiety and depression than

those in the wait-list condition. Whilst, the parent only treatment group found improvements

in global functioning. Furthermore, they found that the inclusion of family members in

treatment shows a differential benefit, as did Cohen et al., (1998) in their study.

Arnold, et al., (2003) utilised gender-specific CBT in their study of 100 sexually

abused adolescent girls, aged 12-17 years of age. They used the Multidimensional Adolescent

Scale (MAS; Hudson, 1996), to assess the severity of personal and social problems. Results

showed significant differences in 14 of the 16 subscales, thus demonstrating a positive

response to gender-specific CBT.

Further evidence for CBT in improving PTSS and trauma-related outcomes is

highlighted in Deblinger, Lippmann, and Steer’s (1996) randomised control study of 100

sexually abused children aged 7-13 years. The outcome measures of CDI; CBCL; STAIC;

and K-SADS-E demonstrate that CBT shows significant improvements in depressive

symptoms, PTSD, PTSS and externalising behaviours. These improvements were notably

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sustained in Deblinger, Steer and Lippmann (1999) two year follow up studies, which

included measures at three months, six months, one year and two years.

In examining group interventions, Tourigny, Hébert, Daigneault and Simoneau (2005)

in their quasi-experimental study, demonstrated significant improvements in 27 adolescent

girls in PTSS and externalising behaviour problems, which were addressed directly within

two-hour group intervention sessions over 20 weeks. Tourigny and Hébert (2007) further

demonstrated the efficacy of this approach in their quasi-experimental approach with teenage

girls reporting CSA. They pose group therapy as a promising approach to working with

sexually abused adolescents. Their study of 55 girls, aged 13-17 years of age, found that both

open group intervention and closed group were correspondingly effectual in yielding

significant changes in behavioural problems. They used the outcome measures of TSC-C;

Youth Self-Report and Profile (YSRP; Achenbach, 1991); Ways of Coping Questionnaire

(Folkman & Lazarus, 1988); Empowerment Scale (Rogers, Chaberlin, Langer, Ellison &

Crean, 1997); Children’s Attributions and Perception Scale (CAPS; Mannarino, Cohen &

Berman, 1994); and Self-Injurious Behaviors Questionnaire (SIBQ; Sadowsky, 1995). The

results of both group interventions showed significant improvements in PTSS, behavioural

problems, positive coping and empowerment.

Similarly, McCain and McKinzey (1995) evaluated the efficacy of group therapy, but

using a wait-list design. They used the Revised Behavior Problem Checklist (RBPC; Quay &

Peterson, 1987), to rate problem behaviours, as well as the Eyeberg Child Behavior Inventory

(ECBI; Eyeberg, 1980), to assess symptomatic change. The study demonstrated reduced guilt

and depression and improved self-esteem. As per Tourigny et al.’s (2005, 2007) studies,

McCain, et al.’s (1995) study indicates that group therapy improves behavioural problems in

sexually abused children/adolescents. Conversely, Trowell et al. (2002) in their randomised

comparison study of 71 sexually abused girls, aged 6-14 years, found individual

9

psychotherapy to more efficacious than group therapy. Their study utilised a shortened

version of K-SADS, as well as the Children’s Global Assessment Scale (C-GAS; Shaffer, et

al., 1983) to assess global impairment of functioning. The results showed a reduction in both

groups on trauma-related symptoms and improvements in functioning. However, individual

psychotherapy showed a further reduction in PTSD and PTSS. Thus, demonstrating that

individual psychotherapy has a greater impact on treatment outcomes than does that of group

therapy.

Similarly, Lanktree and Briere (1995) studied 105 sexually abused children, 8-15

years of age, using the TSC-C and the CDI, to assess psychological symptoms within

individual psychotherapy and group therapy. In contrast to Trowell et al. (2002) the results

demonstrated no definitive answers, with Lanktree et al., (1995) stating that reductions in

symptoms could be due to clinical intervention, or arise from time passing. In reviewing the

efficacy of group therapy, it is important to note that relatively few studies have been

conducted on this method in relation to CSA. Putnam (2003) conclude that not enough

randomised controlled trials have been performed to state unquestionably that a decrease in

symptom severity is owing to psychosocial treatments and not purely the passage of time

Jaberghaderi et al., (2004) is the only study to compare Eye Movement

Desensitization and Reprocessing (EDMR; Shapiro, 1989) in girls who have experienced

CSA. Their randomised control study comparing EDMR and CBT in 14 sexually abused

Iranian girls, aged 12-13 years, assessed PTSS outcomes using the Child and Parent Report of

Posttraumatic Symptoms (CROPS, PROPS; Greenwald & Rubin, 1999); and the Rutter

Teacher Scale (RTS; Rutter, 1999). Both treatment approaches reported large effect sizes in

reducing PTSS, and medium effect sizes in improving external behaviours. Whilst both

EDMR and CBT appeared to be effective in reducing trauma-related symptoms, EDMR was

noticeably more effectual. However, the limited power of such a small population makes it

10

difficult in detecting significant differences between the two therapies. Therefore, replication

with greater power is warranted. Furthermore, other treatment approaches may be beneficial

in treating sexually abused children/adolescents. Eggiman (2006) and Pifaloo (2006) suggest

approaches such as play, art and pet therapy to be effective in relieving symptoms and

behaviours resultant from CSA. However, before recommending any of these treatments

more research is required, as there are currently a lack of publications on the efficacy of such

approaches.

Recommendations

In reviewing the literature, it is important to consider that symptom patterns of CSA

vary by age. Many of the reviewed studies of CSA consisted of a preponderance of girls and

focused on a specific age sub-group, i.e. adolescents, preschool children. Therefore, the

diversity of this population makes it questionable that one particular therapeutic approach

may be effectual or appropriate for all children (Australian Psychology Association,

Presidential Task Force on Posttraumatic Stress Disorder and Trauma in Children and

Adolescents, 2008). However, the UK National Institute for Health and Clinical Excellence

(NICE; 2005) report evidence of effectiveness, and recommend use of TF-CBT or EMDR

approaches for trauma-related outcomes of CSA. Whilst, the National Child Traumatic Stress

Network (2008) views TF-CBT as best-practice treatment for CSA in reducing PTSD, PTSS

and various trauma-related symptoms and behaviours. Yet, Greenspan, Moretzsohn and

Silverstone (2013) state that CBT is analogous with TF-CBT in treating trauma-related

outcomes of CSA. Furthermore, the literature review revealed that treatment approaches with

a CBT component (i.e. TF-CBT, SAS-CBT) showed beneficial results for the inclusion of

non-offending parents/carers, in relation to enhanced parenting skills and improved support,

with less negative feelings (Celano et al., 1998; Cohen et al., 2000; Deblinger et al., 2001;

King et al., 2000). Based on the aforementioned studies in this review, TF-CBT is

11

recommended as an efficacious short-term therapeutic approach to treating

children/adolescents who have been sexually abused. This finding is in line with Greenspan

et al., (2013), who suggest CBT to be beneficial for adults over 25 years, with TF-CBT being

more appropriate for children and adolescents. Furthermore, the review has demonstrated that

involving non-offending parents/careers is integral to positive treatment outcomes for

children/adolescents who have been sexually abused.

Conclusion

It is evident within the literature that significant advances in the development and

evaluation of psychosocial treatment approaches for trauma-related symptoms associated

with CSA have been made. Several trauma-focused therapeutic approaches have been

established to assist children/adolescents to recover from the debilitating effects of CSA

within a safe and professional environment. Many of the reviewed psychosocial treatment

approaches demonstrate significant decreases in trauma-related symptoms such as PTSD,

PTSS, anxiety, depression and various behavioural concerns. As highlighted, TF-CBT is the

most commonly investigated treatment approach for sexually abused children/adolescents,

with the strongest empirical evidence. Still, findings from CBT are comparable to those of

TF-CBT, with many other treatments available having not been sufficiently tested therefore,

the evidence of the effectiveness or ineffectiveness of these approaches is undetermined

(LaGreca, Silverman, & Lochman, 2009). Consequently, the American Psychological

Association Presidential Task Force on Posttraumatic Stress Disorder and Trauma in

Children and Adolescents (2008) state that in treating trauma-related outcomes of CSA it is

imperative that professionals use best-practice psychosocial therapeutic approaches; are

informed of the developments within the field; and receive ongoing professional development

in order to improve the lives of children and adolescents exposed to CSA.

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