Predictors of treatment outcome in sexually abused children

PROBLEM: This study evaluated the impact of child and family characteristics on treatment outcome of sexually abused children. METHOD: Forty-nine recently sexually abused 7- to 14-year-old children were randomly assigned to either abuse-focused cognitive behavioral therapy or nondirective supportive therapy, and assessed pre- and post-treatment using several standardized instruments. These included five measures of psychological symptomatology and four measures of child and family characteristics hypothesized to mediate treatment response. Correlational and multiple regression analyses were utilized to evaluate the impact of the following mediating factors on treatment outcome: Children's abuse-related attributions and perceptions; family cohesion and adaptability; parental support of the child; and parental emotional reaction to the child's abuse. RESULTS: Children's abuse-related attributions and perceptions and parental support of the child were strong predictors of treatment outcome in this population. CONCLUSIONS: Therapeutic attention to children's sexual abuse-related attributions and to enhancing parental support may be important factors in optimizing treatment outcome in 8- to 14-year-old sexually abused children.     

Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms

OBJECTIVE: The present study sought to determine whether the 12-session pre- to posttest therapeutic gains that had been found by Deblinger, Lippmann. and Steer (1996) for an initial sample of 100 sexually abused children suffering posttraumatic stress disorder (PTSD) symptoms would be sustained 2 years after treatment. METHOD: These sexually abused children, along with their nonoffending mothers, had been randomly assigned to one of three cognitive-behavioral treatment conditions, child only, mother only, or mother and child, or a community comparison condition, and were followed for 3 months, 6 months, 1 year, and 2 years after treatment. RESULTS: A series of repeated MANCOVAs, controlling for the pre-test scores, indicated that for the three measures of psychopathology that had significantly decreased in the original study (i.e., externalizing behavior problems, depression, and PTSD symptoms), these measures at 3 months, 6 months, 1 year, and 2 years were comparable to the posttest scores. CONCLUSIONS: These findings suggest that the pre- to post-treatment improvements held across the 2-year follow-up period. The clinical and research implications of these findings are discussed.     

Dissociation predicts later attention problems in sexually abused children

OBJECTIVE: The goals of this research are to develop and test a prospective model of attention problems in sexually abused children that includes fixed variables (e.g., gender), trauma, and disclosure-related pathways. METHODS: At Time 1, fixed variables, trauma variables, and stress reactions upon disclosure were assessed in 156 children aged 8-13 years. At the Time 2 follow-up (8-36 months following the initial interview), 56 of the children were assessed for attention problems. RESULTS: A path analysis involving a series of hierarchically nested, ordinary least squares multiple regression analyses indicated two direct paths to attention problems including the child's relationship to the perpetrator (beta=.23) and dissociation measured immediately after disclosure (beta=.53), while controlling for concurrent externalizing behavior (beta=.43). Post-traumatic stress symptoms were only indirectly associated with attention problems via dissociation. Taken together, these pathways accounted for approximately 52% of the variance in attention problems and provided an excellent fit to the data. CONCLUSIONS: Children who report dissociative symptoms upon disclosure of CSA and/or were sexually abused by someone within their family are at an increased risk of developing attention problems. PRACTICE IMPLICATIONS: Findings from this study indicate that children who experienced sexual abuse at an earlier age, by someone within their family, and/or report symptoms of dissociation during disclosure are especially likely to benefit from intervention. Effective interventions should involve (1) providing emotion regulation and coping skills; and (2) helping children to process traumatic aspects of the abuse to reduce the cyclic nature of traumatic reminders leading to unmanageable stress and dissociation.     

Sexual abuse characteristics associated with survivor psychopathology

OBJECTIVE: This study was designed to examine predictors of psychopathology in non-clinically referred, sexually abused (SA) children, ages 6-16 years, 30-60 days following abuse disclosure and termination. METHOD: Eighty SA children were administered a structured diagnostic interview and a variety of rating-scale instruments. Several forms of psychopathology were assessed, including posttraumatic stress, global functioning, anxiety, depression, and externalizing behavior. Abuse interviews also were used to guide the collection of demographic (victim age, gender) and abuse-related information (e.g., frequency of abuse). RESULTS: Abuse-related factors and demographic variables accounted for greater than half of the variance predicting global functioning, and accurately predicted posttraumatic stress disorder (PTSD) status for 86% of the participants. Also, analyses yielded significant predictors of parent-reported attention problems and sexual behavior. Of additional importance, none of the abuse-related and demographic variables predicted scores on measures of general anxiety, depression, and externalizing behavior. CONCLUSIONS: Specific demographic and sexual abuse information may, to some extent, be used to identify children who are at increased risk for short-term post-abuse psychopathology. Although the present findings suggest that such information may not be useful in the prediction of general anxiety, depression, and externalizing behavior, demographic and abuse-related variables importantly appear to account for significant variance in the prediction of global functioning, posttraumatic stress, attentiveness, and sexual behavior. Additional research is needed to improve mental health professionals' ability to identify SA children who are at high risk for psychopathology.     

Behavioral/emotional indicators of sexual abuse in child psychiatric inpatients: A controlled comparison with physical abuse

Several behavioral and emotional indicators of child sexual abuse were compared for both sexually (n = 29) and physically abused (n = 52) children from a sample of 103 hospitalized psychiatric patients. The measures included (1) scores from a factor-analyzed sexual abuse symptom checklist covering home/community behavior that was rated by parents during a clinical interview and (2) frequency counts of psychological symptoms exhibited by the children during a 3-week period of hospitalization. Results of a 2 (sexual abuse status) X 2 (physical abuse status) X 2 (gender) Multivariate Analysis of Variance indicated that sexually abused children exhibited greater sexual behavior, fear/mistrust/anxiety, and withdrawal at home, and greater sexual behavior, fear/anxiety, and sadness in the hospital than nonabused children. In contrast, there were no significant differences between physically abused and nonabused children, and no significant interactions. Few significant correlations were found between symptoms exhibited at home and in the hospital.     

Sexual abuse: somatic and emotional reactions

A chart review and telephone interview of 72 sexual abuse victims was conducted to determine if children and adolescents who are victims of sexual abuse suffer from symptoms similar to the "rape trauma syndrome," which has been reported in adults. Symptoms similar to the rape trauma syndrome were found in 48 of the 72 abused children and only 26 of the matched control group, p less than .01. Common somatic complaints in the sexual abuse patients included dysuria, vaginal discharge and chronic abdominal pain. Some of the emotional and behavioral problems noted during the follow-up period among the sexual abuse patients included sleep problems, runaway behavior, and suicide attempts. The duration of abuse and age of the victim at the time of abuse significantly affected the frequency of reported somatic symptoms, but the type of abuse and type of assailant did not significantly affect the frequency of reported somatic and emotional reactions. There was no difference in the occurrence of school problems and early pregnancy between sexually abused patients and controls. Since 67% of all sexually abused patients suffered from emotional and somatic reactions, close follow-up of these patients is indicated.     

Maternal variables related to sexually abused children's functioning.

OBJECTIVE: The purpose of this study was to explore how mothers' developmental history and current functioning affects their sexually abused children's functioning and recovery. METHOD: A sample of 67 African-American mothers and their sexually abused children participated in this study. Interviews and a range of adult and child measures were administered in order to assess maternal developmental history and current functioning, and child functioning. RESULTS: Mothers' past experiences as children were associated with their children's behavior and general functioning following the sexual abuse. Mothers who experienced more discontinuity of childhood care, who were sexually abused as children, and/or had more problems in their family of origin had children who showed poorer functioning and more behavioral symptomatology. In addition, mothers who currently were experiencing more trauma symptomatology, reported substance abuse, and/or were less able to provide support to their children, had children with more behavior problems and poorer functioning. CONCLUSIONS: The findings from this study point to the impact of mothers' developmental history and current functioning upon the symptomatology of their sexually abused children.     

Physical and mental health of children with substantiated sexual abuse: Gender comparisons from a matched-control cohort study

When compared to children from the general population, sexually abused children receive more medical services, both for physical and mental health problems. However, possible differences between sexually abused boys and girls remain unknown. The lack of control group in studies that find gender differences also prevents from determining if the differences are specific to sexual abuse or to gender. The objective of the study was to assess differences in physical and mental health between sexually abused boys and girls in comparison to those from the general population. Administrative databases were used to document physical and mental health problems of 222 males and 660 females with a substantiated report of sexual abuse between 2001 and 2010. A comparison group individually matched to those from the sexually abused group on gender, age and geographic area was also used to document gender differences in the general population. Yearly incidence rates of diagnoses resulting from medical consultations and hospitalizations of males and females were compared over five years after a first substantiated sexual abuse report using the mixed general linear model. Sexually abused girls were up to 2.2 times more likely to consult a physician than sexually abused boys for physical health problems. Similar findings are observed in the general population. Conversely, results revealed that sexually abused boys were up to 2.3 times more likely than females to consult a physician for mental health problems. This gender difference was not apparent in the general population group.     

The efficacy of group treatment for survivors of childhood abuse

OBJECTIVE: To assess the effectiveness of a new model of group treatment for sexual abuse survivors over individual therapy alone. METHOD: In this quasi-experimental design, 32 women were in either group treatment (N = 22) or a wait-list comparison group (N = 10). They completed standardized measures on depression, self-esteem, and trauma symptomatology at pretest and after completing the 10 to 12 week group. All were in concurrent individual therapy. RESULTS: On average, both groups of women decreased depression and trauma symptoms as well as increased self-esteem. However, the clients in the treatment group improved their depression and anxiety to a statistically significantly greater degree than clients in the wait-list comparison condition. Improvement approaching statistical significance was found in levels of self-esteem in the treatment as compared to the wait-list condition. CONCLUSION: The group intervention was significantly more effective than individual treatment alone on depression and anxiety. The inclusion of the wait-list comparison group was critical in interpreting the improvement noted by all of the women in treatment.     

An assessment of the behavior of sexually abused and nonsexually abused children with anatomically correct dolls

The behaviors of two groups of children were observed and recorded in their play with anatomically correct dolls. One group had been determined to have been sexually abused and the other group had not been determined to have been sexually abused. The findings show that significantly more children who had been sexually abused demonstrated sexual behavior(s) with the anatomically correct dolls than did the group of children who had not been sexually abused. These findings suggest that anatomically correct dolls are a useful instrument in sexual abuse investigations.     

Sexual abuse in young children: its clinical presentation and characteristic patterns

A retrospective record survey was performed using all child clients aged less than 7 years seen at a community mental health center during the period 1982-1984. The total number of 202 children fell into three groups: sexually abused (n = 37), physically abused (n = 35), and nonabused clinical children (n = 130). These groups were compared in order to learn more about sexual abuse in young children. Family background of both abused groups were similar to each other but differed from the nonabused group in having more factors related to family stress than the nonabused group. Clinical presentations of all the children overlapped a great deal symptomatically; however, the sexually abused children had a statistically significant higher frequency of inappropriate sexual behavior than the other two groups. Several characteristics of the abusive patterns suffered by the two abuse groups differed at or near statistical significance: sexually abused children were more often victimized in single acts by nonrelated child perpetrators than were physically abused children.     

Sexual behavior problems in sexually abused children: a preliminary typology

OBJECTIVE: The goal was to develop an empirically derived typology for sexually abused children exhibiting sexual behavior problems to assist practitioners in differential assessment, treatment, and case planning. METHOD: Data were systematically gathered from the clinical records of 100 sexually abused children, aged 3 years to 7 years, enrolled in two treatment programs. Twelve indexes were created corresponding to major areas of child and family history, functioning, and treatment response. After initial sorting into subgroups based on the presence or absence of interpersonal sexual behavior problems, further subdivision was based on hierarchical cluster analysis. RESULTS: Five distinctive sexual behavior profiles emerged: (1) developmentally expected; and developmentally problematic (2) interpersonal, unplanned, (3) self-focused, (4) interpersonal, planned (noncoercive), and (5) interpersonal, planned (coercive). Elements of the child's sexual abuse experience, opportunities to learn/practice problematic sexual behavior, and familial variables best differentiated between the types. CONCLUSIONS: The five types differed not only in child sexual behavior but in most areas of child and family functioning, including treatment outcome. The findings offer support for the development of an empirically-based typology for children with sexual behavior problems utilizing a range of variables which go beyond typical classification systems based on offender and victim characteristics.     

Psychological symptoms in sexually abused girls

This study examined psychological symptoms exhibited by children who had recently been sexually abused. Twenty-four girls aged 6 to 12 years old were evaluated within six months of being abused using a variety of standardized child psychiatric instruments. Results showed a marked discrepancy between child and parent reports of symptoms. The abused children did not exhibit significant depressive, anxiety, or low self-esteem symptoms by self-report; however, their parents rated them as having significantly more behavioral problems than a normative sample but as somewhat less pathological than a clinical sample. The implications of these findings in relation to our current understanding of the psychological problems manifested by sexually abused children and for future research are discussed.     

Child sexual abuse prevention: Evaluation of a teacher training model

Teachers are potentially helpful resource persons for large numbers of sexually abused children who may have difficulty disclosing abuse, particularly to family members. In the present study, the effectiveness of a 6-hour teacher training workshop on child sexual abuse prevention was evaluated. Responses of 26 female elementary teachers who participated in the workshop were compared to responses of 19 control teachers on several pre-, post-, and follow-up measures. Relative to controls, trained teachers demonstrated significant increases from pre- to post-testing in knowledge about child sexual abuse and pro-prevention opinions. On a post-only vignettes measure, trained teachers were better able than control teachers to identify behavioral indicators of abuse and suggest appropriate interventions for hypothetical sexually abused children. Over a 6-week follow-up period, trained teachers read more about child abuse than control teachers but did not differ on other behavioral dimensions such as reporting suspected abuse cases. Further research will examine the effects of additional teacher training over an extended follow-up period.     

The sexually mistreated child: Diagnostic evaluation

Ten children, ages five through eleven, who had been sexually abused, were seen for diagnostic evaluations. The children represented a wide spectrum of sexual abuse. Nine of the children had numerous behavioral symptoms, the most frequent of which were sleep disturbances and school problems. Nine of the families were viewed as dysfunctional. The children displayed similar psychodynamic themes and were preoccupied in obtaining adequate parental care and affection of which they were deprived. The presence of unmet affectional needs in the child cut across all types of sexual abuse giving rise to the conclusion that a child with unmet affectional needs is at high risk for sexual abuse.Evaluations of sexually mistreated children should focus on family dynamics. The Kinetic Family Drawing test and the Conger Sentence Completion test are effective diagnostic tools. All children who have been sexually abused should be carefully evaluated and provided with appropriate treatment in their own right.     

A meta-analytic investigation of therapy modality outcomes for sexually abused children and adolescents: an exploratory study

OBJECTIVE: The purpose of the current study was to investigate the independent effects of different treatment elements on a number of secondary problems related to childhood and adolescent sexual abuse, as well as investigate a number of different moderators of treatment effectiveness. METHOD: Twenty-eight studies that provided treatment outcome results for children and adolescents who had been sexually abused were included in the meta-analysis. Different aspects of psychological treatment, such as specific treatment modalities (individual, cognitive-behavioral, etc.) or secondary problems (behavior problems, psychological distress, etc.) were investigated. RESULTS: The overall mean weighted effect size for the meta-analysis was d=.72 (SE=.02). The results indicate that psychological treatment after childhood or adolescent sexual abuse tended to result in better outcomes than no treatment. There was significant heterogeneity in the effectiveness of the various psychological treatment elements. Play therapy seemed to be the most effective treatment for social functioning, whereas cognitive-behavioral, abuse-specific, and supportive therapy in either group or individual formats was most effective for behavior problems. Cognitive-behavioral, family, and individual therapy seemed to be the most effective for psychological distress, and abuse-specific, cognitive-behavioral, and group therapy appeared to be the most effective for low self-concept. CONCLUSIONS: The choice of therapy modality should depend on the child's main presenting secondary problem. Further research should be conducted investigating other possible moderators and secondary problem outcomes.     

Build-a-Person Technique: an examination of the validity of human-figure features as evidence of childhood sexual abuse

OBJECTIVE: This exploratory study examined the discriminant validity of 10 human-figure features commonly used by many proponents of the draw-a-person (DAP) projective technique as evidence of childhood sexual abuse. Two exploratory features were also examined. METHOD: Rather than drawing human figures, 64 children (M = 8 years, 9 months), including 19 sexually abused children, 26 nonsexually abused but emotionally/behaviourally troubled children, and 19 nonabused, nonclinical children, were instructed to build male and female figures using groups of prefabricated pieces of human-figure body parts. Unbeknownst to the children, each group of parts contained a potential sexual abuse feature (or features). RESULTS: None of the human-figure features under examination, either individually, or in combination, distinguished the sexually abused group from the other two groups of children. CONCLUSIONS: In accordance with years worth of DAP projective technique research, no support for the validity of the human-figure features under examination as evidence of childhood sexual abuse, was found.     

A comparison of sexually abused and non-sexually abused adolescents in a clinical treatment facility using the MMPI-A

OBJECTIVE: In the current study, the adolescent version of the Minnesota Multiphasic Personality Inventory, the MMPI-A, was used to address concerns voiced about the mixing of different developmental ages, use of inadequate comparison groups, and the lack of reliance on reliable and valid measures of psychological, behavioral, and psychosocial problems used in previous studies of sexually abused children and adolescents. METHOD: A total of 107 adolescents in residential treatment (73 boys and 34 girls) were included in the study. Seventy-two of these adolescents had reportedly been sexually abused (42 boys and 30 girls); 35 had not been abused (31 boys and 4 girls). Predictions based on previous research with adolescents were made and tested regarding which MMPI-A validity, clinical, and content scales would differ between the sexually abused and non sexually abused groups of adolescents. RESULTS: Overall, and consistent with many predictions, sexually abused adolescents had both statistically and clinically higher elevations on several MMPI-A scales than did their non-abused counterparts. No scales were more elevated for non-abused adolescents than for abused adolescents. CONCLUSIONS: Sexually abused adolescents in residential treatment, as a group, present with concerns that their non-abused counterparts did not have, or did not share to the same extent. Treatment recommendations based on the MMPI-A scale elevations are provided, limitations of the current study discussed, and directions for further research are suggested.     

Abuse of children in foster and residential care

OBJECTIVE: There have recently been many debates in the UK about how to provide good care for children placed away from home. Professionals have realized that the level of child abuse in foster care and children's homes is high. This research examines the characteristics of physical and sexual abuse of children in foster and residential care in a city in England. The number of cases of abuse reported by pediatricians in this group was compared to the number reported by the same pediatricians for the population of Leeds as a whole. METHOD: This is a retrospective study of 158 children, fostered or in residential care who were involved in 191 episodes of alleged physical and/or sexual abuse assessed and reported by pediatricians over a 6 year period from 1990 to 1995 in Leeds, England. Details of the child including the reason for placement in care, their physical and mental health, abuse characteristics, including perpetrator and case management were studied. RESULTS (see Table 1): 158 incidents of abuse in 133 children in foster/residential care are described. In foster care, 42 children were physically abused, 76 were sexually abused, and 15 experienced both forms of abuse. In residential care, 12 children were physically abused, 6 were sexually abused, and 6 experienced both forms of abuse. In foster care 60% of sexual abuse involved girls and 60% of physical abuse involved boys. In residential care almost twice as many boys as girls were reported to be abused. Foster carers perpetrated the abuse for 41%, natural parents on contact for 23%, and children 20% of incidents. A significant proportion of abuse was severe with 1 death, 8 children with burns, 18 with genital, and 34 with anal penetration. Long-standing emotional, behavioral and learning difficulties were common. Most children (80%) had been abused prior to entry into care. Foster children were 7-8 times and children in residential care 6 times more likely to be assessed by a pediatrician for abuse than a child in the general population. CONCLUSIONS: Children in foster or residential care form an at risk group for maltreatment. Their special needs include additional measures to protect them from abuse.