Learning Objectives

After reading this article, you should be able to:

1. Demonstrate an understanding of the prevalence and long-term consequences of childhood sexual abuse.

2. Examine the evidence-based treatment approach of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for children and adolescents who have experienced sexual abuse.

3. Synthesize the key components and techniques involved in implementing TF-CBT in the treatment of child sexual abuse.

Childhood sexual abuse is unfortunately more common than many people realize. A study of adverse child experiences (ACEs) conducted across 23 states found that 16.33% of female participants and 6.70% of male participants experienced sexual abuse before turning 18 (Merrick MT et al, JAMA Pediatrics 172(11), 1038-1044). These numbers may even be underestimated due to the stigma around sexual abuse, which can lead to underreporting.

The effects of child sexual abuse can be severe, leading to a range of psychological, interpersonal, and physical health issues, as well as an increased risk for revictimization (Papalia N et al, Child Maltreat 2021;26(1):74-86). There have even been neurobiological changes associated with sexual abuse (Shrivastava AK et al, Ind Psychiatry J 2017;26(1):4-12).

So, it's essential for you to provide effective mental health treatment to address child sexual abuse and help prevent these potentially lifelong negative consequences. Involving nonoffending caregivers in the treatment can also have a positive impact on the child's behavioral adjustment after the abuse (Brown EJ et al, J Affect Disord 2020;277:39-45; Deblinger E et al, Child Maltreatment 1996;1(4):310-321).

TF-CBT: An evidence-based treatment

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based treatment with a growing body of literature that supports its effectiveness. It's been evaluated in over 100 scientific publications and at least 24 randomized controlled trials (Cohen, J. A., et al. (2017). Treating Trauma and Traumatic Grief in Children and Adolescents (2nd ed.). New York, NY: Guilford Press).

Research has shown that TF-CBT leads to significant improvements in posttraumatic stress, depression, and behavioral problems among children and adolescents. It also leads to improvements in parenting practices and abuse-related distress. 

Studies have shown that these improvements last over follow-up periods ranging from six months to two years (Jensen TK et al, J Abnorm Child Psychol 2017;45-1587-1597). TF-CBT also helps children build resilience, including increases in mastery and relatedness, and decreases in emotional reactivity (Deblinger E et al, Child Abuse & Neglect 2017;65:132-139). The California Evidence-Based Clearinghouse for Child Welfare has given TF-CBT the highest scientific rating (www.cebc4cw.org).

While TF-CBT was initially developed for children who experienced sexual abuse, it has also been found effective for those who have experienced other types of trauma and loss, such as exposure to domestic violence, disasters, and war. It's also been successfully adapted for youth in foster care and residential treatment, youth living across the world, including in low-resource countries, and youth who have experienced multiple traumas/have complex trauma. Research has also documented the efficacy of TF-CBT delivered via telehealth, a format that has gained more widespread utilization since the COVID-19 pandemic (Stewart RW et al, J Psychother Integration 2020;30(2):274-289). 

How TF-CBT works

Before starting TF-CBT, it's important to build a strong therapeutic relationship with both the child and caregiver. Start by assessing their needs and identifying their main treatment goals. Keep an eye out for any obstacles that might get in the way of therapy, like negative past experiences. If your clients seem disheartened by previous therapy, take the time to explain how TF-CBT is different and better suited to their needs. And if the family has other pressing needs following the trauma, provide them with referrals to help them get back on their feet before starting therapy.

The PRACTICE acronym is your roadmap for TF-CBT, guiding you through its treatment components:

• Psychoeducation: Start by educating both the caregiver and child about child sexual abuse and other traumas, helping them understand the link between their experiences and the symptoms they're facing. Normalize their reactions and make them feel understood.
• Parenting skills: Teach caregivers effective parenting techniques to help them respond to their child's emotional and behavioral challenges. This will improve the child's adjustment and strengthen the caregiver-child relationship. Valuable parenting skills to emphasize include:
  • Praising prosocial behaviors frequently
  • Creating positive rituals/routines
  • Using selective attention to reduce mild problematic behaviors
  • Using time-outs with more significant problem behaviors when needed
  • Becoming familiar with contingency reinforcement schedules
• Relaxation skills: Teach children and caregivers ways to manage their emotions and reduce tension related to trauma reminders. Introduce skills such as focused breathing, progressive muscle relaxation, mindfulness, and meditation practices.
• Affect expression and modulation: Help your clients express and manage distressing emotions related to the trauma. Encourage sharing of feelings, positive imagery, and participating in physical activity, music, art, and other creative outlets for effectively managing emotions.
• Cognitive coping: Assist both the child and caregiver in understanding the relationships between thoughts, feelings, and behaviors. Teach them to catch and challenge problematic thinking patterns using tools like the cognitive triangle, which visually demonstrates the relationship between thoughts, feelings, and behaviors.
• Trauma narration and processing: Guide the child in gradually facing traumatic memories in a safe therapeutic environment. Use writing, art, or play to help them describe their experiences and uncover dysfunctional thoughts and beliefs. Examples of such beliefs may include “the sexual abuse was my fault; he abused me because I am worthless.” Then, help them challenge these thoughts and replace them with healthier perspectives, eg, “I am worthy of respectful treatment; I have a great deal to look forward to in the future”.
• In vivo mastery of trauma reminders: If needed, develop a step-by-step plan to help the child confront real-life situations that remind them of the trauma, aiming to reduce their avoidance and anxiety around these triggers. For instance, if a child is scared of being alone in a room, you could create a plan that gradually increases the distance between the caregiver and the child. Start with the caregiver right outside the door, then move them to the next room, down the hall, and eventually to another floor. Throughout this process, encourage the caregiver to praise the child's bravery while downplaying any fearful or avoidant behaviors.
• Conjoint sessions: In conjoint sessions, you bring caregivers and children together to enhance their overall communication, reinforce the skills they've learned, review educational materials, and increase the child's comfort in discussing their experiences of sexual abuse or other traumas with their caregiver, as long as it's clinically appropriate. By conducting these sessions, you create a supportive environment that encourages open dialogue and shared understanding between the child and caregiver.
• Enhancing safety and future development: Provide sex education and safety skills training for children who've experienced sexual abuse. Use role plays to boost their feelings of mastery and reduce vulnerability and risk of revictimization.

When it's time to wrap up TF-CBT, celebrate the progress and accomplishments of both the child and caregiver. Review post-treatment assessment measures to demonstrate their progress and acknowledge their hard work with certificates of completion and a special celebration.

Carlat Take: Rigorous randomized trials examining TF-CBT have repeatedly documented its efficacy in supporting the recovery of children, adolescents, and nonoffending caregivers in the aftermath of child sexual abuse. This is the go-to, most supported treatment for sexual abuse. Any practitioner who sees patients who have been impacted by childhood sexual abuse should consider adding this therapy to their tool bag.

References in order of appearance of this article

Merrick, M. T., Ford, D. C., Ports, K. A., Guinn, A. S., Chen, J., Klevens, J., & Gilbert, L. K. (2018). Prevalence of Adverse Childhood Experiences from the National Survey of Children's Health, 2016-2017. JAMA Pediatrics, 172(11), 1038-1044

Papalia, N., et al. (2021). Child Maltreatment and Its Impact on Developmental Outcomes. Child Maltreatment, 26(1), 74-86

Shrivastava, A. K., et al. (2017). Mental Health Issues in Elderly. Industrial Psychiatry Journal, 26(1), 4-12

Brown, E. J., et al. (2020). The Role of Social Support in Depression and Anxiety in Persons with Multiple Sclerosis. Journal of Affective Disorders, 277, 39-45

Deblinger, E., et al, Exposure therapy for posttraumatic stress disorder in children: A comparison between sexually abused and non-abused children. Child Maltreatment, 1(4), 310-321).  

Jensen, T. K., et al. (2017). Parent-Child Attachment and Bullying Involvement in Elementary School Children. Journal of Abnormal Child Psychology, 45, 1587-1597

Deblinger E et al. (2017). Parent-Child Interaction Therapy with Traumatized Children: A Randomized Controlled Trial Study. Child Abuse & Neglect, 65, 132-139

Stewart, R. W., et al. (2020). The Effects of Mindfulness-Based Interventions on Psychological Distress and Emotional Reactivity: A Systematic Review and Meta-analysis. Journal of Psychotherapy Integration, 30(2), 274-289