Trauma-Focused CBT for Child Sexual Abuse
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Recent conservative estimates indicate that approximately one out of five girls and one out of 20 boys experience sexual victimization involving physical contact prior to the age of 18 (Saunders BE & Adams ZW, Child Adolesc Psychiatr Clin N Am 2014;23(2):167–184). However, these findings may underestimate the true rates of victimization because the stigma often associated with sexual abuse may keep some of those surveyed from reporting instances of abuse.
The effects of child sexual abuse vary. Some children have limited symptoms and other children experience mild to severe symptoms that can persist into adulthood (see for example, Kendall-Tackett KA et al, Psychol Bull 1993;113(1):164–180). The types of symptoms vary widely as well, and include poor self-esteem, depression, interpersonal difficulties, anxiety, dissociation, sexualized behaviors, substance use, suicide attempts, and an increased risk for revictimization (see for example, Maniglio R, Clin Psychol Rev 2009;29(7):647–657).
Psychiatric disorders associated with child sexual abuse include posttraumatic stress disorder (PTSD), major depressive disorder, panic disorder, alcohol/drug dependence, and bipolar disorder (Pérez-Fuentes G et al, Compr Psychiatry 2013;54(1):16–27). Sexual abuse also has been associated with neurobiological changes (Trickett PK et al, Dev Psychopathol 2011;23(2):453–476) as well as physical health difficulties that can persist into adulthood (Irish L et al, J Pediatr Psychol 2010;35(5):450–461).
A variety of unalterable factors, including increased frequency and invasiveness of the sexual abuse and the use of force, are associated with more severe abuse-related effects. However, one important factor that appears to positively impact youth outcomes is the degree of support received by these young people from non-offending caregivers (Elliot AN & Carnes CN, Child Maltreat 2001;6(4):314–331). In fact, research findings suggest that the participation of a non-offending caregiver in treatment positively influences children’s behavioral adjustment in the aftermath of sexual abuse (Deblinger E et al, Child Maltreat 1996;1(4):310–321).
The Evidence for Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
There are several promising treatments for child sexual abuse that involve youth with and without non-offending caregivers. However, with the exception of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), few of these treatments have been subjected to rigorous evaluations and replication studies (Cohen JA et al. Treating Trauma and Traumatic Grief in Children and Adolescents. New York: Guilford Press; 2006).
The efficacy of TF-CBT, a treatment model specifically designed for child sexual abuse, has been evaluated in over 25 scientific investigations, including more than a dozen randomized controlled trials (eg, Deblinger E et al. Introduction. In: Cohen JA et al, eds. Trauma-Focused CBT for Children and Adolescents: Treatment Applications. New York: Guilford Press; 2012;1–26).
TF-CBT research studies have documented significant improvements in anxiety, PTSD, depression, and behavioral problems among children and adolescents, as well as positive changes in parenting practices and abuse-related distress.
More specifically, the results of randomized controlled trials have demonstrated significantly greater improvements in youth and non-offending parents who participated in TF-CBT as compared to those on a waitlist and those who received community therapy services, nondirective supportive therapy, educational support group services, and/or child-centered therapy.
Several studies have documented the maintenance of these improvements over follow up periods ranging from six months to two years. Further, TF-CBT has received the highest ratings for efficacy and dissemination based on extensive reviews conducted by the US Department of Health and Human Services (www.nrepp.samhsa.gov) and the California Evidence-Based Clearinghouse for Child Welfare, a state-funded group whose goal is to advance the use of evidence-based practices for children and families in the child welfare system (www.cebc4cw.org).
How it Works
TF-CBT helps families heal from child sexual abuse and/or other childhood trauma(s) by engaging youth and their caregivers in parallel individual sessions as well as conjoint parent-child sessions. Though structured and time limited, mental health professionals can flexibly implement TF-CBT to address the therapeutic needs of youth who have experienced a single-incident trauma or repeated, complex trauma(s) that have impacted their functioning in multiple domains.
Prior to starting the TF-CBT journey, it is important to therapeutically engage the child and caregiver by taking into consideration their general needs. It is also important to attend to potential obstacles that can impede or hinder the therapeutic engagement, including negative prior experiences with therapy. It is often useful to highlight how TF-CBT may differ from prior therapy experiences. If there are other high-priority issues following the trauma, providing the family with appropriate referrals may help to engage them in therapy once their basic needs have been met. The treatment components of TF-CBT, described briefly below, are captured by the acronym PRACTICE (Cohen JA et al, op.cit).
Psychoeducation begins the journey and continues throughout the treatment process. It includes educating the caregiver and child by providing general information about the prevalence, dynamics, characteristics, and impact of child sexual abuse. The educational information often helps clients to understand the link between the specific symptoms experienced by the child and the proposed treatment plan.
Parent skills training is provided to all parents to assist them in optimally responding to children’s abuse-related behavioral and emotional difficulties. The implementation of positive praise, selective attention, time-out, and contingency reinforcement schedules often have a positive impact on the child’s behavioral adjustment as well as the caregiver-child relationship.
Relaxation training is an effective way to help the child and caregiver manage their emotions and to reduce tension that may result from reminders of the sexual abuse. It includes relaxation skills that may be practiced by the child and caregiver as well as mindfulness and meditation practices.
Affective expression and modulation skill building helps youth and their caregivers to express and manage distressing emotions. The child and caregiver learn to express basic feelings, along with feelings that may be associated with the sexual abuse. Other affective regulation skills that may be introduced during individual, as well as conjoint, sessions include the sharing of feelings, the use of positive imagery, and participation in positive activities, such as exercise, music, art, and other creative outlets for managing emotions.
Cognitive coping is introduced with the goal of assisting the caregiver and child in understanding the relationships between thoughts, feelings, and behavior, while learning to catch and challenge problematic thinking patterns. The cognitive triangle is presented, which visually demonstrates the relationship between thoughts, feelings, and behaviors, and clients learn to track, catch, and correct dysfunctional thoughts that may interfere with their daily functioning.
Trauma narrative and processing helps children gradually and repeatedly face traumatic memories in the context of a safe therapeutic environment. The narrative is typically created in written form, but art or play activities may also provide the mediums for describing the trauma(s) endured.
The narrative often reveals dysfunctional thoughts and beliefs such as “the sexual abuse was my fault,” or “he abused me because I am worthless,” that may underlie children’s emotional difficulties. When the narrative is complete, therapists can then assist youths in identifying and challenging unhelpful and inaccurate thoughts, while replacing them with healthier views of themselves, their relationships, and their expectations for the future (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 occurs when narrative and other exposure activities are not sufficient in helping youth overcome problematic avoidant behaviors. In such instances, a systematic in vivo plan may be developed to diminish or extinguish unnecessary anxiety and avoidance related to trauma cues in the environment.
During in vivo exposure, the child faces real-world reminders of the trauma. For example, a clinician should develop a plan for a child who fears being in a room alone. The exposures may involve having the parent at gradually greater distances from the room the child is in (eg, right outside the door, in the next room, down the hall, on another floor, etc). The parent is then coached to praise the child’s courage while minimizing attention to fearful behavior.
Conjoint parent-child trauma-focused sessions are designed to strengthen general communication between caregivers and children, help them practice the skills they have learned, review educational information, share the trauma narrative (when clinically appropriate), and increase children’s comfort in discussing the sexual abuse they have experienced with their caregiver.
Enhancing future safety and development is accomplished with youth who have endured sexual abuse through the provision of sex education and training in safety skills. These activities, which often include role plays, are designed to enhance children’s feelings of mastery, while simultaneously reducing their feelings of vulnerability and their risk of re-victimization.
TF-CBT typically ends with a celebration that acknowledges the accomplishments and progress made by the youth and caregiver. Celebratory activities, such as handing out certificates of completion and eating cake, are designed to acknowledge the hard work of therapy, while also encouraging optimism and confidence about the family’s continued success in using the skills learned in treatment.
Recent large-scale training efforts designed to assist therapists using this model have expanded the dissemination of TF-CBT, thereby greatly enhancing its accessibility for youth impacted by child sexual abuse as well as other trauma(s). Therapists interested in learning more about TF-CBT can complete a free training online at http://tfcbt.musc.edu as a first step toward developing the skills needed to implement TF-CBT with youth and their families.
TCRBH’s Take: Rigorous randomized trials examining TF-CBT have repeatedly documented its efficacy in supporting the recovery of children, adolescents, and non-offending 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 are victims of childhood sexual abuse should consider adding this therapy to their toolbag.