Subjects were 229 consecutively referred children ages 8–14 years, who had experienced contact sexual abuse which was confirmed by Child Protective Services (CPS), law enforcement or professional independent forensic evaluator, who met all study criteria and agreed (along with a custodial adult) to participate in the study. Children were recruited from two sites, one in a large metropolitan area and one in a suburban setting. Both sites are academically-affiliated outpatient clinical treatment programs for abused/traumatized children. Referral sources included CPS, police, victim advocacy centers and Child Advocacy Centers, pediatric care providers, mental health care providers, and self-referrals. No recruitment ads were placed. The recruitment, assessment and treatment protocols were identical at both sites and were reviewed and approved by the programs’ respective Institutional Review Boards.
For inclusion in the study, children had to meet at least 5 criteria for sexual abuse-related DSM-IV-defined PTSD, including at least one symptom in each of the three PTSD clusters (reexperiencing, avoidance or numbing, and hyperarousal). In addition, children were required to have a parent or other caretaker (including long-term foster parents) who was willing and able to participate in the parental treatment component of the study. Informed child assent and parental consent were required for admission to the study.
Children were excluded if they had an active psychotic disorder or an active substance use disorder which resulted in significant impairment in adaptive functioning, or if the parent or primary caretaker who would be participating in the treatment had such a disorder. Additionally, children were excluded if they were not fluent in English, and/or had a documented developmental disorder (e.g., autism). Children who were currently on psychotropic medication had to have been on a stable medication regimen for at least two months prior to admission to the study. Children in the study could not be receiving psychotherapy for sexual abuse outside of the study.
Of the original 229 children in the sample 5(2%) never returned for treatment, 8 (3%) left after attending one session, and 13 (6%) left after attending only two sessions. These 26 (11%) children and their parents were defined as dropouts. Therefore, 203 (88%) of the children attended at least three psychotherapy sessions, and this is the final sample upon which the analyses of covariance (ANCOVA) below are based. All 229 original subjects were included in the intent-to-treat analyses. The following flow sheet accounts for subjects at all stages of the study.
Nineteen (9%) of the final sample were currently taking psychotropic medications, and 39 (20%) had previously received counseling for the present sexual abuse episode. According to the Kiddie-Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version PTSD section (K-SADS-PL-PTSD), 180 (89%) met full criteria for current PTSD. These children were described by their parents as having a variety of other psychological and behavioral problems. For example, although the mean pretest CBCL T score of the 203 children was 63.61 (SD=10.87), indicating that the average child had above normal levels of psychopathology, 71 (35%) children had T scores greater than 70, representing severe psychopathology.
The K-SADS-PL-PTSD was used to identify children’s exposure to traumatic events other than sexual abuse. For example, 144 (70%) these children had been confronted with news of the sudden unexpected death or life-threatening illness of a loved one, 118 (58%) had witnessed domestic violence; 53 (26%) were victims of physical abuse, 75 (37%) had witnessed or been involved in a serious accident; 35 (17%) were victims or witnesses of community violence; 28 (14%) had experienced a fire or natural disaster, and 51 (25%) had experienced other PTSD-level traumatic events, such as medical traumas, traumatic custody situations (e.g., being kidnapped by non-custodial parent), school violence not included in the K-SADS definition of community violence, and terrorist attacks. These children experienced a mean of 2.66 (SD=1.61) of traumatic events in addition to sexual abuse.
Among the 203 children, there were 14 sibling pairs, therefore there were 189 caretakers from whom we collected pretreatment data. Sibling pairs were assigned to the same treatment as it was essential for parents to receive only one parent treatment model. Sibling pairs were evenly distributed between the two treatment models. It should be noted that parents completed only one BDI at each evaluation point, even if they had more than one child in the study. Demographic information about participating children and parents are summarized in .
Demographics of Child Sample (N=203) and Participating Parents (N=189)
Upon referral to either participating center, an extensive initial phone screen was conducted, and the possibility of participating in the study was discussed with parents of children who appeared to meet study criteria. Those who agreed were scheduled for an initial assessment, which was conducted by independent evaluators at each site. Independent evaluators from the two sites were trained together in the administration and scoring of the semi-structured assessment instruments. Training was provided by the first and third authors, who had been trained to criteria in the administration of the K-SADS at Western Psychiatric Institute and Clinic. Acceptable inter-rater agreement was established between interviewers at the two sites. At the initial assessment, children and parents completed the assessment instruments described below, and those who qualified for admission to the study read and signed informed assent/consent forms. They were then assigned to a study therapist who was informed by one of the investigators as to the type of treatment they would be offering. The independent evaluator was blind to the treatment condition and informants were told that they would be paid $25 for the initial evaluation and $50 for each follow-up assessment.
The following instruments were administered by the independent evaluators at pre- and post-treatment to the children to measure psychiatric symptomatology: Kiddie-Schedule for Affective Disorders and Schizophrenia- Present and Lifetime Version (K-SADS-PL)
(Kaufman et al., 1996
), a semi-structured interview administered independently to child and parent to assess the presence of DSM-IV psychiatric disorders (for this study, the PTSD, Psychosis and Substance Use Disorders sections were used); Children’s Depression Inventory (CDI)
(Kovacs, 1985), a well established self-report instrument for depressive symptoms in children; State-Trait Anxiety Inventory for Children (STAIC)
), a widely used self-report measure of both present (state) and trait anxiety symptoms; and Children’s Attributions and Perceptions Scale (CAPS)
(Mannarino et al., 1994
), a self-report measure of children’s stigmatization, interpersonal trust, self-blame for negative events, and perceived credibility.
The following instruments were administered pre- and post-treatment to the parents: K-SADS-PL
(described above); Child Behavior Checklist (CBCL)
) which includes 4 broad band scales and 9 narrow band scales to assess child behavior problems (for the purposes of this study, only the broad band scales of social competence, internalizing, externalizing and total behavior problems were analyzed); Child Sexual Behavior Inventory (CSBI)
(Friedrich et al., 1992
), a parent report instrument for normative as well as inappropriate sexual behaviors; Beck Depression Inventory II (BDI)
(Beck et al., 1996
), a parent self-report measure of depression; the Parent’s Emotional Reaction Questionnaire (PERQ)
(Mannarino & Cohen, 1996
), a parent self-report measure for emotional distress related to their children’s sexual abuse experience; the Parental Support Questionnaire (PSQ)
(Mannarino & Cohen, 1996
), a self-report measure of parental support of their sexually abused child and attributions about responsibility for the abuse; and the Parenting Practices Questionnaire (PPQ)
(Strayhorn & Weidman, 1998
), a parent self-report instrument of parenting practices modified for use with this population (Stauffer & Deblinger, 1996
). Three items from the original PPQ were modified from questions about general parenting practices to questions specific to interactions with children specific to sexual abuse. This revised version of the PPQ had an alpha coefficient of .72. All of these instruments have established acceptable psychometric properties and have been used in previous treatment studies of sexually abused children.
Subjects were randomly assigned to either trauma-focused cognitive-behavioral therapy (TF-CBT) or Child Centered Therapy (CCT). Both treatments were manualized (Cohen & Mannarino, 1996b
; Deblinger & Heflin, 1996
). Study therapists at both sites were trained together over a three day period. Therapists were diverse in terms of their professional training (i.e. psychologists and social workers) and theoretical backgrounds (i.e. cognitive-behavioral, psychodynamic and play therapy). Three therapists had extensive experience in both TF-CBT and CCT; one had extensive experience in primarily providing CCT and one in primarily providing TF-CBT, and two therapists had relatively little experience in either modality. All therapists learned both treatment modalities and provided both treatments throughout the study. This design was used both to maintain the blindness of independent evaluators (who typically knew which therapist was treating each family), and also to eliminate the potential bias of a particularly effective therapist skewing treatment response in favor of one treatment over the other. Therapists had intensive weekly supervision in each treatment model. Additionally, twice monthly cross-site phone supervision for each treatment modality was provided. Fidelity to assigned treatment modality was monitored through supervisors listening to all treatment audiotapes, and through independent random rating of 25% of all audiotapes. Therapist fidelity for both treatments was >95%.
The treatment models used in this study were selected because they each had strong theoretical bases for treating sexually abused children, were widely used in community settings, and were sufficiently distinct from one another. Each treatment was provided in 12 weekly individual sessions to parent and child. One therapist treated each child-parent dyad. Treatment sessions lasted 90 minutes, with 45 minutes for each individual session. In three of the TF-CBT sessions, a joint parent-child session lasting approximately 30 minutes was provided; for these sessions, the individual child and parent sessions were reduced to 30 minutes.
Child Centered Therapy (CCT)
Child Centered Therapy (CCT) is a child/parent centered treatment model focused on establishing a trusting therapeutic relationship which is self-affirming, empowering and validating for the parent and child. This model is consistent with those widely used in rape crisis centers and other community settings to treat sexually abused children. It is based on the empirically supported premise that these children and their parents develop difficulties because they have experienced a violation of trust and disempowerment (Barker-Collo & Read, 2003
; Finkelhor, 1987). CCT aims to reverse these difficulties through the establishment of an empowering trusting relationship and by encouraging children and parents to direct the content and structure of their own treatment, thereby allowing them to choose when, how and whether to address aspects of the child’s sexual abuse rather than the therapist deciding this. Therapists provided active listening, reflection, accurate empathy, encouragement to talk about feelings, and belief in the child’s and parent’s ability to develop positive coping strategies for abuse-related difficulties. Therapists offered limited interpretations when clinically appropriate, and addressed behavioral difficulties by encouraging the parent and child to formulate their own personal strategies for behavioral change, rather than providing prescriptive advice in this regard. Although sessions were generally client directed, written psychoeducational information about child sexual abuse was provided and children specifically prompted to share feelings about the sexual abuse during two therapy sessions if they did not do so spontaneously.
Trauma-focused CBT (TF-CBT)
The TF-CBT treatment model is informed by effective interventions for adult PTSD and for non-PTSD child anxiety disorders, and by cognitive and learning theories about the development of PTSD in children. It includes several components which are presented in a logical sequence with each module of treatment building on skills and progress gained from previous sessions.
Specific elements of the TF-CBT model include feeling expression skills, coping skills training, recognizing the relationships between thoughts, feelings and behaviors, gradual exposure (also referred to as creating the child’s trauma narrative), cognitive processing of the abuse experience(s), joint child-parent sessions, psychoeducation about child sexual abuse and body safety, and parent management skills.
As sessions proceeded, children were encouraged to confront increasingly detailed and distressing abuse-related reminders and memories. Children created narratives of their sexual abuse experiences, typically by writing and illustrating a book, which was shared with parents in their parallel sessions. The three joint parent-child sessions were used to optimize comfortable communication, to provide education about personal safety and healthy sexuality and to allow the child and parent to share and discuss the child’s trauma narrative together.