Elsevier

Child Abuse & Neglect

Volume 29, Issue 2, February 2005, Pages 135-145
Child Abuse & Neglect

Treating sexually abused children: 1 year follow-up of a randomized controlled trial

https://doi.org/10.1016/j.chiabu.2004.12.005Get rights and content

Abstract

Objective:

To measure the durability of improvement in response to two alternative treatments for sexually abused children.

Method:

Eighty-two sexually abused children ages 8–15 years old and their primary caretakers were randomly assigned to trauma-focused cognitive-behavioral therapy (TF-CBT) or non-directive supportive therapy (NST) delivered over 12 sessions; this study examines symptomatology during 12 months posttreatment.

Data analysis:

Intent-to-treat and treatment completer repeated measures analyses were conducted.

Results:

Intent-to-treat indicated significant group × time effects in favor of TF-CBT on measures of depression, anxiety, and sexual problems. Among treatment completers, the TF-CBT group evidenced significantly greater improvement in anxiety, depression, sexual problems and dissociation at the 6-month follow-up and in PTSD and dissociation at the 12-month follow-up.

Conclusion:

This study provides additional support for the durability of TF-CBT effectiveness.

Résumé

Objectif:

Mesurer la durabilité des progrès thérapeutiques suite à deux types de traitements pour enfants agressés sexuellement.

Méthode:

Deux types de thérapies (une thérapie béhaviorale axée sur le traumatisme vécu et une thérapie d’appui à caractère non directif) ont été prodiguées de façon aléatoire à quatre-vingt deux enfants victimes d’agressions sexuelles, âgés de 8 à 15 ans, ainsi qu’aux personnes qui en avaient la charge. Les traitements comprenaient douze sessions. L’étude a examiné les symptômes durant les douze mois suivant le traitement.

Analyse des données:

On a mené des analyses portant sur l’intention d’entreprendre un traitement et sur les traitements achevés.

Résultats:

Les analyses sur l’intention d’entreprendre un traitement indiquent des effets importants favorisant la thérapie béhaviorale par rapport à la dépression, l’angoisse et les difficultés sexuelles. Parmi ceux qui ont achevé le traitement, cette même thérapie apporte des améliorations plus notables au niveau de l’angoisse, de la dépression, des difficultés sexuelles et de la dissociation dans les six mois suivant le traitement; et du désordre de stress posttraumatique et de la dissociation au bout de douze mois suivant le traitement.

Conclusion:

Cette étude appuie davantage les constats à savoir la durabilité du traitement béhavioral.

Resumen

Objetivo:

Medir la durabilidad de la mejoría como respuesta a dos tratamientos alternativos utilizados en niños sexualmente abusados.

Método:

Ochenta y dos niños abusados de 8–15 años de edad y sus cuidadores primarios fueron asignados al azar a terapia conductual cognitiva enfocada en el trauma (TF-CBT) o a terapia no directiva de apoyo (NST) realizada durante 12 sesiones; este estudio examina la sintomatología durante los 12 meses después del tratamiento.

Análisis de los Datos:

Se realizaron análisis de mediciones repetidas de intentos de tratamiento y tratamientos completos.

Resultados:

Los intentos de tratamiento indicaron un grupo significativo × veces con efectos a favor de TF-CBT en medidas de depresión, ansiedad, y problemas sexuales. Entre los tratamientos completos, el grupo de TF-CBT evidenció significativamente mayor mejoría en ansiedad, depresión, problemas sexuales y disociación en el seguimiento a los 6 meses y en PTSD y disociación a los 12 meses de seguimiento.

Conclusión:

Este estudio ofrece apoyo adicional sobre la efectividad de la durabilidad de TF-CBT.

Introduction

Child sexual abuse is associated with psychiatric difficulties which can potentially be long lasting and cause significant functional impairment. Sexually abused children and adolescents have been found to have increased rates of depression, anxiety, posttraumatic stress disorder (PTSD), externalizing symptoms, and substance use disorders (Saywitz, Mannarino, Berliner, & Cohen, 2000). Although it has been suggested that these deleterious outcomes are attributable to family factors which heighten risk for both sexual abuse and psychiatric dysfunction, recent epidemiologic and twin studies have demonstrated that sexual abuse per se accounts for increased rates of depression, suicide attempts, PTSD, substance use disorders and sexual victimization in adulthood (Kendler et al., 2000, Nelson et al., 2002). Thus, it is critical to identify treatments which optimally reduce these difficulties in children who have been sexually abused, and which produce lasting symptomatic remission. In the past decade, knowledge about efficacious treatments for sexually abused children has grown substantially, due to the publication of several empirically rigorous treatment outcome studies for this population. These studies have incorporated “gold standard” elements of evidence-based treatment trials, such as random assignment to well defined, manualized treatments, and the comparison of index treatments to alternative treatments or wait list controls.

Deblinger et al., 1996, Deblinger et al., 1999 followed 100 sexually abused children who were randomly assigned to receive trauma-focused cognitive-behavioral therapy (“TF-CBT”) provided to the child only, the non-offending parent only, or to the child and parent, and compared these three groups to children who received standard community care. This study documented that the children who received TF-CBT (either child only or child + parent treatment conditions) experienced significantly greater improvement in PTSD symptoms, whereas children whose parents received TF-CBT (in the parent only or parent + child treatment conditions) experienced significantly greater improvements in child-reported depression and parent-reported behavioral problems, and that these differences were maintained at a 1-year follow-up.

Cohen and Mannarino, 1996, Cohen and Mannarino, 1998 randomly assigned 69 sexually abused preschool children to TF-CBT or non-directive supportive therapy (NST); children receiving TF-CBT experienced significantly greater improvements in PTSD symptoms including sexualized behaviors, and in internalizing and total behavior problems. These differences were maintained over the course of a 1-year follow-up. Cohen and Mannarino (1998) conducted a parallel study for sexually abused children ages 8–15 years, and found significant group × time differences among 49 treatment completers, with children who received TF-CBT experiencing significantly greater improvement in depression and social competence compared to children who received NST.

King et al. (2000) randomly assigned 36 5- to 17-year-old sexually abused child to one of three conditions: CBT provided individually, CBT family therapy, or a wait list control condition. This study indicated that the two CBT conditions were both superior to the wait list condition and that at a 3-month follow-up, the children whose families were included in treatment experienced significantly greater improvement in anxiety than those who received only individual CBT. Another randomized controlled trial compared 30 sessions of individual psychoanalytic treatment to18 sessions of group psychoeducation and found that children in the individual psychoanalytic condition experienced significantly greater improvement in PTSD symptoms. However, the design of this study did not make it possible to determine whether these differences were because of the treatment orientation (psychoanalytic vs. psychoeducation), the mode of treatment (individual vs. group), or the length of treatment (30 weeks vs. 18 sessions).

Cohen, Deblinger, Mannarino, and Steer (2004) conducted a multisite study in which 229 sexually abused children were randomly assigned to TF-CBT or supportive Child Centered Therapy (CCT). At posttreatment, the TF-CBT group demonstrated significantly greater improvement in PTSD, depression, behavior problems, abuse-related attributions, and shame. Parents receiving TF-CBT also showed greater improvement with regard to their own depression, abuse-specific distress, support of the child and effective parenting practices.

In developing, testing, and disseminating evidence-based treatments for traumatized children, it is important to address not only the efficacy of treatment (how well it works to achieve specified results), but also the efficiency of treatment (how quickly it achieves these results) and the duration of treatment effects (how long treatment effects are maintained after treatment is completed). These issues may be particularly relevant for sexually abused children because of the documented deleterious long-term effects of child sexual abuse (Kendler et al., 2000, Nelson et al., 2002) and the potentially negative psychobiological impact of this type of child maltreatment. Sexually abused children have been found to have abnormalities in stress hormones related to dysregulation of the hypothalamic–pituitary–adrenal axis (DeBellis, Baum, et al., 1999; Kaufman et al., 1997), increased adrenergic tone as evidenced by elevated resting and reactive heart rate and blood pressure (Perry, 1994), and alterations in immunological functioning (DeBellis, Burke, Trickett, & Putnam, 1996). Perhaps most concerning is the finding that sexually abused children had smaller intracranial volume and lower scores on intelligence tests than carefully matched controls, with earlier age of onset and longer duration of abuse predicting smaller brain size and lower intellectual functioning (DeBellis, Keshavan, et al., 1999). Although it is not clear that psychosocial treatment can reverse these changes, one case report indicates that successfully treating children's abuse-related psychological symptoms may reverse the associated psychobiological abnormalities (DeBellis, Keshevan, & Karenski, 2001). Thus, it may be critically important to identify treatments that not only reduce psychological symptoms, but also lead to the most prompt and long-lasting symptom remission. For this reason, it is essential to examine treatment response to relatively brief interventions, and to assess outcome not only immediately at the conclusion of therapy, but for a period of time after therapy has ended.

By definition more efficient treatments result in faster symptomatic improvement (thus shortening the time that children must suffer from these psychiatric symptoms); the DeBellis, Keshavan, et al. (1999) findings suggest that more efficient treatments are also associated with less psychobiological adversity. Treatments with longer duration of effects (i.e., that maintain superior symptom remission over time) not only provide ongoing relief from psychological symptoms, but may also have the most promise for potentially halting or even reversing the adverse psychobiological effects of child sexual abuse. Such treatments may optimally protect children from the deleterious adult outcomes associated with child sexual abuse discussed above (Nelson et al., 2002). Thus, while minimizing psychological suffering more quickly is in itself an important goal, maintaining this effectiveness over time may be of even greater value in preventing the long-term negative sequelae of child sexual abuse.

The current study evaluates the duration of treatment effects of two alternative brief (12 week) treatments for sexually abused children over the course of the year following the end of treatment. TF-CBT was selected as the index treatment because TF-CBT interventions were superior to play therapy in improving these symptoms in sexually abused younger children (Cohen and Mannarino, 1996, Cohen and Mannarino, 1997), have been effective in treating PTSD in adult sexual assault victims (Foa, Rothbaum, Riggs, & Murdock, 1991), and have a sound theoretical basis for alleviating PTSD, depressive and anxiety and associated symptoms (Cohen, Mannarino, Berliner, & Deblinger, 2000). We selected the comparison treatment, NST, because it typifies the empowering, supportive and non-directive techniques provided to children and adults in many rape crisis and community mental health settings, and because it contains therapeutic elements which theoretically might reverse some of the traumagenic dynamics (Finkelhor, 1987) associated with child sexual abuse (i.e., powerlessness, stigmatization, traumatic sexualization and betrayal). Although this type of treatment is often provided over a longer period of time (New & Berliner, 2001), the importance of evaluating treatment efficiency led to the decision to limit treatment duration to 12 weeks.

It was hypothesized that, although both treatments were theoretically sound and frequently used for treating this population, TF-CBT would be more effective for reducing psychological difficulties, particularly depressive and anxiety symptoms, and that these differential treatment effects would be sustained over the course of a 1-year follow-up. This was based on TF-CBT but not NST containing treatment components specifically targeting conditioned fear responses and cognitive errors which contribute to symptom development and maintenance in these particular disorders (Cohen et al., 2000), as well as a treatment component aimed at helping children optimally integrate the abuse experience into their view of themselves, others and their world. An initial analysis of pre to posttreatment results for 49 treatment completers (30 CBT, 19 NST) in this study indicated that TF-CBT was superior to NST in improving depressive and social competence problems (Cohen & Mannarino, 1998). A subsequently published review of cognitive-behavioral therapies for children and adolescents suggested the importance of following children after completion of treatment, using intent-to-treat analyses to determine the durability of treatment effects (Brent, Gaynor, & Weersing, 2002). The present paper examines the outcomes of these children during the course of 1 year following treatment completion.

Section snippets

Subjects

Subjects were 82 children and adolescents aged 8–15 years old who were referred to an urban outpatient child psychiatric program specializing in the treatment of traumatic stress in children. This clinic is part of the Department of Psychiatry in an academically affiliated, not-for-profit general hospital. It receives referrals from child protective services (CPS), pediatric clinics and offices, police, forensic investigative agencies, victim advocacy programs, community mental health agencies,

Intent-to-treat analyses

As shown in Table 1, significant intent-to-treat group × time differences were found on the CDI, the State and Trait scales of the STAIC, and the anxiety, depression and sexual problems factors of the TSCC, with the TF-CBT group experiencing significantly greater improvement over time than the NST group on all of these measures. Group × time differences also approached significance (p = .07) on the TSCC dissociation factor. It should also be noted that most instruments demonstrated significant time

Discussion

The results of this study indicate that TF-CBT was superior to a prototypical supportive, empowerment therapy (NST) in producing durable improvement in depressive, anxiety, and sexual concern symptoms over the course of a year following treatment. Additionally, treatment completers receiving TF-CBT demonstrated significantly greater improvement than those receiving NST in PTSD and dissociative symptoms at the 1-year follow-up. These findings are consistent with previous studies (Cohen &

Acknowledgment

The authors thank the study therapists, project coordinators, the children and families who participated in this project, and Ann Marie Kotlik for assistance in manuscript preparation.

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    This study was funded by the Office of Child Abuse and Neglect (formerly NCCAN), Administration for Children, Youth and Families, Department of Health and Human Services, Grant No. 90-CA-1545.

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