CHILD SEXUAL ABUSE:

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• CHILD SEXUAL ABUSE
• Psychopathology and Treatment
• Barry Nurcombe, MD

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TOPICS

• DEFINITION
• PREVALENCE
• PSYCHOLOGICAL EFFECTS
• THEORETICAL MODELS
• TREATMENT RESEARCH
• CONCLUSIONS

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THE DEFINITION OF SEXUAL ABUSE

• Sexual act or acts
• Perpetrated on a minor
• With sexual intent
• Involving significant difference in age between
  child and perpetrator
• Coercion and trickery
• Violating the normal protective relationship
  between adults and children

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PREVALENCE

• Estimated from
• 1. Official reports of substantiated cases
  evaluated by child welfare authorities. A gross
  underestimate of true prevalence
• Retrospective surveys of adults Associated with
  serious methodological problems
• Longitudinal studies Fewer methodological
  problems

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PREVALENCE RETROSPECTIVE SURVEYS

• Sample
• Most reliable estimates are derived from
  random, representative population samples
• Response Rate
• Often lt 75

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PREVALENCE RETROSPECTIVE SURVEYS(Continued)

• Method of Ascertainment
• ? Questionnaire
• ? Interview, telephone or face-to-face
• Response Bias and the Unreliability of Memory
• ? Over-reporting
• ? Under-reporting

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PREVALENCEAnderson et al. (1993)

• 3000 New Zealand women, randomly selected from
  electoral rolls, aged 20-60 years
• 73 response rate, questionnaires and interviews
• Prevalence of unwanted sexual contact under 16
  years
• ? 31.6, all cases
• ? 7.3, sexual intercourse
• Age of greatest risk 8-12 years

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PREVALENCEAnderson et al. (1993)(Continued)

• Perpetrators were mainly family members and
  friends
• Only 15 were strangers
• 30 never disclosed the abuse
• No rural-urban difference
• Stable incidence over 40 years

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PREVALENCEDunne et al. (2003)

• Telephone-based survey of randomly selected
  Australian national sample aged 18-59 yrs (876
  males, 908 females)
• 61 acceptance rate
• Non-penetrative CSA under 16 years 33.6 in
  women, 15.9 in men
• Penetrative CSA under 16 years 12 in females,
  4 in males

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PREVALENCEDunne et al. (2003)(Continued)

• Unwilling sexual intercourse under 16 yrs 6.7
  in women, 1.2 in males
• There is evidence that the prevalence of CSA is
  declining in both sexes, particularly males

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THE ADULT OUTCOME OFCHILD SEXUAL ABUSE

• From retrospective studies of different groups of
  mentally disturbed subjects
• Serious methodological problems, e.g.,
• ? Sample bias
• ? Response bias
• ? Control method

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THE ADULT OUTCOME OFCHILD SEXUAL
ABUSE(Continued)

• Nevertheless, the confluence of numerous studies
  suggests an association between CSA and certain
  forms of adult psychopathology

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THE ADULT OUTCOME OF CSA

• Distortion of self concept and personal
  relationships
• Chronic emotional distress, depression, suicide
• Substance abuse
• Sexual dysfunction
• Dissociation, conversion, somatization
• Damaging lifestyles, revictimization, perpetration

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PSYCHOPATHOLOGYAnderson et al. (1993)

• Reported CSA is related to
• ? Psychiatric symptoms
• ? Substance abuse
• ? Suicidal behaviour
• ? Eating disorder
• ? Sexual dysfunction
• ? School drop-out
• ? Early marriage and pregnancy

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PSYCHOPATHOLOGYAnderson et al. (1993)(Continued)

• CSA operates in a complex matrix of social
  disadvantage

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THE OUTCOME IN CHILDHOOD OF CSA

• Posttraumatic stress disorder (40-50)
• Impulsive/disruptive behaviour (20-30)
• Anxiety / depression (25-35)
• Distorted attitudes to the self and others
• Dissociation / conversion / somatization
• No symptoms (? 21-49)

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NO SYMPTOMS POSSIBLE REASONS

• Some children are resilient ?
• Evaluation insensitive or not comprehensive ?
• Child too young ?
• Symptoms suppressed, denied, or dissociated ?
• 30 of asymptomatic children have symptoms 2
  years later (Gomez-Schwarz, 1996)

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RISK FACTORS FOR PSYCHOPATHOLOGY AFTER CSA

• Antecedent factors
• The nature of the abuse
• Events after disclosure
• Attitudes to self and others
• Coping style

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ANTECEDENT FACTORS

• Family dysfunction
• Previous neglect, discontinuity of attachment,
  exposure to domestic violence
• Previous coping style
• Developmental level

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ANTECEDENT FACTORS Developmental level

• Developmental level
• ? Amnesia lt 3-6 years
• ? Unaware that CSA is wrong, 3-6 years
• ? Self-blame, 6-12 years
• ? Self-stigmatization gt 12 years

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THE NATURE OF THE ABUSE

• Perpetrator a family member
• Repeated abuse
• Genital penetration
• Coercion / violence
• No clear evidence concerning age, sex, number of
  perpetrators, denigration, or secrecy

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EVENTS AFTER DISCLOSURE

• Family dysfunction
• Maternal psychopathology
• Lack of parental support (disbelief, denial,
  secrecy, rejection)
• Giving testimony against the abuser

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ATTITUDE TO SELF / OTHERS

• Negative self-concept
• Ambivalence to non-offending parent
• Sense of powerlessness
• Expectation of betrayal
• Threat to family integrity

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ADVERSE COPING STYLES

• Denial, suppression
• Dissociation
• Conversion, somatization
• Repetition compulsion
• Distraction and tension-discharge

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THEORETICAL MODELS OF PSYCHOPATHOLOGY AFTER ABUSE

• Post-traumatic stress disorder and dissociation
• The tetrad of traumatic dynamics self-blame,
  betrayal, traumatic sexualization, powerlessness
• Distortion of the working model of attachment
• The transactional model

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THE TRANSACTIONAL MODELSpacarelli (1994)

• ANTECEDENT
• FACTORS
• THE ABUSE FAMILY RESPONSE
• MEDIATING
• FACTORS
• Attitudes
• Coping style
• PSYCHOPATHOLOGY

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A REVIEW OF RESEARCH INTO THE TREATMENT OF CHILD
SEXUAL ABUSE

• Uncontrolled studies (17)
• Quasi-experimental studies (5)
• Experimental studies (16)

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EXPERIMENTAL STUDIES (1986-88)GROUP THERAPY

• Baker (1987) Group Therapy gt Indiv. Therapy
• Burke (1988) Group Therapy gt No Treatment
• Perez (1986) Group Therapy Indiv. Therapy
• gt No Treatment
• Verleur et al. (1986) Group Therapy gt No
  Treatment
• Monck et al. (1986) Group Therapy Group
• Therapy Family Therapy

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EXPERIMENTAL STUDIES (1986-88)GROUP
THERAPY(Continued)

• The results of these studies should be cautiously
  interpreted because of
• ? small sample sizes
• ? limited outcome evaluation
• ? lack of follow-up
• ? lack of standardization of treatment
• ? lack of fidelity checks

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EXPERIMENTAL STUDIES (1996- )Cognitive
Behaviour Therapy

• Larger samples
• One-year to two-year follow-up
• Comprehensive outcome evaluation
• Standardization of treatment (manuals)
• Supervision of clinicians
• Fidelity checks

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyBerliner Saunders (1996)

• 154 abused children, 4-13 years, randomly
  assigned to two 8-week treatment groups
• The comparison group received Group Therapy
  alone the index group received Cognitive
  Behaviour Therapy as well as Group Therapy
• Trained therapists

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyBerliner Saunders (1996)(Continued)

• Follow-up at 1 and 2 years
• Results Both treatment groups improved
  significantly, but no significant differences
  between the groups

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCelano et al. (1996)

• 32 girls, aged 8-13 yrs, and caretakers, randomly
  assigned to two 8-week programs
• I. Structured CBT targeting
• self-blame, betrayal, traumatic sexualization,
  powerlessness
• II. Non-specific therapy, NST

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCelano et al. (1996)(Continued)

• Clinicians trained in manualized CBT program
• No fidelity checks
• Attrition rate 30
• Both groups decreased in PTSD symptoms,
  self-blame, powerlessness. CBT gt NST only in
  promoting caretaker support

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyDeblinger et al. (1996, 1998)

• 100 abused children, 7-13 years, randomly
  assigned to 4 12-week treatment conditions
• I. Standard Community Care
• II. CBT to child only
• III. CBT to parent only
• IV. CBT to child and parent

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyDeblinger et al. (1996, 1998)(Continued)

• Attrition rate 11 at end of treatment
• Results CBT parent child gt CBT child CBT
  parent gt community care, in regard to behaviour
  problems, PTSD symptoms, anxiety, depression

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCohen Mannarino (1996)

• 86 abused children, 3-6 years, randomly assigned
  to two 12-week treatment conditions
• I. CBT, parent and child
• II. Non-specific therapy (NST), parent and
  child
• Trained therapists, fidelity-checked, using
  treatment manuals

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCohen Mannarino (1996)(Continued)

• Attrition rate 20 at end of treatment
• Results CBT exceeded NST in regard to general
  psychopathology and internalizing symptoms.
  Children who received NST did not improve

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCohen Mannarino (1998)

• 82 children, aged 7-14 years, randomly assigned
  to two 12-week treatment programs
• I. CBT, child and parent
• II. NST, child and parent
• Trained therapists, fidelity-checked, using
  manuals

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCohen Mannarino (1998)(Continued)

• Attrition rate 40 at end of treatment
• Results CBT exceeded NST only in social
  competence and depression, possibly because of
  high attrition rate. More of the NST group were
  removed from treatment because of persistent
  sexual behaviour problems

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyKing et al. (2000)

• 36 abused children aged, 5-17 years, randomly
  assigned to three 20-week treatment conditions
• I. CBT, child alone
• II. CBT, child and mother (separate)
• III. Waiting list control
• Trained therapists, rotated, fidelity-checked,
  using manuals

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyKing et al. (2000)(Continued)

• Attrition rate 22 at end of treatment
• Results The two CBT groups improved
  significantly more than controls in PTSD, fear,
  anxiety, and global functioning. No evidence
  that parental involvement improved outcome

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyDominguez (2002)

• 32 subjects aged 6-17 yrs randomly assigned to
  two 20-week programs
• I. CBT (N18)
• II. NST (N7)
• Attrition rate, 22
• Not manualized, no fidelity checks

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyDominguez (2002)(Continued)

• Both groups improved in depression, aggression,
  general behaviour, but no difference between CBT
  and NST
• Statistical power weak

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCohen et al. (2004)

• 229 abused children 8-14 years with PTSD randomly
  assigned to two 12-week treatment conditions
• I Trauma-focussed CBT, child and parent
• II Non-specific treatment (NST)
• Trained therapists, manualized, fidelity checks

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EXPERIMENTAL STUDIESCognitive Behaviour
TherapyCohen et al. (2004)(Continued)

• Attrition Rate 27
• Results Children in both groups improved
  significantly but CBT exceeded NST in regard to
  PTSD, depression, behaviour problems
• Comment Multisite laboratory study

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EXPERIMENTAL STUDIESCognitive Behaviour Therapy
and Family TherapyWooding, Marrington et al.
(2004)

• 71 abused children, 6-16 years, randomly assigned
  to two 18-week treatment conditions
• I CBT, parent and child
• II FT, parent and child
• Trained therapists, fidelity-checked, manualized

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EXPERIMENTAL STUDIESCognitive Behaviour Therapy
and Family TherapyNurcombe,Wooding, Marrington
et al. (2004)

• CBT and FT both produced clinically sig. effects
  on behaviour problems, anxiety, anger,
  depression, posttraumatic stress, dissociation
  and avoidant coping
• No difference between effectiveness of CBT and FT
• Attrition rate 58
• Comment Community-based study

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EXPERIMENTAL STUDIESIndividual Psychotherapy
and Group TherapyTrowell et al. (2002)

• 71 sexually abused girls, aged 6-14 years,
  randomly assigned to two treatment conditions
• I. Individual Psychodynamic Psychotherapy
  (up to 30 sessions)
• II. Group Psychotherapy (up to 18 sessions)
• with support to parents

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EXPERIMENTAL STUDIESIndividual Psychotherapy
and Group TherapyTrowell et al.
(2002)(Continued)

• Trained therapists, supervised, using manuals,
  but no fidelity checks
• Attrition rate 32 after recruitment, 1 after
  treatment began, 11 at follow-up (1,2 years)
• Results Both treatments showed significant
  improvement in global functioning and PTSD
  symptoms, but no difference between the two
  treatments

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CONCLUSIONS

• CBT and Group Therapy have been the most studied.
  Little is known about the effectiveness of
  Psychodynamic Psychotherapy or Family Therapy
• CBT and Group Therapy are more effective than no
  treatment or a dummy treatment
• Neither CBT nor Group Therapy has ever been shown
  to do better than a genuine competitor
• Non-specific counselling is ineffective

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CONCLUSIONS(Continued)

• Despite treatment, some children deteriorate
• Depression, aggression and sexual problems are
  problematic
• The optimal duration of treatment is unclear
• The drop-out rate is high
• It is unclear which asymptomatic children should
  be treated
• The psychosocial problems that usually accompany
  CSA must be addressed

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CONCLUSIONS(Continued)

• Most experimental studies have been conducted in
  a laboratory setting, and lack ecological
  validity
• We need studies involving large samples,
  comprehensive evaluation, extended follow-up,
  trained clinicians, manualized and
  fidelity-checked treatments based on explicit
  theoretical models, with abuse-specific goals and
  strategies