The Impact and Treatment of Child

Sexual Abuse

Judith A. Cohen, M.D.Medical DirectorCenter for Traumatic Stress in Children

and AdolescentsAllegheny General HospitalDrexel University College of MedicinePittsburgh, PAjcohen1@wpahs.org

Impacts of Child Sexual Abuse

ABC’S:• Affect• Behavior• Biology• Cognition• Social• School

Affective Impacts

• Sadness• Anxiety (with increased motor

activity)• Anger (with behavioral regulation

problems)• Loss of affect (flat, no feelings)• Affective regulation problems: 0 to 60• Dissociation

Behavioral Impacts

• Avoidance: don’t talk, think about it• Traumatic reenactment: sexualized

behaviors• Behavior problems: aggression, don’t

listen, poor attention, poor concentration (“ADHD”)

• Self-injurious behaviors, e.g., cutting• Substance abuse• Risk-taking

Biological Impacts

Significant changes in:• Stress-related neurotransmitters• Hypothalamic-pituitary-adrenal axis

(cortisol)• Brain structure and function (emotion

regulation; hemisphere communication)

• Immune function

Cognitive Impacts

Maladaptive cognitions including:• Self-blame• Blame of non-offending parent• Diminished self-worth• Feeble person in dangerous world• Malevolent intent; loss of social

contract• All are associated with worse MH

outcomes

Social Impacts

• Loss of trust (betrayal)• Increased family stress/conflict

(especially if perpetrator was family member)

• Associate with deviant peers• Media attention loss of privacy,

gossip• Risky or inappropriate behaviors

may lose status or reputation

School Impacts

• Poor concentration/attention• Disruptive behaviors in school• Decline in grades• More missed days of school• Higher rate of school drop out• Trauma reminders may occur in

school may be helpful to change schools

Mental Health Diagnoses

Diverse mental health diagnoses including:

• Posttraumatic Stress Disorder• Depressive disorders• Anxiety disorders• Behavioral disorders (e.g. ODD; ADHD)• Substance use disorders• Bipolar disorder; ADHD may be

misdiagnosed

Medical Problems

Diverse medical problems including significantly increased rates of:

• Pulmonary disease (asthma, bronchitis)

• Headache• GI problems• Allergy and immunologic problems• Health care usage

“Asymptomatic” Victims

Some children are highly resilient• Gene X environment (exposure)

interaction• Other protective factors:• Parental support• Adaptive cognitions• Active coping skills• Lack of diagnosis does not mean SA

was benign

Long Term Problems

• One time assessment is “hit or miss”• Severe problems often have “sleeper

effect” • Adult studies show significantly greater• Depression and suicide• PTSD• Substance abuse• Medical problems• Early death

Effective Treatment

• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): strongest evidence of efficacy

• TF-CBT components: PRACTICE acronym

TF-CBT Components: PRACTICE

P: Psychoeducation; Parenting skillsR: Relaxation SkillsA: Affective Expression and Modulation SkillsC: Cognitive Coping SkillsT: Trauma Narrative and ProcessingI: In Vivo Mastery of Trauma RemindersC: Conjoint Child-Parent SessionsE: Enhancing Safety and Future

Development

Promise Video

The Promise of Trauma Focused Treatment for Child Sexual Abuse: www.nctsn.org

Developed by the NCTSN for stakeholders—Judges, parents, CPS, teachers, GAL

To recognize elements of effective treatment:

• COPING SKILLS• TALK DIRECTLY ABOUT SEXUAL ABUSE• INCLUSION OF PARENTS/CAREGIVERS

Standards for Effective Treatment/

Best Practices

• Treatment plan: must include how treatment will address individual child’s problems

• Coping skills to address ABC’S• Trauma narration: directly talking about

CSA to address avoidance/CSA reminders• Include parents/caregiver if feasible to: decrease parental distress improve parental support and

attunement optimize child and family outcomes

Recognizing Appropriate Providers

• Evidence-based treatments have specific training requirements, certification will be available

TF-CBT Certification: Licensed practitioner completing:

• Free 10 hour web-based training in TF-CBTWeb: www.musc.edu/tfcbt

• 2 day training + 6 months of twice monthly consultation calls or year long Learning Collaborative

• Complete 5 TF-CBT cases with standardized assessment instruments

• Pass written test assessing clinical competence

Benchmarks for Determining Progress

• Treatment plan: required by MH treatment

• Each progress note should reflect how treatment is addressing treatment plan

• What to reasonably expect: TF-CBT significantly improves PTSD in 12-16 sessions

• Other problems (e.g., behavior problems, attachment issues) often take longer to address (20-25 session for children in foster/RTF settings).

Reunification Issues: Sibling Abuse

• Sibling/older youth=40% of perpetrators • MH guidelines for returning to home: SAFETY

FIRST• Victim and parent have completed TF-EBT• Perpetrator acknowledges perpetration,

understands harm, has attempted restitution (e.g., apologized)

• Family has effective, realistic safety plan• Victim shows ability to use learned safety skills • Perpetrator publicly reinforces this safety plan

CSA with Intimate Partner Violence

• IPV victim (mother) charged with failure to protect child from father who abused child

• IPV=power imbalance; if mother didn’t know about SA further victimize mother and child

• But child protection is essential• Do you remove the child or order mother

to keep father out of the home?• Watchful Shepherd: http://watchful.org:

no episodes of IPV or SA when WS was in place.

Resources

NCTSN webinars:• How to Create a Trauma Informed

Program to Help Young Children in Juvenile Court

• The Courts Cant Stop Child Trauma if They Don’t Know About It: How to Question Alleged Child Victims

NCTSN product:Caring for Kids: What Parents Need to

Know about Sexual Abuse

Summary

• Impacts of CSA are diverse• No “Child Sexual Abuse Syndrome”• Effective treatment includes coping

skills, directly talking about CSA, including parents

• EBT have clear standards for training therapists and will soon certify therapists

• Working together we can enhance children’s safety after child sexual abuse.

Maya Angelou:

“The world is changed one child at a time.”

Thank you for all you do for traumatized children.