Sexual abuse recovery using CBT
Using cognitive-behavioural approaches to support the recovery of children who have experienced sexual abuse
- There was evidence that CBT reduced symptoms of poor mental health but these results mostly were not significant
- The evidence was of a moderate strength
- Most evidence reviewed was from the USA
- Trauma-Focused Cognitive Behavioural Therapy (USA)
- Anna Freud National Centre for Children and Families (UK training provider)
Overall effectiveness: 0 (maximum 2)
Strength of evidence: 2 (maximum 3)
Overall effectiveness: 0 (maximum 2)
Strength of evidence: 2 (maximum 3)
What is this?
In the UK, child sexual abuse involving unwanted sexual contact has been estimated to affect approximately 1 in 20 children aged between 11 and 17. Child sexual abuse can occur at any point in childhood and may be a one-off event or take place repeatedly over a period of time. The abuse might be perpetrated within a child’s family (approximately a third of cases), by somebody known to them outside of their home or by a stranger. The perpetrator may be an adult or another child or young person. A child who has experienced sexual abuse may develop poor mental health, including fear, anxiety or depression. Child sexual abuse also increases the risk for mental health problems in adulthood. Cognitive behavioural therapy (CBT) models have been developed to help children recover from sexual abuse and prevent them from experiencing these poor mental health outcomes. This support might be provided directly to the child and/ or their (non-abusing) parent.
How is it meant to work?
CBT is based on theories of learning, including how we learn by observing others, how we respond to environmental conditions, including rewards and punishment and how our thought patterns affect our feelings and behaviour. When CBT is used to treat children who have been sexually abused, the therapist seeks to identify the psychological impact of the sexual abuse on the child and their parent, identify inaccurate or harmful beliefs (e.g. the child’s belief that they are to blame) and address negative emotional and behavioural consequences (e.g. low self-esteem, depression or sexualised behaviour).
Strategies for coping with emotional distress might include helping children to learn skills for relaxation, emotional expression and healthy coping mechanisms. Children and their parents learn how to understand and talk about their feelings about the abuse. They also learn to identify unhelpful beliefs about the abuse and replace these with more accurate and manageable beliefs.
Strategies for managing anxiety might include recognising the signs of anxiety, how it is triggered and how to cope with these feelings more effectively. This includes helping the child to face situations that might provoke feelings of anxiety rather than avoiding them. Techniques might include relaxation, desensitisation through exposure to stressors and changing anxiety provoking thought-processes. Similarly, strategies for addressing behavioural problems might involve parents learning about how the behaviour is triggered and influenced by the child’s environment and identifying how they can make changes to reduce the behaviour.
These therapeutic elements are accompanied by education for parents about the impact of child sexual abuse on children’s behaviour, and education for children about child sexual abuse, healthy relationships and sexuality and protective behaviours.
What are the evaluated outcomes?
- Child's psychological functioning
- Child behaviour
How effective is it?
The primary outcomes considered in the review were depression, post-traumatic stress disorder (PTSD), anxiety and child behaviour problems (including sexualised behaviour and externalising behaviour). The review also considered some parent-related outcomes, including the parent’s knowledge, skills and beliefs about the child.
Child’s psychological functioning
Overall, CBT treatment models had no effect on children’s psychological functioning. Children who had CBT treatment often experienced a positive reduction in their symptoms of depression, anxiety or PTSD but in most studies the reduction was not significantly different when compared with the control group. Nine out of ten of the studies included in the analysis provided other therapies to children in the control group (often psychotherapy). These findings are based on moderate strength evidence.
The review suggests that CBT may have a positive (but as yet unproven) impact on the following symptoms:
Analysis of five studies, involving 421 participants, showed that CBT had a moderately positive effect in decreasing symptoms of depression. Four studies which looked at effects 12 months after the intervention found that these improvements were still present, but had reduced.
Post-traumatic stress disorder
Analysis of 6 studies involving 442 participants showed that CBT had a moderately positive effect in decreasing symptoms of PTSD immediately after treatment and 12 months later. Evidence of longer term impact was based on three studies and 246 participants.
Analysis of five studies, including 434 participants, showed that CBT had a small positive effect on decreasing symptoms of anxiety. Four of these studies, with 278 participants, showed that this decrease was sustained 12 months later.
Overall, CBT treatment models had no effect on child sexualised behaviour and externalising behaviours. This is based on moderate strength evidence. Findings between the five studies that looked at sexualised behaviour and the seven studies that looked at externalising behaviours presented a mixed picture (some studies reported increases in symptoms while others reported decreases).
Where has it been studied?
Ten studies were analysed in this review. Nine were carried out in the USA and one in Australia. None of the evidence reported here is from the UK, therefore it is not known if these findings are generalisable to the UK. The review authors suggest that the evidence should have cross-cultural relevance as the CBT treatments are informed by an understanding of child sexual abuse and of how children learn, which should apply in different contexts and environments.
Who does it work for?
The review does not provide sub-group analysis to show which groups of children particularly benefited from CBT treatment following sexual abuse as the sample sizes were considered to be too small.
The children participating in the 10 reviewed studies were aged between 3 and 17. Two studies only included girls and the remaining 8 studies were all mixed sex. In the mixed sex studies, the proportion of male participants varied between 11 per cent and 42 per cent. All studies specified in their inclusion criteria that the participating children had experienced contact sexual abuse. Five studies also required that children showed some psychological or behavioural symptoms (e.g of depression, PTSD or sexualised behaviour) in order to be eligible.
When, where and how does it work?
Some of the key components of the treatment models delivered included:
- Psychoeducation (e.g. learning about fear)
- Teaching skills for managing stressful situations and coping with difficult emotions
- Techniques for addressing harmful beliefs and behaviours, including cognitive reframing, positive imagery and stopping negative thoughts
- Teaching parents strategies for managing their children’s behaviour.
The review did not include analysis of factors that made the different CBT treatment models more or less effective.
What are the costs and benefits?
There is no information on the cost-benefit of using CBT to support children’s recovery from sexual abuse.
How is it implemented?
The CBT treatment models described in the 10 reviewed studies took a variety of forms. Two CBT models offered group therapy to children. In one CBT model children and their mothers had group therapy in separate groups, with a short joint parent and child activity session each week. The other seven CBT models involved individualised therapy sessions, either for children and their mothers together or for comparing support for children and their parent separately. One study compared three scenarios: individual CBT for the child, individual CBT for the parent, and teaching parents how to use CBT strategies to help their child.
The CBT treatments were provided in varying levels of intensity. The number of sessions provided in the group therapies varied between six and 10 sessions. Individual therapies varied between eight and 20 sessions. One model provided hour-long sessions of support that were mostly divided between the mother and the child, with a few sessions delivered jointly. Three studies provided 90 minute sessions of support divided between the parent and child. One study compared providing 45 minute sessions of support to either the parent or the child, or sessions of up to 90 minutes for the parent and child jointly.
The review did not include information about the therapists who delivered the CBT treatment (e.g. their professional qualifications and training) or about how model fidelity was maintained.
- Evidence from this review suggests that children who had experienced sexual abuse experienced reduced symptoms of depression, PTSD and anxiety following CBT treatment
- However, most of these results did not reach statistical significance, therefore it is not yet possible to attribute these effects to the treatment
- There was no evidence that CBT helped to reduce child behaviour problems
- Only a small number of studies with small sample sizes were available for review. Larger, more robust studies are needed to provide evidence of the effectiveness of CBT in aiding children’s recovery from sexual abuse
- The evidence in this review was from the USA and Australia, therefore it may have limited applicability to the UK.
This summary comes from an original systematic review called: Cognitive‐behavioural interventions for children who have been sexually abused: A systematic review. (Macdonald, G., Higgins, J. P., Ramchandani, P., Valentine, J. C., Bronger, L. P., Klein, P., O’Daniel, R., Pickering, M., Rademaker, B., Richardson, G. & Taylor, M.) Published 2012.