Curr Psychiatry Rep (2012) 14:599–607
DOI 10.1007/s11920-012-0316-5
HOT TOPIC
Treatment of Childhood Sexual Abuse: An Updated Review
Marissa Cummings & Steven J. Berkowitz &
Philip V. Scribano
Published online: 26 September 2012
# Springer Science+Business Media, LLC 2012
Abstract Childhood sexual abuse (CSA) involves multiple
complex factors that make the evaluation of therapeutic
interventions especially complicated. PTSD prevalence
rates of CSA are approximately 37 % -53 %. Several other
psychiatric sequelae of CSA exist. CSA appears to disrupt
brain and body physiology. One co-located service delivery
model reported a 52 % linkage rate of CSA survivors with
mental health treatment. This article reviews current litera-
ture on the treatment of CSA, including psychosocial
interventions, pharmacotherapy, and early preventative
interventions. It also provides an update on the short- and
long-term sequelae of CSA and implications for future re-
search directions. A literature search of papers published in
the last 3 years was conducted using the keywords treat-
ment, sexual abuse, childhood, epigenetics, resilience and
review, and searching the following databases: PsycInfo,
PubMed, Substance Abuse and Mental Health Services Ad-
ministration, and Centers for Disease Control.
M. Cummings (*)
Department of Child and Adolescent Psychiatry and Behavioral
Sciences, Children’s Hospital of Philadelphia,
Philadelphia, PA, USA
e-mail: cummingsm@email.chop.edu
S. J. Berkowitz
Penn Center for Youth and Family Trauma Response and
Recovery, Department of Psychiatry, University of Pennsylvania,
Philadelphia, PA, USA
e-mail: steven.berkowitz@uphs.upenn.edu
P. V. Scribano
Safe Place: Center for Child Protection and Health,
Department of Pediatrics, The Children’s Hospital
of Philadelphia, Perelman School of Medicine,
University of Pennsylvania,
Philadelphia, PA, USA
e-mail: scribanop@email.chop.edu
Keywords Childhood sex abuse . CSA . Post-traumatic
stress disorder . PTSD . Intervention . Treatment . Sexual
abuse . Childhood . Epigenetics . Resilience . Review .
Family . Psychosocial interventions . Pharmacotherapy .
Preventative interventions . Psychiatry
Introduction
Child sexual abuse (CSA) remains a significant and
pervasive health problem in the US and international-
ly. Recent scandals involving trusted figures have
brought national media attention to CSA but are not
new. New, emerging science continues to improve our
understanding of the problem and offer more effective
interventions.
CSA: Definition
The definition of childhood sexual abuse varies widely
in the literature. Many general population surveys de-
fine childhood sexual abuse (CSA) as “unwanted sexual
contact” without describing specific behavior [1]. Other
studies distinguish between “contact abuse,” “non-con-
tact abuse” or “penetrative abuse” and “non-penetrative
abuse.” Higher prevalence rates occur in studies that
use a broad-based definition [1]. Different age cutoffs
are also used (e.g., prior to age 15, 16, 17 and 18). The
Child Abuse Prevention and Treatment Act (CAPTA,
1996) includes using enticement, persuasion and other
inducements to coerce a child into engaging in sexually
explicit conduct or simulation of sexual acts [1]. Child
pornographic exposure also remains an understudied
and often overlooked area of child sexual abuse. Very
little is known about how to identify, approach and
600
help children used as subjects of pornography and/or
exposed to it [2]. An additional issue that has been
hard to characterize is the differential naturalistic out-
comes regarding the age of CSA occurrence as well as
chronicity.
Previous Treatment Reviews
Putnam [3] conducted a review of the literature in 2003 and
discussed the treatment of asymptomatic children and the
importance of evaluating for risk factors to account for the
10 % to 20 % of asymptomatic children who deteriorate
over 12 to 18 months after initial evaluation [4, 5]. Psycho-
educational intervention designed to prevent further victim-
ization, clarify and normalize feelings and educate parents
was recommended. At the time of that review, CBT models
for sexually abused children often combined with similar
treatment for the non-offending caregiver were the most
effective and evidence-based treatments. Effective preven-
tion strategies such as home visitation strategies were also
reviewed. Home visitation programs aim to reduce child
abuse and neglect by providing the knowledge, skills and
supports to improve the parenting skills of at-risk or over-
whelmed parents. Compared to abused controls without
home visitation, abused children who received home visita-
tion showed a positive effect in reducing early behavior
problems when exposed to child maltreatment [6]. Putnam
concluded that these data suggested that early intervention
programs such as home visitation might moderate child
abuse outcomes. Putnam further proposed that future re-
search should focus on the establishment of the relationship
between neurobiological abnormalities and the symptoms
and problematic behaviors associated with CSA. Another
proposed area for expansion of the research on CSA was
investigation of the reversibility of neurobiological markers
as a result of treatment in the context of symptom remission.
At the time of the 2003 review, because of the delayed
presentation of problematic symptoms in some sexually
abused children, co-morbidities and impaired life trajecto-
ries, Putnam saw a need for large-scale effectiveness trials
with longitudinal follow-up. Research in community set-
tings to evaluate the generalizability of results in the “real
world” was also suggested.
Update: Sequelae of Childhood Sexual Abuse
To examine the occurrence of adverse childhood experien-
ces (ACEs) reported by adults , the Centers for Disease
Control (CDC) studied a randomly selected population of
26, 229 adults in five states using the 2009 ACE module of
the Behavioral Risk Factor Surveillance System (BRFSS).
Curr Psychiatry Rep (2012) 14:599–607
They found overall prevalence rates for CSA of 12.2 % for
all adults 18 and over with a gender distribution of 17.2 %
females and 6.2 % males [7].
Pereda et al. analyzed 65 research studies across 22
countries to estimate an “overall international figure” for
sexual abuse and found that an estimated 7.9 % of men and
19.7 % of women globally experienced sexual abuse prior to
the age of 18 [8].
CSA disrupts both brain and body physiology [9••] and
does not seem to cause a single well-defined disorder but
rather the physiological disruption can lead to a myriad of
physical and mental symptoms and disorders. A study of
adults with a primary mood disorder found that the impact
of CSA (defined by the sexual abuse subscale of the Child-
hood Trauma Questionnaire) on illness burden was roughly
comparable to the effects of adding 8 years of age to a
person’s life [10]. In the areas of activities of daily living
and pain, the illness burden was even more pronounced as
20 years of age was added [10]. CSA disturbs family sys-
tems by subjecting them to the stress of complex health,
protection services and systems [11]. These systems can also
be unsympathetic, blame families and deliver incompetent
care [11]. Exposure to these systems may also cause sec-
ondary traumatization, further aggravate dysfunction in
struggling families or cause new problems in previously
intact families [12].
In the short-term, CSA among adolescents frequently
leads to sequelae such as sexual dissatisfaction, promiscuity,
homosexuality and an increased risk of revictimization.
Depression and suicidal behavior or ideations are also more
common in this cohort when compared to normal and psy-
chiatric nonabused controls [13]. PTSD prevalence rates of
approximately 37 % to 53 % have been reported in sexually
abused children [14–16]. Long-term sequelae include a
higher incidence of eating disorders, obesity, depression
and suicide attempts. Low self-esteem, maladaptive coping
skills, disturbed self-identity, poor interpersonal skills, lack
of social support and increased vulnerability to stress is
found in adult survivors of childhood sexual abuse [1,
9••]. Trickett and colleagues (2011) reported findings of a
23-year longitudinal study of females who survived intra-
familial sexual abuse and found that these women were, on
average, different on many biopsychosocial domains (e.g.,
sexual and interpersonal behaviors, cognition, social net-
works, weight management and presence of psychopathol-
ogy) from matched comparisons [9••]. This study
demonstrated the repetition of generational patterns of ne-
glect, abuse and family dysfunction.
It also reemphasized the importance of intervention at
many stages of development [9••]. Van der Kolk (2005) [17]
has proposed a new diagnostic category, Developmental
Trauma Disorder, to account for the complex symptom
profiles of chronically traumatized children. This impact of
Curr Psychiatry Rep (2012) 14:599–607
cumulative trauma on childhood development is not simply
a result of greater severity than single incident trauma, but
suggests a qualitatively different phenomenon in that multi-
ple interpersonal and affective domains are affected. Factors
consistently associated with more adverse impacts are: lon-
ger duration of abuse, force or violence, and the father or
father figure as perpetrator [9••]. In addition, greater risks of
mental health problems are associated with sexual abuse at a
later age, a greater number of abuse incidents, multiple
abusers and penetration [18]. People with psychotic disor-
ders who are victims of CSA and/or childhood physical
abuse (CPA) have an earlier onset of illness, a more severe
clinical course and a higher number of hospitalizations.
They also show lower remission rates and poorer compli-
ance with treatment [19]. Evidence is developing to suggest
that treatments addressing trauma are beneficial for patients
with psychosis [20].
There is a growing body of literature on the effects of
maltreatment on the developing brain [21]. Structural differ-
ences such as decreases in corpus callosum volume (particu-
larly the middle and posterior regions) have been reported in
children and adolescents exposed to maltreatment when com-
pared to non-maltreated controls [22–26]. Since the corpus
callosum controls inter-hemispheric communication of pro-
cesses such as arousal, higher cognitive abilities and emotion
[26, 27], this finding may have a functional correlate. In
addition, decreased cerebellar volume in maltreated children
and adolescents is also a consistent finding in the literature
[28–30]. This is significant because of the mounting evidence
demonstrating the crucial role the cerebellum plays in emotion
processing, fear conditioning [31] and executive functioning
[32]. Functionally, research examining event-related poten-
tials (ERP) (record of the brain’s electrical activity and reso-
lution in milliseconds of cognitive operations throughout the
brain) has demonstrated hypoactivity in the prefrontal cortex
and limbic and paralimbic systems. ERP findings in various
studies [33–38] suggest that some maltreated children distrib-
ute more resources and remain in a hypervigilant state when
exposed to social environmental threat, perhaps at the expense
of other processes of development [21].
Research investigating biological correlates of resilience
and vulnerability following maltreatment [39] has gained
increasing interest. It appears that specific genetic polymor-
phisms may confer vulnerability or resilience after maltreat-
ment. Despite the heterogeneity of samples of maltreated
children in the study of gene-environment interactions, the
epigenetic changes that affect gene expression are proving
to be an exciting new area of research that promises to
inform treatment in the future [21].
Recognizing the therapeutic implications of the multidi-
mensional, developmentally deviating clinical profile of a
child who has experienced complex trauma, the field of
child trauma treatment is moving toward component-based
601
treatment models that provide an array of tools and techni-
ques for therapists to consider [9••, 40–42].
Update on Service Delivery and Treatment of Childhood
Sexual Abuse
Co-located Treatment Services
The Child Advocacy Center (CAC) model was first estab-
lished in Alabama, through congressional sponsorship by
US Congressman Bud Cramer [43]. He saw the need to
coordinate and integrate the many services abused children
receive [43]. Since its inception, over 800 Children Advo-
cacy Centers have been established in the US and more than
ten countries throughout the world [43]. The National Child-
ren’s Advocacy Center located in Huntsville, Alabama,
offers training and serves as a model for CACs. While not
all CACs have co-located models and especially co-located
behavioral health services, an integrated model is consid-
ered the gold standard. Co-located services may hold prom-
ise in improving access to specific trauma-focused services
as described in a recent paper addressing this issue.
McPherson, Scribano and Stevens performed a retrospec-
tive chart review on a sample of children evaluated at a co-
located, hospital-based child advocacy center for suspected
CSA and referred to their trauma treatment program called
the Family Support Program (FSP) for trauma-focused men-
tal health counseling. Assessment and treatment services are
co-located within the Center. The demographic reviewed in
this paper includes urban, suburban and rural children and
families in the central Ohio region. Study participants were:
(1) ages 3–16, (2) evaluated for CSA and (3) referred to the
FSP for trauma-focused counseling services (individual
treatment, group therapy and/or family therapy). Trauma-
focused Cognitive Behavior Therapy was a frequently used
treatment modality. Patients already involved with therapy
or who required a higher level of care were not included in
the study. Patients whose geographical distance interfered
with the ability to participate in weekly therapy had signif-
icant developmental delays, and those who did not make a
disclosure of CSA during the medical evaluation or who had
not engaged in sexually reactive behaviors were also ex-
cluded from the study. This last exclusion changes the focus
from sexually abused children in general to children exhib-
iting an important post-sexual abuse behavior. Of note,
exposure to pornography and/or the patient being used as
the subject of child pornography was also included in the
definition of CSA victimization. Data were obtained from
clinical and administrative databases during the study period
of 1 September 2005 to 31 August 2006 [44].
Significant linkage with therapy (individual, group and/
or family therapy) was associated with referral to other
602
mental health services during or after completing the initial
therapy treatment. Participants were more likely to complete
therapy if the caregivers participated in the services or if
they were referred to other mental health services beyond
the initial therapy. This study interestingly did not demon-
strate a significant difference in therapy participation in
different SES populations. A possible explanation for this
is the billing procedure and funding source of the center.
The program provides services on a sliding fee scale based
on income level. The FSP also accepts all insurance plans
including Medicaid. In addition, the FSP receives other
resources from the county mental health board, which sup-
plements Medicaid coverage. Therefore, access was not a
significant barrier in this study. A referral to an in-house
therapy program, after the initial medical and psychosocial
evaluation, may facilitate adherence to treatment recommen-
dations in populations that are at higher risk for attrition and
noncompliance. Of the 490 patients followed in this study,
52 % were linked with FSP counseling services (i.e.,
attended at least one session). The rate of linkage to mental
health services would have been higher (77 %) if the fam-
ilies already engaged in community therapy treatment had
been included in the data analysis. A total of 40 % of
subjects completed treatment goals that were initially for-
mulated with family input and defined a priori by the ther-
apist [44]. These findings are important but need to be
generalized.
Secondary Prevention
Child and Family Traumatic Stress Intervention (CFTSI)
Berkowitz, Stover and Marans report on their development of
a four-session brief intervention aimed at reducing post-
traumatic stress symptoms (PTSS) and preventing PTSD,
implemented within 30 days of a potentially traumatic event.
One hundred six subjects aged 7–17 were randomized to the
control condition and treatment condition. The CFTSI focuses
on two key risk factors of poor social or familial support and
poor coping skills in its effort to prevent chronic PTSD. The
CFTSI ameliorates these risks by (1) increasing communica-
tion between the affected child and the caregivers about feel-
ings, symptoms and behaviors, with the goal of increasing the
caregivers’ support of the child, and (2) providing specific
behavioral skills that are taught both to the caregiver and child
to assist in coping with symptoms. The treatment is delivered
in four sessions with a combination of individual and joint
sessions of child and caregiver. The Trauma History Ques-
tionnaire (THQ) [45] is administered at baseline and follow-
up to establish the number of previous potentially traumatic
events [46•]. Posttraumatic Stress Disorder Checklist–Civilian
version (PCL-C) [47] is administered to the caregiver. The
Mood and Feelings Questionnaire (MFQ) [48] and modified
Curr Psychiatry Rep (2012) 14:599–607
versions of the UCLA Posttraumatic Stress Disorder Reaction
Index (PTSD-RI) [49] are administered to the child and
caregiver as clinical interviews at baseline and the end of
the intervention. Symptomatic reactions to the PTE are nor-
malized, and relaxation techniques are taught. Feedback
about the child’s status is given and his or her disposition is
discussed post-intervention. Their intervention is compared to
an intervention that provided supportive counseling and
psychoeducation.
After intervention, the CFTSI group was significantly less
likely to have PTSD at follow-up, reducing the odds of PTSD
by 65 % [46•]. CFTSI participants showed a significant de-
crease in the avoidance and re-experiencing criteria, while the
hyperarousal criteria did not show a significant difference
[46•]. Since CFTSI’s core therapeutic method is focused on
increasing caregiver–child communication, the decrease in
avoidance was anticipated. Caregiver attunement to their child-
ren’s symptoms is more likely to lead to expressed concern
about the child’s status and the recent PTE [46•]. Evaluation of
CFTSI’s effectiveness is being evaluated at several CACs
nationally (personal communication).
Treatment
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT has been the primary treatment for children with
traumatic stress symptoms due to CSA for well over a
decade and has the most significant evidence base for the
treatment of childhood PTSD [50]. TF-CBT is usually de-
livered in 16 sessions addressing psychoeducation, parent-
ing skills, relaxation, affective regulation and the
development of a Trauma Narrative (TN), which has been
shown to decrease the anxiety response to the recollection of
the trauma or to trauma reminders, as well as decreasing
avoidance. Recently, Deblinger et al. examined the differ-
ential effects of TF-CBT with or without the inclusion of a
trauma narrative in 210 young CSA survivors (ages 4–11)
[51•]. The recent study attempted to ascertain whether
PTSD, internalizing, externalizing, depression and anxiety
severity as well as sexualized behaviors, fear, shame and
body safety skills would be comparable in both treatment
conditions. Levels of parental depression, emotional distress
about their children’s sexual abuse and parenting practices
were also compared [51•].
In a pre-post randomized design four treatment conditions
were examined: 8 sessions with no TN, 8 sessions with TN, 16
sessions with no TN and 16 sessions with TN. The overall
pattern of results indicate that for children aged 4–11 with a
history of CSA and their nonoffending parents, TF-CBT was
effective in enhancing a broad spectrum of affective and
behavioral functioning as well as parenting and child personal
safety skills. The pre- to post-treatment changes in all four

Table 1 Review of pediatric PTSD psychopharmacology
Medication class
Selective serotonin
reuptake inhibitors (SSRIs)
Anti-adrenergic s (alpha 2
agonists, propanolol)
Second generation
antipsychotics
Mood stabilizers
C&A children and adolescents; RCT randomized controlled trial
a
Level and source of evidence/grade of recommendation: I, systematic review or randomized controlled (includes quasi RCT) trial/A; II, cohort studies, non-randomized controlled trials/B; III, case
control studies, observational studies with controls/B; IV, case series, observational studies without controls/C; V, expert opinion/D (from Oxford Centre of Evidence Based Medicine; http://
www.cebm.net and www.ahrq.gov)
Treatment targets and/or measures
Post-traumatic stress symptoms on KSADS-PL
(re-experiencing, avoidance, hyperarousal)
Primary measure: mean University of California
at Los Angeles (UCLA) PTSD Index Score
Clinician-Administered PTSD Scale (CAPS)
total, symptom cluster scores and Clinical
Global Impression- Severity Scale (CGI- S)
CAPS Child & Adolescent (CA) core PTSD
symptoms
Sleep and nightmares
Intrusive symptoms
Aggression, hyperarousal and sleep difficulty
Nightmares
PTSD – full or subthreshold criteria on
CAPS-CA
PTSD symptoms
Trauma symptoms checklist for children
(TSC-C) t-scores; anxiety, depression
and anger symptoms
Acute stress disorder symptom clusters
PTSD symptoms
PTSD symptoms
Curr Psychiatry Rep (2012) 14:599–607
Description and results Level of evidencea Reference
RCT using sertraline + TF-CBT (n012 C&Aa) vs. Negative RCT Cohen, Mannarino, Perel et al. 2007 [62]
TF-CBT + placebo (n012 C&A); no significant
difference reported
Multi-site RCT comparing efficacy of sertraline Negative RCT Robb, Cueva, Sporn et al. 2008 [63]
(n067 C&A) vs. placebo (n062 C&A); no
significant difference reported
Open label treatment with citalopram C&A (n024) Level IV Seedat, Stein, Ziervogel et al. 2002 [64]
vs. adults (n014) ×8 weeks; no difference between
C&A vs. adults. Significant decrease on all measures
Open Label Study of citalopram (n08 adol.); Level IV Seedat, Lockhat, Kaminer et al. 2001 [65]
significant improvement at week 12; 38 %
reduction in symptoms
Case report on prazosin adjunctive to mirtazapine Level IV Brkanac, Pastor, Storck 2003 [66]
(n01 adol. female); improved sleep, cessation of nightmares
Case report on prazosin monotherapy (n01 adol. Level IV Strawn, Delbello, Geracioti 2009 [67]
female); rapid reduction of symptoms
Case report on clonidine monotherapy and clonidine + Level IV Harmon and Riggs 1996 [68]
imipramine (n07 preschool-aged children); symptom
reduction
Case report on guanfacine (n01 school-aged child); symptom Level IV Horrigan 1996 [69]
reduction
Secondary prevention randomized controlled pilot study Negative pilot study Nugent 2007 [70]
of propanolol vs. placebo (n029 C&A); no difference
Case series of propanolol (on-off-on) (n011 children); Level IV Famularo, Kinscherff, Fenton 1988 [71]
significantly fewer symptoms
Case series of quetiapine (n06 adolescents); improvement Level IV Stathis, Martin, McKenna 2005 [72]
in all measures
Case report of risperidone (n03 preschool-aged Level IV Meighen, Hines Lagges 2007 [73]
children); reduction of all symptom clusters
Case report of risperidone adjunctive to divalproex and Level IV Keeshin, Strawn 2009 [74]
clonidine (n01 adol. male); reduction of symptoms
Open label study of carbamazepine (n028 adol.); 22/28 Level IV Looff, Grimley, Kuller et al. 1995 [75]
asymptomatic; 6/28 significant improvement
603
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groups represented “moderate-to-large” effect sizes, suggest-
ing that all TF-CBT conditions were efficacious. There were
some differential responses depending on the outcome of
interest. The TN component seems to be particularly impor-
tant in reducing a child’s abuse-related fear and general anx-
iety, as well as alleviating parental abuse-specific distress,
while 16 sessions of TF-CBT treatment without the TN com-
ponent seem to lead to the most improvement with respect to
parenting practices and fewer externalizing child behavior
problems. A 1-year follow-up of children and families in each
condition is in progress [51•].
Scheeringa, Cohen, Amaya- Jackson and Guthrie (2010)
evaluated the effectiveness of TF-CBT in children ages 3–6.
There have been previous questions about the effectiveness
of TF-CBT in this young population because of concerns
about cognitive developmental limitations in this age group.
Although the evidence base for trauma-focused cognitive
behavioral therapy (TF-CBT) to treat PTSD in youth is
convincing, there is a paucity of controlled trials in pre-
school aged children. One well-controlled study examined
the efficacy and feasibility of TF-CBT for treating PTSD in
3- through 6-year-old children exposed to heterogeneous
types of traumas. Procedures and feasibilities of the protocol
were refined in phase 1 with 11 children. Thereafter, 64
children were randomly assigned in phase 2 to either 12-
session manualized TF-CBT or a 12-week wait list [52•]. If
children in the wait list group still met study inclusion
criteria after the wait period, they received TF-CBT treat-
ment and were combined to form a single group for the
purpose of estimating effect sizes at the 6-month follow-up
and for examining how well TF-CBT content can be under-
stood in preschool-aged children [52•, 53].
Symptoms were ascertained using the Preschool Age
Psychiatric Assessment (PAPA) [54]. Developmental mod-
ifications were made for the determination of PTSD. Current
DSM-IV PTSD criteria and preschool-aged criteria similar
to those proposed for DSM-V validated by multiple studies
for this age group were used in alternative analyses. Major
Depressive Disorder symptoms and Separation Anxiety Dis-
order symptoms improved in both conditions. Oppositional
Defiant Disorder and Attention Deficit Hyperactivity Disor-
der symptoms showed improvement in the treatment group
but not in the wait list group. There were trends towards
improvements of ADHD and ODD symptoms, but they did
not reach statistical significance. The variability of scores
appeared to prevent the improvement in ODD and ADHD
symptoms from reaching statistical significance. The effect
size estimate (based on the total number of children in a
treatment condition; n075) for PTSD in this study was large
(d01.01; d>0.5 is considered large) [55]; however, because
of low retention and a need to replicate the finding, it should
be viewed tentatively. TF-CBT studies in older youth have
all produced large effect sizes [50], but differences in
Curr Psychiatry Rep (2012) 14:599–607
sampling and designs make direct comparisons speculative
[52•]. The 6-month follow-up data of 16 treatment partic-
ipants who were reassessed demonstrated significantly de-
creased PTSD symptoms, MDD, SAD and ODD but not
ADHD. While two previous studies had shown effective-
ness for young children with sexual abuse [53, 56], this is
the first to show effectiveness for a variety of types of
traumatic events (domestic violence, acute injury and the
Hurricane Katrina disaster).
Pharmacotherapy
Pharmacotherapy shows limited effectiveness for the treat-
ment of pediatric PTSD [57], and there have been few
randomized controlled trials in children. The data that exist
are also derived from case reports and open label trials. The
children studied are a heterogeneous group and have not
experienced solely sexual abuse. In general, pharmacother-
apy is best used to manage debilitating symptoms rather
than a first line treatment for PTSD in children. A summary
of the data is included in Table 1.
Conclusion
Childhood sexual abuse involves multiple complex factors
that make the evaluation of therapeutic interventions espe-
cially complicated. Family systems are disrupted, and chil-
dren may be placed out of the home. Typically multiple
systems and organizations are involved with potentially
competing agendas that result in increased stress on the
child and family. Additionally, the lack of a standard defi-
nition of childhood sexual abuse causes a challenge, as it
seems unlikely that the range of CSA represented in these
studies is equally traumatagenic. The chronicity of the abuse
clearly confers differing risk and treatment needs. Also, the
lack of a uniform definition may exclude children from
studies who deal with more subtle but potentially chronic
sequelae such as digitally exploited or pornographically
exposed children. The long-term sequelae of childhood sex-
ual abuse can increase the illness burden and cause high
rates of PTSD and other psychiatric illness. Evidence for
trauma-focused treatment is expanding. It may be possible
to decrease the treatment length of TF-CBT if externalizing
behaviors and parenting practices are of primary concern.
This is especially relevant when treating families who have
difficulty participating in prolonged treatment. Co-located
treatment can help increase the likelihood of treatment ac-
cess and completion. Pharmacotherapy shows limited effec-
tiveness in the treatment of pediatric PTSD, but should be
used as an adjunct intervention in children and adolescents
if limited gains are being made with psychotherapy. The
evidence for the feasibility and effect of using the TF-CBT
Curr Psychiatry Rep (2012) 14:599–607
model with preschool aged children is also developing.
From a public health perspective, mitigating or preventing
the morbidity of disease as early as possible is more cost
effective than subsequent treatment [9••]. Given the long-
term burden, impact of CSA and resultant psychiatric mor-
bidity, secondary prevention models are promising in pre-
venting the development of PTSD and comorbid conditions.
More research in this area is clearly indicated. Since care-
givers are poor at recognizing acute PTSS in their children
[58, 59], it is important for providers of child welfare and in
emergency departments to identify children exposed to trau-
matic events early on and direct them to appropriate care
providers to either prevent the development of PTSD or
mitigate morbidity [46•]. Despite the clear evidence of the
deleterious effects of CSA, many individuals do not suffer
long-term negative sequelae. Increasing research attempting
to define how and why these individuals are resilient has
great promise in aiding development of effective models of
prevention and treatment for CSA. [60, 61].
Disclosure M. Cummings: none; S.J. Berkowitz: consultant to Yale
University School of Medicine; research support from the First Hos-
pital Foundation, Hearst Foundation and National Institute of Mental
Health, and royalties from Yale University Press; P.V. Scribano: none.
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• Of importance
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