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Treatment for Sexually Abused Children and Adolescents

Article in American Psychologist · September 2000

DOI: 10.1037/0003-066X.55.9.1040 · Source: PubMed

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 Treatment for Sexually Abused Children
and Adolescents
Karen J. Saywitz
Anthony P. Mannarino
Lucy Berliner
Judith A. Cohen
The authors review research demonstrating the variable
effects of childhood sexual abuse, the need for intervention,
and the effectiveness of available treatment models. The
well-controlled treatment-outcome studies reviewed do not
.focus on sensationalistic fringe treatments that treat sexual-
ly abused children as a special class of patients. Instead,
studies demonstrate empirical evidence for extending and
modifying treatment models from mainstream clinical child
psychology to sexually abused children. The authors pro-
pose a continuum of interventions to meet the needs of this
heterogeneous group. Interventions range from psychoedu-
cation and screening, to short-term, abuse-focused cogni-
tive-behavioral therapy with family involvement, to more
comprehensive long-term plans for muItiproblem cases. Last
discussed are gaps in the research and suggestions for
future research to address the pressing dilemmas faced by
clinicians and policymakers.
W i examine key issues in the treatment of sex-
ally abused children l and their families. Af-
er reviewing the principal findings on the ef-
fects of childhood sexual abuse, we describe the available
research on treatment efficacy and discuss a number of the
difficult questions still facing practitioners, researchers, and
policymakers today.
What Are the Effects of Child
Sexual Abuse?
The bulk of past research on childhood sexual abuse has
suggested two important findings. First, the impact of child
sexual abuse is highly variable. Some children show no
detectable negative effects; others show highly adverse re-
actions with severe psychiatric symptomatology (e.g., Ken-
dall-Tackett, Williams, & Finkelhor, 1993). Second, child
sexual abuse is a risk factor for the development of psychiat-
ric disorders and distress in adults, although not all individu-
als will experience long-term effects (e.g., Fergusson, Hor-
wood, & Lynskey, 1996; Glaser, 1991; Mullen, Martin,
Anderson, Romans, & Herbison, 1996; Saunders, Kilpatrick,
Hansen, Resnick, & Walker, 1999; Silverman, Reinherz, &
Giaconia, 1996; Widom, 1999).
1040
University of CaliJbrnia, Los Angeles (UCLA) School
of Medicine, Harbor-UCLA Medical Center
MCP-Hahnemann University School of Medicine
and Allegheny General Hospital
University of Washington
MCP-Hahnemann University School of Medicine
and Allegheny General Hospital
Variability in the effects of child sexual abuse is not
surprising given the wide range of experiences that consti-
tute sexual abuse and the disparate contexts in which it can
occur, ranging from indecent exposure in a park, to kidnap-
ping and rape at knife point, to many years of multiple forms
of maltreatment in a chaotic family situation. Findings from
both clinical and community samples emphasize that sexu-
ally abused children exhibit more symptoms than nonabused
children in comparison groups (e.g., Browne & Finkelhor,
1986; Green, 1993; Kendall-Tackett et al., 1993; Mannari-
no, Cohen, & Gregor, 1989; Wind & Silvern, 1994). Yet, no
one symptom characterizes the majority of sexually abused
children, and there is no evidence of a single cohesive
syndrome resulting from child sexual abuse.
Although no syndrome has been identified, studies do
suggest that more than 50% of sexually abused children meet
partial or full criteria for post-traumatic stress disorder (PTSD;
McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988; Mckeer, De-
blinger, Henry, Orvashel, 1992). One of the impediments to re-
search has been that diagnostic criteria for PTSD are not suffi-
ciently sensitive to developmental factors, especially the ways in
which younger children exhibit effects of trauma. Moreover,
such symptoms can be difficult to measure, and available instru-
ments are of limited use with children. Hence, the disorder may
be underdiagnosed among children (American Academy of Child
and Adolescent Psychiatry [AACAP], 1998).
Editor's note. MelissaG. Warren servedas action editor for this article.
Author's note. KarenJ. Saywitz,Departmentof Psychiatryand Behavioral
Sciences, Universityof California, Los Angeles (UCLA) School of Medi-
cine; Departmentof Psychiatry,Harbor-UCLAMedical Center, Torrance,
CA. Anthony P. Mannarinoand Judith A. Cohen, Departmentof Psychia-
try, MCP-HahnemannUniversitySchool of Medicine; Departmentof Psy-
chiatry, Allegheny General Hospital, Pittsburgh, PA. Lucy Berliner,
HarborviewCenter for Sexual Assault and TraumaticStress, Universityof
Washington.
Correspondenceconcerningthis article should be addressedto Karen
J. Saywitz, Department of Psychiatry, Harbor UCLA Medical Center,
1000 WestCarsonStreet,Torrance,CA 90509. Electronicmail may be sent
to ksaywitz@ucla.edu.
References to children are intended to include both children and adoles-
cents except when specificage ranges are provided.
September 2000 • American Psychologist
Copyright 2000 by the American Psychological Association, Inc. 0003-066X/00/$5.00
Vol. 55, No. 9, 1040~1049 DOI: 10.1037//0003-066X.55.9.1040
 Most researchers underscore the need for longitudinal
designs to disentangle the separate effects of sexual abuse
(e.g., PTSD symptoms and sexual behavior problems) from
the effects of difficulties that predate the abuse and/or con-
tinue thereafter (e.g., depression and aggressivity; see, e.g.,
Briere, 1992; Green, 1993; Stevenson, 1999). In a compre-
hensive review of 45 studies, Kendall-Tackett et al. (1993)
concluded that sexual abuse accounted for 15% to 45% of
the variance. Investigators are beginning to tease apart the
multiple pathways by which abuse leads to adverse conse-
quences and the underlying psychological mechanisms re-
sponsible (e.g., Coffey, Leitenberg, Henning, Turner, &
Bennett, 1996). Evidence is beginning to accumulate to
demonstrate that the experience of sexual abuse itself makes
an independent contribution to later symptoms of PTSD
(e.g., Wind & Silvem, 1994).
As with any potentially traumatic experience, the ef-
fects depend not only on the characteristics of the incident
but also on a given child's vulnerability and resilience.
Effects are influenced by the child's level ofpreabuse func-
tioning (e.g., temperament, neurodevelopmental reactivity,
attachment status) and by the existence of risk and protec-
tive factors, including the social resources (e.g., family func-
tioning), emotional resources (e.g., mental health of nonof-
fending parents), and financial resources (e.g., access to
treatment) available to help the child cope with the abusive
incident or incidents. Sometimes abuse exacerbates preex-
isting problems; sometimes abuse overwhelms children who
have been functioning reasonably well because sequelae
unseat protective factors (e.g., children are relocated be-
cause of divorce or foster placement, which results in the
loss of attacbanent figures, friends, mentors, and activities
that provided recognition, like athletics).
Two thirds to one half of sexually abused children
appear to improve over time, but many either do not im-
prove or deteriorate (e.g., Kendall-Tackett et al., 1993; Oates,
O'Toole, Lynch, Stem, & Cooney, 1994). In empirical stud-
ies, most of the children who present as asymptomatic re-
main symptom free (70%), although some (30%) do develop
symptoms later (Kendall-Tackett et al., 1993). The propor-
tion of sexually abused children who present with no detect-
able symptoms varies across studies from 21% to 49%. In
some cases, children may be experiencing symptoms not
measured by investigators, or children may be at an early
stage before symptoms emerge. Researchers have found
evidence of a sleeper effect in severely abused children, with
more serious symptoms not manifesting themselves until a
year after disclosure (Mannarino, Cohen, Smith, & Moore-
Motily, 1991). In other cases, asymptomatic children may
represent a particularly resilient group that copes well and
never shows symptoms. Other children may not display
symptoms of trauma simply because the event was a rela-
tively minor incident that was not experienced as traumatic,
although it was exploitative and illegal.
Early studies of long-term effects indicated that child
sexual abuse is a major risk factor for a variety of problems
in adult life, especially those studies that focused on the
effects of more serious abuse, on female samples, and/or on
September 2000 • American Psychologist
patients in treatment, as well as those that used objective and
retrospective self-report measures (e.g., Berliner & Elliott,
1996; Browne & Finkelhor, 1986; Coffey et al., 1996; Finkel-
hor, 1990; Green, 1993; Mullen et al., 1996; Stevenson,
1999). However, conclusions have been restricted by the
potential biases inherent in retrospective data. Recently,
studies with enhanced designs have provided further support
for the notion that child sexual abuse is a risk factor for adult
difficulty. These include prospective studies of adults with
independently confirmed histories of abuse (e.g., Widom,
1999), studies with repeated childhood testings of psychiat-
ric symptomatology (e.g., Fergusson et al., 1996), and stud-
ies using national probability samples (Saunders et al., 1999). 2
Some children experience events legally defined as
sexual abuse but show no immediate symptoms requiring
psychological treatment; nonetheless, these children may
benefit from psychoeducational efforts to prevent future
victimization and from periodic reassessment to check for
sleeper effects, as discussed in the Asymptomatic Children
section. In contrast, other children and adolescents experi-
ence serious abuse and serious abuse-related sequelae that
clearly cause them to need treatment. Currently, there is no
reliable means of predicting, in individual cases, which
children will have persistent symptomatology or will devel-
op symptoms later and which children require no or minimal
intervention, although some predictive variables have been
identified. In aggregate, studies have tended to describe four
sizable groups of children to be considered for intervention:
1. Some children have no detectable difficulties on
standardized measures of child behavior problems. Kendall-
Tackett et al. (1993) estimated this group to be about one
third of children studied.
2. Some children have a few symptoms that do not
reach clinical levels of concern (e.g., emotional distress,
anxiety, self-esteem or identity difficulties) or have behav-
ior problems that reach clinical levels but are not as severe
as in the general clinical population (Cohen & Mannarino,
1988; Einbender & Friedrich, 1989; Gomes-Schwartz,
Horowitz, & Cardarelli, 1990; Mannarino et al., 1989;
Tong, Oates, & McDowell, 1986; Wolfe, Gentile, & Wolfe,
1989).
3. Some children have serious psychiatric symptoms,
such as depression (e.g., Shapiro, Leifer, Martone, & Kas-
sere, 1990), anxiety (e.g., Kolko, Moser, & Weldy, 1988),
sexualized behavior (e.g., Friedrich et al., 1992; Gale,
Thompson, Moran, & Sack, 1988; Kolko et al., 1988),
substance abuse (e.g., Hibbard, Ingersoll, & Orr, 1990;
Singer, Petchers, & Hussey, 1989), aggressivity (e.g.,
Friedrich, Beilke, & Urquiza, 1987), self-esteem or iden-
tity difficulties (e.g., Cavaiola & Schiff, 1989; Hotte &
Rafman, 1992; Wozencraft, Wagner, & Pellegrin, 1991),
shame and cognitive impairments or distortions (Einbend-
: For example, in one longitudinal study of a community sample of
abused children, researchers found high rates of depression, substance
abuse, and PTSD among the participants as young adults, with suicidal
ideation specifically associated with child sexual abuse in female partici-
pants (Silverman et al., 1996).
1041
er & Friedrich, 1989), and isolated post-traumatic symp-
toms, such as flashbacks, nightmares, and repetitive play
(e.g., Conte & Schuerman, 1987; McLeer et al., 1992;
Wolfe et al., 1989).
4. Some children meet full criteria for psychiatric dis-
orders, most notably PTSD, major depression, overanxious
disorder, and sleep disorder (e.g., McLeer et al., 1988). In
addition, comorbidity is a significant problem with trauma-
tized children and adolescents (AACAP, 1998). Studies of
clinical populations estimate that 55% of children referred
for treatment have more than one diagnosis (Target & Fon-
agy, 1996).
Is Treatment Effective?
Obstacles to Evaluating the Efficacy
of Child Treatment
Researchers have faced a number of obstacles to investigat-
ing whether psychological intervention is effective with
children and adolescents. First, it has been difficult to identi-
fy which symptoms to target with treatment and monitor for
change because children are not completely reliable infor-
mants about their own mental states, as their self-awareness,
vocabulary, reasoning, and metacognitive abilities are still
developing. Using parents' and teachers' reports may facili-
tate problem identification; however, these three sources of
information often diverge greatly from one another, thus
producing conflicting pictures of the problem (e.g., Kolko &
Kazdin, 1993).
In cases of sexual abuse, children are not typically
referred for treatment in the usual manner; that is, they are
not referred because of emotional or behavioral difficulties.
Instead, they are referred because it is discovered that they
have experienced a sexually abusive event. Hence, this is a
diverse set of children, varying in age, history, and presenta-
tion, and this diversity impairs the researcher's ability to
administer distinctive standardized treatments and to use the
same outcome measures for all children. Measures need to
have different norms and different forms for children who
differ in age, gender, vocabulary level, reading and writing
ability, and socioeconomic status. Measures for the disor-
ders most common among sexually abused children (e.g.,
PTSD) have not been developed adequately to detect symp-
toms in young children (AACAP, 1998). The heterogeneity
of this population complicates research design, requiring a
great many replication studies on children of different ages,
genders, symptom patterns, and family contexts.
Additionally, improvement is dependent not only on
the efficacy of the treatment and the nature and severity of
the patient's impairment, but also on the functioning of the
adults on whom the child depends. The mental health of
parents, parents' marital conflict, family functioning, the
presence of stressful life events, the family's socioeconomic
status, and cormnunity and cultural factors influence the
degree and maintenance of improvement (Kazdin & Weisz,
1998). In cases of child sexual abuse, parental belief and
support have been found to play a significant role in treat-
1042
merit outcome. In addition, researchers need to consider
unique contextual factors, such as the inclusion of intrafa-
milial perpetrators in treatment plans and outcome studies
where reunification isa goal. Also problematic is the study
of children living in multiproblem families. These children
may have been exposed to community and domestic vio-
lence and other forms of maltreatment, and although sexual
abuse is part of their history, it is not the presenting com-
plaint.
High spontaneous remission rates also make it difficult
to evaluate treatment outcome. Experimental designs need
to assess whether treatment quickens recovery and reduces
the risk of reoccurrence, even if some children's distress
will remit on its own. In addition, the developmental course
of childhood disorders does not always involve a stable set
of symptoms. Changing symptom patterns over the course
of development complicate research designs. The referral
symptom may be improved, but the same underlying diffi-
culty may manifest itself differently at later stages of devel-
opment.
Target and Fonagy (1996) also noted that efficacy
cannot be evaluated without attention to the match between
the treatment modality and the child's capabilities and cir-
cumstances. Despite indications that family therapy may be
best for a particular problem, it is not possible to conduct
family therapy when children are in changing foster care
placements. Certain therapies can be applied only when the
circumstances and the child's capabilities allow them.
Studies of Treatment Outcome With
Children and Adolescents
Given the obstacles to highly controlled research on
treatment outcomes and the very small number o f well-
controlled studies involving sexually abused children,
recommendations for service delivery demand reliance
on a broad literature, namely research on interventions
with children generally. Moreover, many of the symp-
toms displayed by abused children, such as depression,
anxiety, and aggressivity, are also exhibited by children
who have not been sexually abused. Hence, the effec-
tiveness of the available interventions for reducing these
symptoms is also at issue (Stevenson, 1999). On the one
hand, some evidence suggests that victims of child sex-
ual abuse are less responsive to some generic treatment
strategies as adults than individuals without a history of
sexual abuse (Holmes, 1995). On the other hand, once
the immediate abuse-focused work with the family is
complete, researchers do not know whether the moder-
ate and long-term difficulties of the child are all that
different from those of other children in need of treat-
ment for similar symptoms (Stevenson, 1999).
Recently, the literature on children's treatment out-
comes has enjoyed some keen advances in experimental
design and statistical methods that have laid the groundwork
for several large meta-analytic studies of hundreds of fairly
well-controlled investigations. These meta-analyses have
indicated that psychosocial therapies are effective with
children and adolescents and are more effective than the
September2000 • American Psychologist
passage of time alone (e.g., Kazdin, Bass, Ayers, & Rodg-
ers, 1990; Kazdin & Weisz, 1998; Weisz, Weisz, Alicke, &
Klotz, 1987; Weisz, Weisz, Han, Granger, & Morton, 1995).
Effect sizes have varied by presenting problem, with
greater success for phobic, somatic, and anxiety symptoms
than for symptoms related to global adjustment or personal-
ity characteristics (e.g., Casey & Berman, 1985). Most sum-
maries of the field now echo the words of Peter Fonagy
(1998):
The era of generic therapies is over. No treatment can be equally
applicable without modification to every disorder.... Nonspecific,
poorly structured treatments, such as generic counseling, nonfo-
cused dynamic therapy and a variety of experiential therapies are
unlikely to be effective with severe presentations. (p. 133)
Hence, the focus of current research is on determining what
forms of treatment work best for which groups of children
(Target & Fonagy, 1996).
A detailed discussion of the evolving criteria for vali-
dating treatments is beyond the scope of this article. Let it
suffice to say that most reviews of the empirical literature
find the following treatments to be efficacious or possibly
efficacious for use with children and adolescents: cognitive-
behavioral therapy (CBT) for childhood anxiety, coping
skills training for childhood depression, and parent manage-
ment training based on behavioral techniques and cognitive
problem-solving training for externalizing behavior prob-
lems (e.g., aggression). (See Chambless & Hollon, 1998, or
Kazdin & Weisz, 1998, for discussions of efficacy criteria.)
For the most part, tests of these interventions have demon-
strated positive outcomes that have been replicated by dif-
ferent investigative teams.
Generally speaking, studies support behavioral therapy
and CBT over nonbehavioral therapies (see Kazdin & Weisz,
1998, for a thorough review). This does not mean that
behavioral approaches are best for all types of children and
all types of problems. These approaches may enjoy the
greatest empirical support in part because they are the most
frequently studied. They are short term and are among the
easiest to manualize, standardize, and therefore utilize in
well-controlled treatment trials. The kinds of nonbehavioral
approaches that are most prevalent in clinics have not been
well evaluated (e.g., family therapy, brief or focused psy-
chodynamic therapies, structured group treatment). Often
the active ingredients are difficult to manualize and stan-
dardize (e.g., transference). Moreover, some of the changes
such interventions seek to achieve (e.g., altered family-
interaction patterns or intrapsychic changes) do not lend
themselves to the kinds of standardized tests currently avail-
able to measure outcome in terms of symptom relief. Most
studies have focused on symptom reduction, neglecting the
impact of adaptive real-world functioning and development
(Kazdin & Weisz, 1998). The bulk of the studies supporting
behavioral and cognitive-behavioral techniques have taken
place in university settings, and researchers have had diffi-
culty transferring benefits to community clinics where chil-
September 2000 • American Psychologist
dren may present with more severe symptoms (Hoagwood
& Hibbs, 1995; Kazdin & Weisz, 1998; Kendall & Southam-
Gerow, 1995). Still, the past 25 years of research have
produced substantial support for the efficacy of professional
behavioral and cognitive-behavioral interventions with chil-
dren and adolescents, especially when children present with
anxiety-related symptoms, depression, or behavior prob-
lems.
Outcome Studies of Child Sexual
Abuse Treatment
Reviews of studies using quantitative outcome measures
began to appear only in the past decade (Beutler, Will-
iams, & Zetzer, 1994; Finkelhor & Berliner, 1995; Green,
1993). By and large, studies have focused on abuse-specific
therapies that have used cognitive-behavioral techniques in
conjunction with psychoeducational interventions, coping-
skills training, and family involvement. The major emphasis
on cognitive-behavioral and behavioral techniques, specific
rather than generic therapies, and the rapid push toward
randomized clinical trials has clearly been catalyzed by the
conclusions of the general child-treatment literature just
discussed.
Finkelhor and Berliner (1995) conducted a thorough
review of studies that used quantitative measures and siz-
able numbers of participants prior to 1995. They located
only 29 studies worthy of inclusion. The largest number of
these studies used simple comparisons of children at two
times during professional intervention. All of these studies
showed that the treated sexually abused children improved
significantly over time; however, these types of pretest-
posttest designs without control groups have inherent limi-
tations. It is unclear whether improvement is due to treat-
ment, to the passage of time, or to some other factor outside
the treatment. Moreover, studies have found that, as a group,
sexually abused children improve over time whether or not
they receive treatment (e.g., Gomes-Schwartz et al., 1990).
There were a few studies that involved quasi-experi-
mental designs, used large samples of nearly 100 children,
and/or attempted to deal with design problems in other ways
(e.g., self-comparisons; see, e.g., Deblinger, McLeer, & Hen-
ry, 1990; Lanktree & Briere, 1995). These studies suggested
that not all problems and not all sexually abused children
responded to treatment. Some problems, especially exter-
nalizing symptoms as measured on the Child Behavior Check-
list (e.g., aggressiveness) and sexualized behavior under
certain circumstances were resistant to change.
The first few controlled studies using randomized as-
signment to treatment conditions produced somewhat mixed
results. However, not all studies had enough participants or
powerful enough designs to detect possible differences, and
in some cases it was difficult to ensure that the treatments
being compared were distinct (Baker, 1987; Berliner &
Saunders, 1996; Hyde, Bentovim, & Monck, 1995; Perez,
1988). For example, Berliner and Saunders (1996) com-
pared the effects of a stress-inoculation training module
embedded in standard abuse-focused treatment with the ef-
fects of standard treatment alone. In a study of 100 sexually
1043
abused children, they did not find significant differences in
anxiety symptoms between treatment groups. One reason
postulated for the lack of differences was that the treatment
conditions were not different enough from each other in
ways that mattered. Also, the standard treatment may have
been sufficient, given that children did not present with high
levels ofpretreatment anxiety.
The most recent wave of studies has begun to demon-
strate statistically significant benefits. These studies used ran-
domized samples and trials, control groups, standardized
instruments, manualized treatments, and adherence or fidelity
procedures. Usually some form of abuse-specific CBT was
compared with a more nondirective approach or a standard
community treatment. Deblinger, Lippman, and Steer (1996)
compared a 12-week program of abuse-focused CBT provid-
ed to children only, to parents only, or to both children and
parents with standard community care for a total of 100
sexually abused children ages 7 to 13. Results indicated that
all groups improved on PTSD symptoms; however, CBT
provided directly to the children resulted in significantly greater
improvement. Furthermore, providing CBT to the nonoffend-
ing parents resulted in significantly more improvement in the
children's depressive symptoms, as well as improvement in
the parenting skills of the participating parents. These results
support abuse-focused professional intervention with both
children and nonoffending parents.
Celano, Hazzard, Webb, and McCall (1996) randomly
assigned 32 sexually abused girls and their parents to an
eight-session CBT intervention or to a nonspecific treat-
ment. They found that the CBT group reported significantly
more improvement in parental support for the children, sig-
nificantly fewer parental expectations that the abuse would
have negative effects on the children, and less self-blame
among parents. However, children in this group did not
show more improvement on PTSD symptoms than the con-
trol group. Researchers noted that the most talked about
topic even in the control condition was the sexual abuse and
the children's associated reactions. This may have reduced
differences between treatment conditions. Also, the chil-
dren's PTSD symptoms prior to treatment were not severe,
and again, the more structured, manualized approach may
not have been necessary. However, the results highlight the
added value of parents' involvement in the treatment of
sexually abused girls.
Cohen and Mannarino (1996b, 1998b) conducted two
studies of sexually abused children that compared CBT to
nondirective supportive therapy. Both of these studies in-
cluded intervention with the nonoffending parent in each
treatment condition. In the first study (Cohen & Mannarino,
1996b), 67 three- to seven-year-olds and their parents were
randomly assigned to either abuse-specific CBT or nondi-
rective supportive therapy composed of nonspecific play
therapy for the children and supportive counseling for the
parents. Children provided with abuse-focused CBT had
significantly greater improvement in PTSD symptoms, sex-
ually inappropriate behaviors, and internalizing and exter-
nalizing symptoms compared with those receiving nondi-
rective supportive therapy. These differences were sustained
1044
at a one-year follow-up (Cohen & Mannarino, 1997). These
findings strongly support abuse-focused CBT with preschool-
ers and their parents.
In a study of 49 older children ages 7 to 14, those who
were provided with abuse-focused CBT experienced signif-
icantly greater improvement in depression and social com-
petence than those receiving nondirective supportive thera-
py (Cohen & Mannarino, 1998b). However, as in Celano et
al.'s (1996) study, the groups did not differ in PTSD symp-
toms. Again, it could be that when PTSD is not severe and
children are older, they spontaneously discuss the abuse and
their associated feelings and attributions even in the control
condition. However, this study did find that improvement in
older sexually abused children's depressive symptoms was
associated with abuse-specific CBT.
Additionally, recent studies have identified factors that
can exacerbate or ameliorate the psychological impact of sex-
ual abuse and treatment outcome, most notably family factors
and children's attributions. Symptom development and treat-
ment response are influenced by parents' emotional distress
related to the abuse, parents' support of their children, and
children's attributions regarding variables such as locus of
control (Cohen & Mannarino, 2000; Mannarino & Cohen,
1996a, 1996b). In a study that included parent report measures,
Mannarino and Cohen (1996c) found that ratings of family
cohesion, adaptability, and the intensity of parents' reactions
to the abuse were significantly related to ratings of children's
behavior problems. In a preschool population, parents' emo-
tional distress about the abuse strongly predicted treatment
outcome initially (Cohen & Mannarino, 1996a), but at the one-
year follow-up, parents' support was a stronger predictor of
positive outcome (Cohen & Manna-rino, 1998a). In a study of
older children, parents' support and the children's abuse-relat-
ed cognitions most strongly predicted treatment outcome (Co-
hen & Mannarino, 2000). These findings reiterate the impor-
tance of parental involvement to treatment outcome.
In summary, the existing studies of the outcomes of
treatment for children who have been sexually abused suggest
that many of the symptoms associated with child sexual abuse
can be responsive to professional intervention, although symp-
tom changes are influenced by other factors as well (e.g.,
intensity of parental reaction to abuse, children's attributions,
and family adaptability). Often, these factors are also targets of
treatment. As this review demonstrates, however, the number
of treatment outcome studies that have randomly assigned
children to treatment conditions has been quite small, and
these studies have not been sufficiently replicated by different
investigative teams. Still, results consistently favor abuse-
specific CBT over the other forms of treatment to which it has
been compared, although abuse-specific CBT did not always
perform as expected (i.e., it did not always reduce levels of
post-traumatic stress). 3 Also, there is some evidence that be-
3Inconsistentresults on PTSD measuresneed to be furtherinvesti-
gated. As previously mentioned, researchers still have a good deal of
difficultyreliablymeasuringPTSDsymptomsin children,giventhe speci-
ficityof some of the PTSD symptomsin childrenwho have been sexually
abused.
September 2000 • American Psychologist
havioral interventions with parents were required to decrease
externalizing behaviors (aggression) or sexualized behaviors
in young children. When considered in conjunction with the
literature on child-treatment outcomes as a whole, these results
are bolstered by fmdings that support the efficacy of behavior-
al and cognitive-behavioral treatments when children present
with the kinds of symptoms often seen in sexually abused
children, namely, anxiety-related symptoms, depression, or
behavioral problems.
The Need for Additional Research
The empirical support for abuse-specific CBT must be viewed
in the context of a dearth of information about the efficacy
of other treatments. These treatments, prevalent in the field
and based on well-articulated theoretical frameworks, have
not been adequately tested. Victim groups, family therapy,
self-help groups involving offenders (eg., Parents United),
and eye-movement desensitization and reprocessing are
among these modalities. 4 To test these other forms of treat-
ment, however, therapists will need to carefully describe
these therapies to inform investigations. In addition, re-
searchers will need to develop global outcome measures of
real-world functioning and will need to test treatment effec-
tiveness in community clinics where symptom and treat-
ment-use patterns may differ from those of research partici-
pants (e.g., Horowitz, Putnam, Noll,& Trickett, 1997).
Definitive studies to determine which forms of inter-
vention are best suited for which groups of sexually abused
children have yet to be conducted: The influences of mod-
erator variables, risk and protective factors, and preceding
and continuing background factors have not been disentan-
gled. The components of abuse-specific CBT have not been
tested independently; hence, it is difficult to know whether
individual components, such as psychoeducation, would pre-
vent future victimization, deterioration, or late-emerging
symptoms if they were offered to children with few, minor,
or no symptoms. Long-term outcome has rarely been inves-
tigated; hence, researchers know little about the role of
treatment in relapse prevention or in forestalling symptoms
that would otherwise appear.
Similarly, developmental issues in treatment outcome
have rarely been addressed, despite the obvious fact that
sexually abused children are a heterogeneous group. These
children differ in key attributes, including language, cogni-
tive, and emotional skills and sexual maturity, that are nec-
essary for full participation in many forms of treatment.
Generalization from the available studies requires that re-
searchers design studies with multiple age groups to investi-
gate the relative benefits of different treatments for children
at different ages.
Finally, one of the most pressing issues in the field
remains the need to study children who initially present with
no or few symptoms. I f they are included in outcome stud-
ies, they will make it more difficult to detect positive results
when positive results exist, because asymptomatic children
cannot show improvement. These children probably need to
be studied as a distinct group to determine whether early
September 2000 • American Psychologist
intervention does in fact prevent deterioration, late-emerg-
ing symptoms, and further victimization. Informed policy
decisions about who should be offered what kinds of servic-
es demand a better understanding of how asymptomatic
children who have been sexually abused respond to the
abuse and to treatment over time.
How Should Sexually Abused Children
and Adolescents Be Treated?
Given the diversity of the effects of child sexual abuse, no
single type of intervention is likely to be applicable or
effective for all sexually abused children. Often, the treat-
ment of sexually abused children and their families is com-
plex. Treatment plans need to be individualized on the basis
of the clinical presentation of the child and the context in
which treatment will proceed. Multimodal treatment (indi-
vidual, family, group, pharmacological) and different levels
of care (e.g., outpatient, partial, or inpatient) may be re-
quired for different children or for the same child at different
times (AACAP, 1998).
In addition, working with caretakers in one form or
another appears to be essential. Including parents in treat-
ment enables them to manage externalizing symptoms with
behavioral strategies, to monitor children's symptoms, to
develop strategies for preventing revictimization, and to
normalize family functioning. Involvement in treatment
helps parents control their own distress and reframe their
own attributional errors so that they can support the child's
coping.
Standards for practice in cases of child sexual abuse
are no different from those used for other types of cases.
Fundamental principles of screening, assessment, and treat-
ment planning apply. It bears repeating, however, that
there is little empirical support for generic therapies ap-
plied indiscriminately to all cases regardless of the referral
question. Hence, as with referrals for traditional psychiatric
disorders or other potentially traumatic events, clinicians
who work with sexually abused children need to think
strategically. Specific symptoms need to be targeted with
specific strategies.
Abuse-Specific Treatment
One reason that abuse-specific CBTs are potentially helpful
is that they incorporate well-established treatment strategies
to target specific symptoms. Interventions target the chief
symptoms of post-traumatic distress (e.g., reexperiencing
the event with intrusive thoughts or flashbacks, avoidance of
reminders, and hyperarousal). Anxiety and avoidance are
targeted with gradual exposure and desensitization, stress
inoculation and relaxation training, and interruption and
4We locatedonlytwo relevantstudies with sexuallyabusedchildren.
In both studies, researchers found almostno group differenceswhen com-
paring familytherapywith familytherapyplus grouptherapy (Hyde et al.,
1995) or when comparinggroupto individualplay therapy (Perez, 1988).
5A multi-site study of 240 sexually abused children is currently
underway to address some of these questions (Cohen, Deblinger, &
Mannarino, 1997).
1045
replacement of upsetting thoughts to regain control over
thoughts and feelings. Depressive symptoms are targeted
with coping-skills training and correction of cognitive dis-
tortions. Behavior problems that interfere with functioning
are targeted with conventional behavior-management strate-
gies. Given the limited but consistent support for abuse-
focused behavioral and cognitive-behavioral interventions,
those who work with sexually abused children will want to
familiarize themselves with this approach as one of the
methods available in their repertoire of therapeutic options
(see Cohen, Mannarino, Berliner, & Deblinger, 2000).
One assumption underlying the need for abuse-spe-
cific treatment is that these children have been involved
in a potentially traumatic and inappropriate sexual experi-
ence that warrants a treatment focus not only on ameliora-
tion but also on prevention--prevention of both further
victimization and later behavior problems (e.g., substance
abuse, promiscuity, or depression in adolescence). This is
not an unreasonable assumption given the rates at which
children in high-risk situations are abused multiple times
and the fact that a portion of children who initially present
with no measurable symptoms do develop difficulties later.
However, the specific methods used to implement abuse-
specific treatment must be carefully considered.
A dilemma is created by the fact that interventions with
the most empirical support involve exposure-based treat-
ment. When abuse is the source of extreme anxiety and
avoidance triggered by remembering, some direct discus-
sion of the abusive event or events is indicated for exposure
and desensitization to be effective. When the abuse is the
source of distorted cognitions that underlie depression, some
direct discussion of the abusive event is often indicated for
cognitive restructuring to be effective. However, if the dis-
cussion is not carefully conducted, it may contaminate the
child's report and the disclosure process. Sometimes it may
be appropriate to delay direct discussion of the abusive
event with a child until the abuse is substantiated by the
local child protection service system.
Much potentially therapeutic work can occur early in
treatment without extensive discussion of the specifics of
the abuse. This work can include crisis intervention to deal
with police or out-of-home placement and symptom reduc-
tion through pharmacological agents for depression or anxi-
ety. However, final resolution within the legal system is
often a matter of years, not weeks or months. If intervention
is delayed for too long, symptoms can exacerbate or become
chronic and resistant to treatment. Withholding empirically
supported treatment from children who exhibit serious symp-
toms of post-traumatic stress (e.g., flashbacks, nightmares,
phobic avoidance) raises ethical questions to be carefully
weighed.
It is clear that therapists need to be aware of the legal
implications of their interventions. Caution and forethought
must be exercised before discussing the event with a child to
minimize the potential for distortion. Familiarity with the
research on young children's suggestibility will highlight
the dangers of telling rather than asking young children what
happened (Saywitz & Lyon, in press). Children need to be
1046
able to describe events in their own words. Currently, re-
searchers are developing and testing innovative techniques
that minimize the potential for distortion when talking to
children about past experiences (e.g., narrative elaboration
training, which was developed by Saywitz & Snyder, 1996;
see also Camparo, Wagner, & Saywitz, in press). In addi-
tion, when therapists transform into interrogators, they can
find themselves in an ethical quagmire created by the dual
roles. Most professional organizations recommend that fo-
rensic evaluations be undertaken separately by specially
trained professionals. There is probably no way to escape
the inherent tensions among the goals of mental health
recovery, child protection, due process for the accused, and
justice, all of which need to be carefully balanced on a case-
by-case basis. Caution, interdisciplinary coordination, and
consultation with colleagues is often required.
Asymptomatic Children
Whether to allocate limited treatment resources to children
who present with no detectable symptoms is a difficult
issue. Unfortunately, little research is available to guide
decision making. However, it is routine to provide debrief-
ing and psychoeducation to all exposed children in the after-
math of natural disasters or school violence, even though
most of the children display no overt symptoms. This is
widely considered an important preventive intervention, as
well as an opportunity to screen for risk factors. Just like
children exposed to other potentially traumatic events, sexu-
ally abused children may very well benefit from efforts to
prevent them from developing misperceptions, unrealistic
fears, and maladaptive coping patterns that can grow into
problems of clinical proportions. Also, providers will be in
an excellent position to identify potential risk factors, as
well as to assess for symptomatology and impaired func-
tioning. Abuse characteristics known to be associated with
elevated risk (e.g., violence, penetration, longer duration),
negative attributions, and parental distress can be evaluated.
In addition, children can be assessed for risk factors that are
not specific to the abuse, such as family dysfunction, prior
trauma, an immature or mentally ill caretaker, disability, and
so forth.
Hence, when children present with no overt symptoms,
it may be sufficient to provide psychoeducation, screening,
and prevention awareness that could be accomplished with-
in a few sessions. Psychoeducation can be aimed at preven-
tion of further victimization, normalization, positive self-
image, and parent edification. Through psychoeducation,
parents can be taught to identify signs of difficulty that can
emerge at later developmental stages, which can increase
the probability of reevaluation when appropriate. Such lim-
ited professional intervention lays the groundwork for later
treatment seeking if it becomes necessary.
For children with no symptoms but high levels of risk,
psychoeducational efforts can be followed by monitoring
with periodic reevaluation to detect signs of deterioration or
late-emerging symptoms that were not apparent initially,
perhaps because of an avoidant coping style or external
supports that later gave way.
September 2000 • American Psychologist
Multi-Problem Cases
At the other end of the spectrum are children for whom
sexual abuse is only one of many adverse life experiences
that need to be addressed. Sexual abuse can last for years
and can cooccur with other forms of maltreatment, commu-
nity violence, and other comorbid psychiatric conditions.
Sometimes sexual abuse exacerbates already existing devel-
opmental delays or potentiates ongoing psychological, be-
havioral, or interpersonal difficulties. With placement in
foster care, some sexually abused children suffer conse-
quences, including the loss of family and friends, that cause
additional symptoms distinct from the abusive incident it-
self.
In these complex cases, children's reactions to the
sexually abusive incident or incidents are often not the only
or the most pressing issues in need of treatment. Some cases
require long-term, multi-faceted intervention strategies, strat-
egies that have not been empirically validated. Interventions
aimed at abuse-specific consequences fall short if they are
not part of a more comprehensive treatment plan to address
a multitude of difficulties (e.g., attachment disorders, learn-
ing disabilities).
Although studies show support for short-term ap-
proaches (8 to 16 sessions), long-term approaches have
not been tested, and there is no clear evidence regarding
the proper length of treatment. In the field, some children
and parents participate in wide-ranging therapeutic ac-
tivities that vary over time. For example, children with
multiple problems may benefit from short-term abuse-
focused therapy in conjunction with long-term relation-
ship-based therapies to help them cope with everyday
life. However, treatment-outcome studies have focused
primarily on less complicated diagnostic pictures and
higher functioning families. The results are insufficient
to dictate the most effective ways to organize treatments
for multi-problem cases.
Reunification and Resolution Cases
For children who have been abused by family members,
there are special considerations. In some cases, the child and
nonoffending parent may wish to reunify with an offending
parent or sibling. In other cases, although reunification may
not be a consideration, resolution of the abuse experience
with the offender may nonetheless be important for the child
to fully resolve the impact of the experience, because the
offender who is a relative may continue to be a part of the
child's life. Regardless of residency, biological parents and
siblings remain significant figures for children. At this time,
there are no empirical data regarding the frequency of reuni-
fication when sexual abuse has occurred or whether it is
helpful or harmful to the victim. There are no data address-
ing the safest and most helpful methods to achieve success-
ful therapeutic resolution of this very complex psychologi-
cal circumstance, although helpful clinical descriptions
of family-resolution therapies are available (Saunders &
Mienig, 2000). 6
September 2000 • American Psychologist
Conclusions
Research on the efficacy of treatment for sexually abused
children has been moving with laudable speed from case
studies and seriously flawed designs to studies using ran-
dom assignment to compare alterative treatments. This liter-
ature is poised to make a meaningful and potentially deci-
sive contribution to clinical practice. Current investigations
are not focused on unconventional treatments at the fringe
but on extending the treatment models in the mainstream of
clinical child psychology to the population of sexually abused
children and adolescents. The abuse-specific CBTs being
studied are based on interventions shown to be efficacious
(or probably efficacious) for treating anxiety, depres-
sion, and behavior problems in children and adolescents
generally.
In the beginning of this article, we identified four
groups of children to be considered for intervention. These
children range from those who show no detectable signs of
adverse impact but develop symptoms later to those who meet
full criteria for psychiatric disorder when they are first as-
sessed. To accommodate the different levels of care dictated
by these different groups, a continuum of interventions is
necessary, ranging from psychoeducation, to short-term abuse-
focused CBTs with parental involvement, to more compre-
hensive long-term treatment plans for multi-problem cases.
The available research suggests that abuse-specific
CBTs are probably efficacious for alleviating many of
the chief symptoms displayed by sexually abused children.
Other factors are also influential (e.g., parents' reactions, family
functioning), and it remains difficult to measure some key
symptoms and to demonstrate their consistent responsive-
ness to treatment. Other approaches to treatment that are
prevalent in the field have yet to be adequately tested. How-
ever, with an aggressive research agenda that addresses
many of the issues raised in the foregoing discussion, re-
searchers should be able to identify which interventions are
most beneficial for which groups of children under which
sets of circumstances.
Clinicians who work with sexually abused children
will want to familiarize themselves with the most effica-
cious treatments now available for addressing abuse-
specific consequences and will want to incorporate these
treatments into standard practices of screening, assessment,
and treatment planning. Yet, clinicians can anticipate an
expanding knowledge base and the need to continually re-
consider and revise their approaches. The path to effective
treatment is clear: Rather than polarizing their efforts, re-
searchers and practitioners will need to collaborate to test
the long-term effectiveness of different treatment approach-
es in the community and to deliver optimal services to
sexually abused children and their families.
Outcome studies have focused treatment exclusively on children and
nonoffending parents. When researchers have examined the impact of
perpetrator identity, they have not found it to be a significant moderator of
children's symptomatology or response to treatment (Cohen & Mannarino,
1996a, 2000; Finkelhor, 1990; Mannarino & Cohen, 1996c; Mannafino et
al., 1989, 1991).
1047
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