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Treating Child Sexual Abuse Using TF-CBT

Treating Child Sexual Abuse Using TF-CBT. By: Abby Arico , Amanda Colletti , and Bethany Leonard. Child Sexual Abuse Defined.

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Treating Child Sexual Abuse Using TF-CBT

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  1. Treating Child Sexual Abuse Using TF-CBT By: Abby Arico, Amanda Colletti, and Bethany Leonard

  2. Child Sexual Abuse Defined • “Any behavior which results in touching of the sexual or other intimate parts of a child for the purpose of sexual gratification of the child and/or adult. It includes touching by the child and/or adult without or with clothing. Often, the sexual abuse occurs over time and may not be painful or cause physical injury to the child. The adult gets the child to participate by using rewards, threats, bribes and lying, and takes advantage of the child’s trust. This type of coercion by an adult, whom the child often loves, can result in long term emotional trauma that can last into adulthood”. • Monroe County Department of Human Services, (2003)

  3. Implications of Sexual Abuse • Not treating sexual abuse itself- treating the outcome of the abuse • Is associated with development of PTSD, anxiety, mood, conduct, sexual, and substance abuse disorders • Deblinger, Mannarino, Cohen, Runyon, & Steer, (2011)

  4. TF-CBT • A type of CBT used with children in counseling who are suffering from symptoms or difficulties due various traumas including sexual abuse. • It encourages a caregiver to complete the treatment with the child so that the parent can handle the trauma him or herself and learn skills to help the child at home. • The components of TF-CBT spell out the acronym: PRACTICE Epstein, (2012)

  5. TF-CBT Continued… • Psychoeducation and Parenting Skills                 Goals: normalize reactions to trauma, provide information about trauma, and provide rationale for treatment goals specific to sexual abuse: the above mentioned goals, and encourage body awareness, correct any misinformation about sexuality • Relaxation                Goal: reduce physiological symptoms of trauma • Affective Expression and Regulation                Goals: feeling identification, feeling acceptance, managing feelings, and connecting feelings • Cognitive Coping Goals: teach child and caregiver about the relationship between thoughts, feelings, and behaviors Epstein,(2012)

  6. TF-CBT Continued… • Trauma Narrative Goals: -slowly desensitize child and caregiver to reminders of trauma and thoughts and feelings related to the trauma - break the association between reminders of trauma and negative emotion -challenge cognitive distortions related to the trauma -prepare for reminders of trauma • In vivo Exposure (only included in treatment if clinically necessary) Goal: expose child to feared situation (as a result of trauma) in order to decrease avoidance        • Conjoint Sessions                                            Goal: share information about trauma with parent, challenge cognitive distortions, increase communication • Enhancing Safety Goal: develop body safety skills and increase assertiveness Epstein, (2012)

  7. Goals of TF-CBT • Decrease emotional and behavioral symptoms of trauma • Challenge maladaptive thoughts or beliefs or unhelpful thoughts or beliefs related to trauma • Support child and caregiver in their coping process • Teach skills for child and caregiver to cope 

  8. Empirical Research • Cohen, Deblinger, Mannarino, & Steer(2004) • Purpose: Examining the effectiveness of TF-CBT and Child Centered Therapy for treating PTSD in sexually abused children • Participants: 229 children (8-14 years old) and their caregivers • Methods: assigned to TF-CBT or CCT for roughly 10 sessions • Results: TF-CBT group found to be more effective in PTSD symptom reduction • Support for TF-CBT used with sexually abused children to treat PTSD symptoms

  9. Empirical Research Continued… • Scheeringa, Weems, Cohen, Amaya- Jackson, & Guthrie (2011). • Purpose: Examining the effectiveness of using TF-CBT for treating children with PTSD resulting from trauma • Participants: 64 children ages 3-6 • Methods: Assigned to 12 weeks of TF-CBT or a wait-list control group • Results: PTSD symptoms improved significantly in TF-CBT group

  10. Empirical Research Continued… • Deblinger, Stauffer, & Steer, (2001) • Purpose: Examining the effectiveness of CBT vs. Supportive Therapy in children who have been sexually abused • Methods: Both treatments were group therapy treatments (avg. of 8 sessions) • Participants: 44 children ages 2-8 and their non-offending mothers • Results: Mothers in the CBT group had more improvements in decreasing intrusive thoughts, and with negative emotional reactions than those in the Supportive group • -Children in the CBT group made more improvements in knowledge of body safety skills than children in the supportive therapy group.

  11. Empirical Research Continued… • Deblinger, Mannarino, Cohen, Runyon, & Steer, (2011) • Purpose: Examine the different effects of TF-CBT with and without the trauma narrative (TN) component in 8 versus 16 sessions • Participants: 210 Young CSA survivors and non-offending parent. Children ranged in age from 4-11 • TxTypes: Randomly assigned to one of four different treatment groups- (1) 8 sessions w/no TN, (2) 8 sessions w/TN, (3) 16 sessions w/no TN, or (4) 16 sessions w/TN • Results: TF-CBT effective in a variety of ways for children and parents Pre- and Post-treatment changes in ALL 4 groups show “moderate to large” effects- indicating all Tx groups were efficacious Implications for Practicing: Treatment should be determined depending on client’s presenting symptoms- TN and processing components important for children with anxiety and fear, but trauma-focused parenting and coping skills important for clients with externalizing behavior problems

  12. Empirical Research Continued… • Mannarino, Cohen, Deblinger, Runyon, & Steer, (2012). • Purpose: To determine if improvements seen in previous study (Deblinger, 2011) were sustained at 6 and 12-month follow-ups, as well as to determine difference between treatment conditions was maintained • Participants: 158 children and 144 parents- only included in follow-up if they completed structured interview at the end of their treatment in previous study • Tx Type: Randomly assigned to one of four different treatment groups- (1) 8 sessions w/no TN, (2) 8 sessions w/TN, (3) 16 sessions w/no TN, or (4) 16 sessions w/TN • *Completed 14 measures again at 6- and 12-month follow ups • Results: Treatment gains had been maintained overtime no matter what treatment condition the participant was randomly assigned too in previous study • *Individual treatment differences were not maintained over follow-ups- likely do to “commonalities across four conditions outweighed the differences” • *Parents reports of emotional distress and child’s reports of anxiety significantly lower at 12-month follow-up • Implications for Practicing: Adds to the literature of the effectiveness of TF-CBT in treating PTSD symptoms- helps practitioners to see the different ways to use treatment depending on client’s needs

  13. Empirical Research Continued… • Deblinger, Steer, & Lippman, (1999) • Purpose: Determine whether the 12-week pre- and posttest therapeutic gains found by Deblinger, et al. (1996) would be sustained after 2 years • Participants: 100 sexually abused children between the ages of 7 and 13 who presented with a minimum of three PTSD symptoms and their non-offending mothers • Tx Types: Randomly assigned to 1 of 3 experimental CBT approaches or to a community comparison conditions • *25 children assigned to 12-45 minute sessions of CBT that involved child only • *25 children assigned to treatment the involved 12-45 minutes sessions of CBT for mothers only-learning to be child’s therapeutic agent • *25 children assigned to 12- 90 minute sessions of CBT that involved child and mother • *25 children and mothers referred to therapist in own community for 12 sessions

  14. Empirical Research Continued… • Deblinger et al. (1999) continued • Results: Follow-up at 3-months, 6-months, 1-year and 2-year post-treatment were comparable to post-treatment scores- indicating improvements in externalizing behavior, depression and PTSD symptoms maintained over 2-years • Implications for Practicing: Provide preliminary support for long-term effectiveness of CBT interventions for sexually abused children

  15. Empirical Research Continued… • Deblinger, Mannarino, Cohen, and Steer (2006) • Purpose: To determine if TF-CBT would be more effective than child-centered therapy (CCT) post-treatment in symptom reduction for children who had been sexually abused. • o   CCT supports and validates child & caregiver through client guided work. • Sample: 183 children ages 8-14 who had been sexually abused and suffered from and primary caregivers • Assessment Periods: 6 months & 12 months after completion of treatment (TF-CBT or CCT) • Results: • o   At both 6 and 12 months, children who participated in TF-CBT had significantly less symptoms than those who participated in CCT • o   The children who received TF-CBT also reported less shame. • o   Caregivers who participated in TF-CBT reported significantly less distress at both 6 months and 12 months after treatment. • Conclusion:  Significantly greater symptom reduction for children and stress reduction for parents lasts over a follow-up period of at least one year

  16. Empirical Research Continued… • Cohen, Mannarino, & Knudsen, (2005). • Purpose: determine effectiveness of TF-CBT versus non-directive supportive therapy (NST) one year after treatment             NST: focuses on empowerment, validation, and support of client • Participants: 82 children and adolescents 8-15 years old from an outpatient setting who were sexually abused & a primary caregiver for each. • Methods: 12 sessions of TF-CBT or NST (assessed at 6th and 12 months post treatment) • Results: Individuals in the TF-CBT group had significantly reduced symptoms of depression, anxiety, PTSD, dissociation and sexual problems • Conclusion: TF-CBT is more effective than NST both 6 and 12 months after treatment. Post-treatment, TF-CBT is more beneficial in symptom reduction than NST .

  17. References • Child Welfare Gateway Community. (2012). Trauma-focused cognitive behavioral therapy for children affected by sexual abuse or trauma. Retrieved 3/26, 2013, from https://www.childwelfare.gov/pubs/trauma/trauma.pdf • Cohen, J.A., Deblinger, E., Mannarino, A.P., & Steer, R. (2004). A multi-site, randomized controlled trial for children with abuse-related ptsd symptoms. J Am AcadChild AdolescPsychiatry. 43(4), 393–402. • Cohen,J. A., Mannarino, A.P., & Knudsen, K. (2005). Treating sexually abused children. Child Abuse and Neglect. 29, 135-145. doi:10.1016/j.chiabu.2004.12.005 • Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2006). Treating trauma and traumatic  grief in children and adolescents. New York: Guilford Press. • Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma-focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 28. 67-75. • Deblinger, E., Stauffer, L.B., & Steer, R.A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffendingmothers. Journal of the American Professional Society on the abuse of children 6(4), 332-343

  18. References Continued… • Deblinger, Mannarino, Cohen, and Steer (2006). A follow-up study of a multisite, randomized, controlled trial for Children with Sexual abuse related PTSD symptoms. American Academy of Child and Adolescent Psychiatry, 45(12), 1474- 1484 • Deblinger, E., Steer, R. A., & Lippman, J. (1999). Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post- traumatic stress symptoms. Child Abuse & Neglect, 23 (12),1371-1378 • Epstein, C. (2012, November 15th-16th ). Trauma-Focused Cognitive Behavioral Therapy. Lecture conducted from Hamden, CT.  • Monroe County Department of Human Services. (2003). Working definitions of sexual abuse, physical abuse, neglect. Retrieved from: http://www.dorightbykids.org/ working-definitions-of-sexual-abuse-physical-abuse-neglect • Mannarino, A. P., Cohen, J. A., Deblinger, E., Runyon, M. K., & Steer, R. A. (2012). Trauma-focused cognitive-behavioral therapy for children sustained impact of treatment 6 and 12 months later. Child Maltreatment, 17 (3), 231-241.

  19. References Continued… • Scheeringa, M.S.,Weems, C.F., Cohen, J.A., Amaya- Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioral for posttraumatic stress disorder in three through six year-old children: a randomized clinical trial. Journal of Child Psychology and Psychiatry 52(8), 853–860

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