Treating Victims of Child Sexual Abuse
“Anna” is a 9-year old girl, currently in third grade. She lives with her mother (“Ms. B”) and her 14-year-old brother. At a recent visit to the pediatrician for a well-child appointment, Anna refused to remove her clothes and became extremely agitated when the physician started to examine her. She started crying and disclosed that her stepfather had been “hurting” her. On further inquiry, she said that he had been forcing her to engage in “sex stuff.” Ms. B was visibly shaken and distressed by the disclosure, stating that she had no idea this had happened. She did acknowledge that she and her husband had been experiencing marital problems, which resulted in his moving out of the home temporarily about 6 months ago, but she was still seeing him, and he was still at the house frequently. Ms. B did not understand how this could have happened since she rarely left her children alone with her husband. Furthermore, she said that she and Anna have a very close relationship and that Anna would have shared this if it had occurred. Since Anna was extremely upset after her disclosure and Ms. B was having difficulty believing the allegations, the pediatrician recommended a referral to the local Child Advocacy Center (CAC) for a medical examination and forensic interview. CACs provide a safe, child-focused environment and include a multidisciplinary team of professionals, comprising medical, mental health, law enforcement, prosecution, child protective services, victim advocacy, and school personnel, who work together to coordinate services for children. In addition to providing medical evaluations and forensic interviews after abuse disclosures, CACs offer therapy and medical examinations, courtroom preparation, victim advocacy, and ongoing case management.
While Ms. B was still in the office, the pediatrician contacted the CAC to schedule the evaluation and allow Ms. B to speak directly with the CAC to provide any required information. The pediatrician then explained to Ms. B that a report would have to be made immediately to the local child protective services (CPS) office, as physicians are mandated reporters in cases of suspected child abuse. Ms. B became increasingly hostile, angrily stating that she did not understand why Anna needed to be seen at the CAC and a report needed to be made, as this “really couldn’t have happened.” Because of her obligation as a mandated reporter, the pediatrician explained that the report was required and that the best plan would be for them to make the telephone call together. As the alleged perpetrator was a primary caregiver (the child’s stepfather), the pediatrician made the report to the local CPS office. The CPS intake worker stated that a worker would be at their home that day to interview Anna and her mother and to establish a safety plan. Anna was scheduled for the CAC evaluation the following week, and the CPS worker told the pediatrician and Ms. B that she would also plan to attend that appointment, as a way to reduce the number of times Anna had to undergo in-depth interviews. The CPS worker indicated that she needed to contact law enforcement and asked Ms. B for specific information about her husband, which Ms. B refused to provide. The worker informed her that this would entail the police coming directly to her home to question her husband, to which Ms. B responded, “Do what you need to, but I won’t help you.”
Despite Ms. B’s anger and disbelief, she reluctantly allowed the pediatrician to conduct a cursory physical examination of Anna but deferred a genital examination until Anna could be seen at her local CAC for a medical examination. Ms. B did attend the CAC evaluation, stating that she just wanted to “get this over with so that everyone would leave [her] family alone.” At the CAC evaluation, Anna was noted to have a normal genital examination with no signs of injury. Ms. B asked if this finally “proved” that the abuse never happened. The medical provider explained that the majority of children who are victims of sexual abuse do not have signs of injury regardless of the timing of the examination. In addition to the physical examination, a forensic interview was conducted at the CAC. The purpose of the forensic interview is to determine the details of the child abuse allegations, without asking leading questions or causing undue harm to the child, and to render an opinion on the credibility of the child’s disclosures.
During the course of the forensic interview, Anna said that her stepfather had started abusing her about a year ago and that it happened multiple times a week while her mother, a nurse at the local hospital, was working the evening shift. Anna indicated that her stepfather would read to her in bed and that one night he started touching her chest and rubbing her legs. He said this would help her to sleep. Over the subsequent months, the abuse increased in severity, involving vaginal penetration and forced oral sex. Anna stated that her stepfather warned her not to tell anyone and that no one would believe her, even if she did tell. He also told her that if her mother found out, he would go to jail and Anna would have to go to foster care. Anna also said that she had nightmares, felt scared “all the time,” and was “really scared” of men. Ms. B also was interviewed and continued to express her anger and disbelief. She stated that she had “no idea” how this could possibly have happened. She admitted to marital problems but said that she and her husband were trying to work things out. She agreed to obtain treatment for Anna so that they could put the whole thing behind them.
On the basis of the forensic interview, Anna was referred to a mental health provider housed at the CAC who could conduct a psychosocial evaluation and determine her treatment needs. Evaluation results indicated that Anna met DSM-5 criteria for posttraumatic stress disorder, including reexperiencing symptoms (e.g., nightmares, frequent stomachaches when reminded of the abuse), avoidance of thoughts, feelings, or reminders of the abuse, negative thoughts and feelings (e.g., self-blame about what happened, loss of interest in activities, feeling alone and isolated), and trauma-related arousal (e.g., increased irritability, difficulty sleeping and concentrating in school). Based on these findings, the therapist recommended trauma-focused cognitive-behavioral therapy (CBT) (1), an empirically supported treatment that includes the child and caregiver to address trauma-related symptoms through weekly sessions. An important component of trauma-focused CBT is the inclusion of the caregiver in sessions as a way to build support, teach the same skills being taught to the child, increase communication about the traumatic event, and increase the likelihood that skill acquisition would generalize to the home environment. This parallel treatment model also gives the therapist the opportunity to work with caregivers such as Ms. B who are having difficulty believing their child’s allegations. While Ms. B was initially angry and disbelieving, she did want Anna to “be OK,” and she brought her regularly to the treatment sessions. The therapist worked closely with Ms. B to address her anger and disbelief, providing extensive psychoeducation about why children do not disclose (e.g., shame, fear of not being believed, embarrassment, fear of the offender), sharing specific examples of what her husband had said to Anna and exploring the impact this has had on Ms. B directly. After about a month, Ms. B was more invested in treatment, and although she still struggled with believing “all this,” she did separate from her husband.
Anna evidenced some improvements but was still experiencing significant fear and anxiety, particularly around men, she was still having difficulty sleeping and concentrating in school, and she still had frequent stomachaches when she thought about what happened. As these symptoms were impeding her treatment progress, the therapist made a referral to a psychiatrist for a medication assessment. Anna was started on fluoxetine, which, after titration to 30 mg/day, significantly improved her sleep and anxiety symptoms. She continued to engage in trauma-focused CBT, and after approximately 6 months, Anna’s symptoms substantially improved. Ms. B was able to acknowledge the sexual abuse by her husband and was contemplating filing for divorce. Anna was tapered off fluoxetine approximately 12 months after initiating medication, which she tolerated well.
Childhood sexual abuse is generally defined as a form of child abuse that involves sexual activity. While varying definitions can be found, the U.S. Centers for Disease Control and Prevention (CDC) defines childhood sexual abuse as “any completed or attempted (noncompleted) sexual act, sexual contact with, or exploitation of a child by a caregiver” (2). The CDC specifically defines the different types of sexual abuse, differentiating between those involving direct physical contact, with and without penetration, and noncontact sexual abuse, such as voyeurism, exhibitionism, or exposing the child to pornography. The World Health Organization (WHO) extends the definition of childhood sexual abuse beyond that perpetrated by a caregiver (3):
The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate[s] the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust, or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of a child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performances and materials.
As discussed in their thorough review of childhood sexual abuse worldwide, Murray et al. (4) note that the WHO definition encompasses a broad array of behaviors, and they highlight the fact that children may not even be aware of their victimization (e.g., filming or photographing their images) and that consent may or may not be given by the child. However, by definition, children are not of legal majority and therefore cannot give consent; thus, any sexual activity with a minor child falls under the definition of childhood sexual abuse.
While prevalence data vary depending on the source, best estimates indicate that approximately 8%−12% of children and adolescents in the United States have experienced at least one type of sexual assault in their lifetime (5, 6). According to the most recent available data from state child protective services agencies, 676,000 children in the United States were victims of abuse or neglect in 2016, reflecting a rate of 9.1 unique victims per 1,000 children under age 18 (7). Of these reported cases, 8.5% were victims of childhood sexual abuse; this compares with 74.8% who were neglected and 18.2% who were reported for allegations of physical abuse. While childhood sexual abuse may be less prevalent than other forms of child abuse, it has significant acute and long-term consequences.
It is important to highlight the fact that available statistics are largely dependent on cases reported to authorities, such as law enforcement and child protective services, and are certainly underestimates of the true number of childhood sexual abuse victims (4, 6, 8). As compared with other crimes, rape and sexual assault are less likely to be reported to law enforcement or other authorities. For example, an analysis of data from the National Crime Victimization Survey (9), which collects information only on persons age 12 and older, indicated that 22.9% of rapes or sexual assaults were reported to law enforcement in 2016; this compares with 54.0% of robberies and 42.2% of physical assaults.
Reasons cited among adults for not reporting their sexual assaults include fear of reprisal, fear of not being believed, shame, and embarrassment. Many of these same reasons are found for delay of disclosure among children and adolescents, including perceived responsibility for the abuse, fear of negative consequences, and being the victim of incestuous abuse (10). In addition, particularly for younger children, there is the added barrier related to their reliance on an adult to make the report. Finally, as noted by Saunders and Adams (6), because national data surveys such as the National Crime Victimization Survey do not collect data on children younger than age 12, limited information is available about this vulnerable age group.
It is also important to recognize that exposure to a single traumatic event or abuse incident is rare. Among children who have experienced abuse or other traumatic events, most have been exposed to multiple traumatic events (11). Furthermore, such exposure heightens the likelihood of childhood sexual abuse and increases risk for adverse mental and physical health. Childhood sexual abuse seems to have a unique impact on children, with consequences such as heightened risk for revictimization, substance abuse, depression, legal problems, and poor physical health extending into adulthood (11–13).
Risk Factors
Certain demographic factors, such as sex and age, can increase risk for sexual victimization, with most studies finding higher rates among girls than boys. For example, the National Survey of Children’s Exposure to Violence, which included a nationally representative sample of 4,000 children ages 0–17, indicated that girls were 1.5 times more likely than boys to report at least one episode of sexual victimization within the past year (5, 14). The National Survey of Adolescents (15) and the National Survey of Adolescents–Replication (16), which also involved nationally representative samples of youths, similarly found higher rates for girls than boys (13% and 3%, respectively). The data thus suggest that the risk of sexual victimization is approximately 3 to 4 times greater for girls than for boys. Data regarding prevalence rates across race and ethnicity generally indicate that minority children, especially those of African American and Latino ethnicity, appear to be at higher risk for sexual victimization (17–20). Other factors associated with increased risk for childhood sexual abuse include lower socioeconomic status, residing in a home with a single parent, being in foster care, parental substance abuse or mental illness, living in a rural area, and domestic violence (19, 21, 22).
Impact
Childhood sexual abuse has been associated with increased risk for a multitude of acute and long-term psychological and physical health problems, including depression, posttraumatic stress, and substance abuse problems, as well as sexual revictimization in adolescence and adulthood (12, 13). Research consistently demonstrates that certain risk factors increase the severity of childhood sexual abuse–related sequelae, such as abuse that involves penetration, greater frequency, longer duration, use of force, a closer relationship between the child and the perpetrator, physical injury during the abuse, and a lack of caregiver support (23). Conversely, certain protective factors, such as a child’s coping strategies and the availability of stable, supportive caregivers, can ameliorate the adverse impact of childhood sexual abuse (24).
Screening and Identifying Childhood Sexual Abuse
Mental health and other health care providers (e.g., pediatricians, nurses, nurse practitioners) who do not specialize in treating victims of trauma and abuse may be reluctant to screen children for childhood sexual abuse and other forms of child abuse. Reasons may include a belief that such questioning is not indicated unless trauma is the presenting problem; a scope of practice that does not include trauma interventions; lack of knowledge on how to respond to an abuse disclosure; and limited awareness of appropriate referrals for specialized treatment services. There is nevertheless a cogent argument for routine trauma screening across mental health and primary care practice settings, as this offers the opportunity for children and families to access a professional with the knowledge, skills, expertise, and resources to provide needed assistance (25–27). In an article reviewing best practices for identifying, screening, and treating child victims of sexual abuse in primary care settings, Hanson and Adams (28) suggest the use of brief screening tools as a way to identify children who may have experienced childhood sexual abuse. This can facilitate additional screening and/or referral to skilled providers when warranted. In their review, the authors acknowledge that comprehensive screening can pose challenges, particularly among providers who do not possess the requisite skills and expertise, but they suggest that at least a single question can be asked, such as the one recommended by Cohen et al. (29): “Since the last time I saw you, has anything really scary or upsetting happened to you or your family?” This can help to identify those children in need of additional screening or referrals and can be easily included as part of routine assessment in an array of primary care and mental health settings.
Regardless of whether or not routine screenings are implemented, it remains critical for mental health and other health care providers to be aware of potential signs or symptoms of sexual abuse and related sequelae (23). These may include visible signs of distress at the time of the office visit, such as anxiety about separation from a caregiver, refusal to get undressed, or unwillingness to be examined by the provider. Caregivers may report concerns about the child’s behavior, such as nightmares, difficulty sleeping alone, a sudden or increased fear of the dark, bedwetting for a child who was previously toilet trained, sadness, withdrawal, irritability, and anger outbursts. Children or caregivers also may report physical symptoms, such as headaches, stomachaches, and fatigue. Additionally, children may display sexual knowledge, language, or behaviors that are inappropriate for their age. Any of these behaviors warrants additional screening and assessment (28).
Children for whom there is a concern for sexual abuse should have a physical examination for injuries and any indicated laboratory testing. It is critical that examiners remember that a normal physical examination does not change the credibility of a disclosure or decrease the likelihood that abuse occurred. Genital mucosa and epithelium heal rapidly, and even children examined acutely after childhood sexual abuse are most likely to have a normal examination. Multiple studies estimate that more than 95% of childhood sexual abuse victims have a normal genital examination. Older age (>13 years), a history of genital penetration, and the acuity of an injury are associated with an increased likelihood of diagnostic findings in childhood sexual abuse (30).
Not all children who experience childhood sexual abuse will develop diagnosable mental health conditions. However, children who are victims of childhood sexual abuse are at risk for posttraumatic stress disorder (PTSD) as well as for other mental health conditions. Awareness of the specific symptoms of PTSD and other childhood sexual abuse–related problems (e.g., depression, anxiety, behavior problems) is important to ensure that children are assessed accurately and receive the appropriate treatment. For example, the hyperarousal symptoms of PTSD can be mistakenly attributed to hyperactivity stemming from attention deficit hyperactivity disorder (ADHD), reexperiencing symptoms (nightmares and flashbacks) may be misdiagnosed as early psychosis, and negative cognitions and beliefs about the world may be mistakenly attributed solely to depression. Providers also must recognize that comorbid conditions, such as depression and PTSD, are not uncommon.
Evidence-Based Mental Health Treatments
Not all victims of childhood sexual abuse will evince symptoms that warrant mental health treatment services. However, for those who are experiencing significant mental health problems related to childhood sexual abuse, referral to providers skilled in the delivery of evidence-based trauma-focused interventions is imperative.
As discussed in several literature reviews (31–33), the majority of trauma-focused treatments that have empirical support for children and adolescents are cognitive-behavioral therapies, with several common cross-cutting elements. These elements include psychoeducation about trauma and its impact (e.g., PTSD); affective modulation skills, such as relaxation and controlled breathing; gradual exposure to trauma memories; and cognitive processing to address unhelpful or inaccurate cognitions, such as guilt or self-blame. Gradual exposure appears to be a particularly important treatment element, given the cumulative evidence regarding its specific impact in reducing PTSD symptoms (34–37). In brief, this involves repeated exposure to details of the trauma as a way to extinguish trauma-related emotional and behavioral responses. This treatment strategy also helps improve cognitive processing of the traumatic event(s), which has been demonstrated to facilitate recovery. As noted with most child mental health treatment interventions, involvement of a supportive caregiver in trauma-focused treatments can be another important element related to positive outcomes, including reduced dropout (38), increased family engagement (39), and improved parent-child relationships (40, 41).
While several evidence-based trauma-focused treatments exist, the most effective and widely disseminated psychotherapy intervention for children and adolescents to date is trauma-focused cognitive-behavioral therapy (CBT) (1, 19, 20, 22, 24, 40). In brief, trauma-focused CBT is a structured, components-based, time-limited (i.e., 12–20 therapy sessions) intervention that includes education about trauma and its impact, strategies to promote relaxation and positive coping skills, techniques to address inaccurate or unhelpful thoughts related to abuse, gradual exposure to enable children to share details of their experience and process their trauma-related thoughts and feelings, joint parent-child sessions to increase open communication about the abuse and its impact, and parenting skills to manage problematic child behaviors that may predate or be exacerbated by the childhood sexual abuse. (For more detailed descriptions of trauma-focused CBT, see Hanson and Jobe-Shields [42] and Pollio et al. [43]). In addition, there are several resources for professionals, youths, and families that provide information about childhood sexual abuse and its impact; some also include descriptions and available empirical support for existing interventions (Table 1).
| Host Agency | Resource Name | Web Site | Description |
|---|---|---|---|
| American Academy of Child and Adolescent Psychiatry | Practice Guidelines for Trauma Treatment | www.aacap.org | Addresses assessment and treatment for child and adolescent trauma-related psychiatric disorders |
| American Academy of Pediatrics | PATTeR (Pediatric Approach to Trauma, Treatment, and Resilience) | www.aap.org | Education about the trauma-informed approach in pediatric care. Includes training and educational resources and opportunities |
| American Professional Society on the Abuse of Children | www.apsac.org | Nonprofit national organization for multidisciplinary professionals working with maltreated children and their families. Provides resources, research, and information about state-of-the-art practices for child abuse and neglect | |
| American Psychological Association | Understanding and Preventing Child Abuse and Neglect | www.apa.org/pi/families/resources/understanding-child-abuse.aspx | Discusses definitions, risk factors, and consequences of child maltreatment as well as prevention and treatment resources |
| California Department of Social Services, Office of Child Abuse Prevention | California Evidence-Based Clearinghouse for Child Welfare | www.cebc4cw.org | Searchable database of child welfare–related programs, descriptions of and information on research evidence for specific programs. Provides guidance, tools, and materials to select and implement evidence-based programs |
| Children’s Bureau, Administration for Children and Families | Child Welfare Information Gateway | www.childwelfare.gov | Connects child welfare and related professionals to resources for children and families |
| International Society for Traumatic Stress Studies | www.istss.org | Interdisciplinary professional organization that promotes advancement and exchange of knowledge about traumatic stress. Includes resources, research, and information to understand, prevent, and treat trauma-related stress | |
| Substance Abuse and Mental Health Service Administration | National Child Traumatic Stress Network | www.nctsn.org | Collaborative network of providers, researchers, and consumers with aim of improving quality of care and increasing access to evidence-based trauma-informed services. Provides professional and family resources related to trauma and its impact |
| Substance Abuse and Mental Health Service Administration | National Registry of Evidence-Based Programs and Practices | www.samhsa.gov/nrepp | Evidence-based repository and review system to provide information on treatments, interventions, and programs related to mental health and substance use. Includes ratings based on available empirical support |
| U.S. Department of Veterans Affairs | National Center for PTSD | www.ptsd.va.gov | The section for professionals contains research-supported training materials as well as information and tools to help with assessment and treatment |
TABLE 1. Resources and Information on Childhood Trauma and Abuse
Psychopharmacological Interventions
As noted above, evidence-based trauma-focused mental health treatment interventions are the first line of treatment for symptoms related to childhood sexual abuse. However, for children who have severe or persistent symptoms despite psychotherapy, medications may be warranted, both to ameliorate these difficulties and to generate a more positive treatment response to psychotherapy. As discussed in the review by Hanson and Adams (28), there are no specific protocols to guide pharmacological interventions for childhood sexual abuse specifically. However, recommendations do exist for treatment of children experiencing PTSD symptoms. The American Academy of Child and Adolescent Psychiatry (AACAP) “Practice Parameters for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder” (29) suggests selective serotonin reuptake inhibitors (SSRIs) for the treatment of children and adolescents with PTSD but cautions that these medications should be considered only after an adequate trial of evidence-based psychotherapy alone has been found to be ineffective. Stronger evidence exists for the use of SSRIs in adults with PTSD, but data for use in children with PTSD are limited to a few small studies. In contrast, support for the use of medication in children with comorbid PTSD (with disorders such as depression, anxiety, and ADHD) is much stronger, and pharmacotherapy should be considered on the basis of the degree of severity and impairment. Of note, AACAP’s recommendations highlight the importance of including medications as part of a more comprehensive treatment plan, as an adjunct to psychotherapy, and for simultaneous treatment of comorbid psychiatric diagnoses.
A number of small studies have looked at other psychopharmacologic agents for the treatment of PTSD in children, but evidence to guide practice is limited. For example, antiadrenergic agents (guanfacine, clonidine) have theoretical interest, as the neuroendocrine physiology behind hyperarousal and reexperiencing would potentially be mediated by these types of medications. One open-label study of extended-release guanfacine in patients with ADHD and comorbid PTSD showed a decrease in PTSD symptoms of reexperiencing, avoidance, and hyperarousal (44). Multiple studies in adults support the use of prazosin in PTSD, specifically for hyperarousal, although no such data exist in children.
The use of second-generation antipsychotics and mood stabilizers for children with PTSD is not well studied. Although small studies of risperidone, quetiapine, carbamazepine, and valproic acid in children have been reported, studies to date do not provide sufficient data to recommend the use of these agents (45, 46). In most of these studies, the duration of use was brief or children had significant comorbid diagnoses.
There is significant concern about the use of multiple psychotropic medications in children to treat conditions that are not indicated. Several retrospective studies suggest that polypharmacy is particularly common in children who are victims of trauma and abuse and in children who are in foster care (47, 48). These data further highlight the importance of judicious medication prescribing and close attention to the risks, benefits, and indications for any psychotropic medication. Also critical to note in considering prescribing practices for children with PTSD is that a child’s developmental age, his or her exposure to complex, long-standing trauma, and comorbid diagnoses will influence symptoms and degree of impairment. Much more data are needed to reliably recommend use of medications other than SSRIs for the treatment of PTSD in children, and in these cases prescribers must carefully weigh the risks and benefits of each medication (49).
Conclusions
While childhood sexual abuse is not the most prevalent form of child abuse, it nevertheless affects a significant minority of children and adolescents and heightens risk for myriad acute and long-term consequences. While certain risk factors, such as age, sex, and family structure, increase the likelihood of childhood sexual abuse, supportive caregivers, early identification, and receipt of evidence-based treatment interventions when warranted can ameliorate these adverse effects. Initial screening for children across mental health and other health care settings can increase early identification of those who need further evaluation or treatment services. Optimal treatments, specifically those that directly target the childhood sexual abuse and associated symptoms, are associated with positive long-term outcomes for this vulnerable population.
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