What is trauma-focused CBT for sexually abused children? - Chapter 10

What is this chapter about?

Sexual abuse in children is defined as the use of power (emotional, physical or psychological power) to engage a child or adolescent in behaviors in which he or she must touch or look at sexual body parts, when it is inappropriate for age, uncomfortable, or against the child's will. 1 in 4 women and 1 in 6 men experience sexual abuse before the age of 18.

What is the impact of sexual abuse?

The long-term impact of sexual abuse includes a greater risk on post-traumatic stress disorder (PTSD), depression, substance abuse, suicide, multiple medical problems, interpersonal problems, and premature death. In the short term, PTSD and affective, behavioural, cognitive and social or school problems may also arise. While each case is unique, there are some shared factors:

• Generalized triggers for flashbacks. Example: being abused in the private bathroom leads to fear and panic in every bathroom/toilet room. Abused children relive the trauma, leading to evasive behavior.
• Abusers often train children to accept the sexual abuse. Example: by slowly getting the child to get used to an uncomfortable feeling, the perpetrator always goes one step further (buying presents, watching TV, cuddling, sex). This reduces the likelihood that the child will resist, and will give the child the idea that he/she was partly responsible.
• Developing dysfunctional cognitions: there are always cognitions regarding guilt and responsibility in relation to the abuse.
• Teaching inappropriate behavior: abused children receive positive feedback from the perpetrator for their behavior, leading to sexualized behavior.

What are predictive symptoms of sexually abused children?

Some moderating factors – factors that already exist before sexual abuse took place and cannot be changed (such as age) – predict the degree of symptoms after the abuse. Mediating factors – factors from the time of sexual abuse – also determine the symptoms. Examples of mediating factors are the trauma-related  cognitions, feelings of guilt, parental stress caused by the abuse and the support of the parents. Trauma-focused CBT (2) is designed to identify 1) various symptoms of sexually abused children, 2) identify mediating factors, and 3) develop effective treatments.

What does TF-CBT mean?

Before the therapist decides to start treatment, there is a careful analysis: is the sexual abuse a relevant focus for treatment? Are there other traumas? There should be at least one standardized assessment to assess the initial trauma symptoms and evaluate the impact of treatment. TF-CBT is suitable for children from three years of age with (at least) one traumatic experience. They should also be experiencing significant trauma-related problems. Parental involvement is not required in treatment, but the best results are achieved if a parent also participates (if of course he or she has not been involved in the trauma). It is suitable for children from all kinds of cultural backgrounds and for children with intellectual disabilities. Involvement of the child in the treatments is crucial. The trauma is obviously the focus of the treatment (not the externalizing problems), and this is something that should be explained mainly to the parents. Often parents/children are afraid of treatment. Going to therapy then feels like going to the dentist: it seems scary and painful, but is ultimately the best treatment for a particular problem.

Gradual exposure is an important part of treatment. For example, during the TF-CBT, the child and parent are gradually becoming more and more exposed to things that remind the child of the trauma and the child is trained in achieving better coping skills to the point that he or she can tell the trauma as a story (narrative trauma). Each component of the TF-CBT must be gradually built up/transferred.

What are the PRACTICE components of TF-CBT?

• Psycho-education and parental component: During the whole treatment, the therapist should give realistic information about the trauma, in this case sexual abuse. After the abuse, parents should not drastically change their parenting style, but provide appropriate structure and rules.
• Relaxation techniques such as concentrated breathing and progressive muscle relaxation, are taught to apply in situations where the child experiences physical sensations by thinking about the trauma. Other forms of relaxation are determined by the child (sports, reading, crafting, listening to music).
• Affect-modulating (emotion-regulation) skills can be applied after the child is able to experience feelings, rather than suppress them. Some of these skills include: seeking social support, finding distractions, doing self-reassuring exercises, and learning problem-solving skills.
• Coping mechanisms: as a therapist, try to guide the child in discovering other possibilities, for example "what do you think might be another reason your friend didn't want you to come over? And how would you make that feel or behave if that were true?" Learning adequate coping behavior is the only component that does not directly address the memory of the trauma!
• Trauma as narrative and its processing: the child is encouraged to tell a story of the experienced abuse. This can be stimulated by reading from such a book after which the child is asked to tell his/her story. Chapter 1 is about the child himself (what are the hobbies, what are the name of the school, what about the family in each other, etc.). Chapter 2 deals with the relationship between the offender and the child before the abuse. Chapter 3 discusses the specific trauma, in which the child is encouraged to give details about his or her thoughts, feelings and physical sensations. This story is shared with the parent(s) in a parallel individual session.
• Learning to control things that remind the child of trauma is a process that should not be stopped halfway through, otherwise it reinforces the trauma!
• Involving parents takes place in the last 2 to 3 sessions in which at least one of the four things take place:

1. the child tells about his or her story
2. the child talks about trauma-related  aspects
3. parents and the child talk about healthy sexuality (appropriate to age), and/or
4. planning how to proceed in the future

• Improving safety and the future development is encouraged by talking about general safety and safety for the child specifically. Sex education or (preventive) information about bullying can be part of this. The safety plan must be appropriate for the age and for the living environment of the child.

What empirical support for TF-CBT exists?

There is a lot of empirical support for the short- and long-term benefits of TF-CBT in terms of alleviating PTSD, depression, anxiety, feelings of guilt and behavioural problems. It is suitable for all kinds of traumas, in children from three years of age and of all kinds of cultures. Internationally, it is especially recommended for children with PTSD, and especially for those who have experienced sexual abuse.

Sexual abuse in children is defined as the use of power (emotional, physical or psychological power) to engage a child or adolescent in behaviors in which he or she must touch or look at sexual body parts, when it is inappropriate for age, uncomfortable, or against the child's will. 1 in 4 women and 1 in 6 men experience sexual abuse before the age of 18.