Trauma Focused Cognitive Behavior Therapy in Treating Sexually Abused Children

1. Trauma Focused Cognitive Behavior Therapy in Treating Sexually Abused Children Claudia Lee Stephens, LMSW

2. Sexual abuse is a general term for any type of sexual activity inflicted on a child by someone with whom the child is acquainted. Definition of Sexual Abuse

3. Prohibits certain sexual acts and specifies penalties. • Prohibits sex with a child, regardless of the adults relationship with the child. • The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct, for the propose of producing a visual depiction of such conduct. • It includes the rape, molestation, prostitution, or other form of sexual exploitation of children. Criminal Statute Definition

4. Clinical definitions of sexual abuse are related to the statutes. • However, the guiding principle of its definition is whether the encounter has a traumatic impact on the child. Clinical Definitions:

5. The existence of a power differential implies that one party (the offender) controls the other (the victim) and the sexual encounter is not mutually conceived or undertaken. • The knowledge differential implies that the act is considered abusive when one party has a more sophisticated understanding of the significance and implications of the sexual encounter. Abusive versus Non-abusive Sexual Acts

6. The younger the child, the less able she/he is to appreciate the meaning & consequences of a sexual relationship, especially one with an adult • The gratification differential: In most, but not all sexual victimization, the offender is attempting to sexually gratify him/herself. Abusive v. Non-Abusive

7. Reported child sexual abuse cases: 62,936 cases out of 865,478 cases of all types of abuse United States Statistics 2012

8. Reported Child sexual abuse cases: • 5,928 Texas Statistics 2012

9. Reported Abuse of all Types in the State of Texas for 2012

10. National Crime Victims Research and Treatment Center at the University of South Carolina and the Center for Sexual Assault and Traumatic Stress at Harborview Medical Center at the University of South Carolina, in cooperation with the Office of Victims of Crime, US Department of Justice Jointed together to research treatment approaches throughout the United States. Determining Issues in Treatment

11. Ideal Clinical Science Process to determine “Best Use” treatment protocols for treating victims of childhood sexual abuse: Use in Clinical Settings Disseminate Treatment to the Field Conduct Efficacy Studies Conduct Effectiveness Studies Treatment Development Process Develop Treatment Approach

12. Many children are treated each year for abuse. • Due to sexual taboos, the number of actual reported cases of sexual abuse is grossly under reported. • It is unclear how many of these children receive state-of-the-art, abuse specific mental health treatment. Problems in research of Treatment Approaches

13. Estimates of the extent of sexual abuse comes from three sources: 1. Research on adults who recount their experiences of sexual victimization as a child. 2. Annual summaries of reports field with Child Protective Agencies. 3. Two federally funded studies of child maltreatment entitled National Incidence Studies. Sources of Information

14. Finkelhor conceptualized the traumatogenic effects of sexual abuse • This is the most widely employed view of the trauma of this type of abuse. • It divides the trauma into four general categories, with each category having its own varied psychological and behavioral effects. Impact of Sexual Abuse

15. Finkelhor defines sequelae as a disease or disorder that is caused by a preceding disease or injury in the same individual. Sequalae

16. Psychological outcomes: • Adverse feelings about sex • Overvaluing sex • Sexual identity problems Behavioral Outcomes • A range of hypersexual behaviors as well as avoidance of or negative sexual encounters Traumatic Sexuaization

17. Psychological Effects • “Damaged Goods Syndrome” • Feelings of guilt • Responsibility for the abuse • Responsibility for the consequences of disclosure Stigmatization

18. Behavioral Effects • Reflected in self-destructive behaviors • Substance abuse • Risk-taking acts • Self-mutilation • Suicidal gestures and acts • Provocative behavior designed to elicit punishment Stigmatization

19. Psychological Effects • Most fundamental damage: undermining trust in people who are supposed to be protectors & nuturers • Anger • Borderline functioning Betrayal

20. Behavioral Effects • Avoidance of investment in others • Manipulating Others • Re-enacting the trauma through subsequent involvement in explotive and damaging relationships. • Engaging in angry and acting-out behaviors. Betrayal

21. Psychological Effects • A perception of vulnerability • A perception of victimization • A desire to control and prevail, often by identification with the aggressor Powerlessness

22. Behavioral Effects • Aggression and explotiation of others • Or, as a result of the vulnerability effect of powerlessness, may develop avoidant responses such as dissociation and running away • Behavioral manifestations of anxiety, such as • Phobias • Sleep problems • Elimination problems • Eating problems • Revictimization Powerlessness

23. In the immediate as well as long term aftermath of exposure to trauma, children are at risk of developing significant emotional & behavior difficulties • Maladaptive or unhelpful belief & attributions related to abusive event • Anger at parents for not knowing about the abuse • Fear that people will treat them differently because of the abuse • Development of Post-traumatic Stress Disorder. Trauma

24. Intrusive and recurring thoughts of the traumatic experience • Avoidance of reminders of the trauma • Emotional numbing • Irritability • Trouble sleeping or concentrating • Physical & emotional hyper-arousal (emotional swings, rapidly accelerating anger, excessive crying) Post-traumatic Stress Disorder

25. TF-CBT is an evidenced-based treatment approach shown to help children, adolescents, & their caregivers overcome trauma related difficulties. TRAUMA-FOCUSED COGNITIVE BEHAVIOR THERAPY

26. TF-CBT is designed to reduce negative emotional & behavioral responses following • Child sexual abuse • Domestic violence • Traumatic loss • Other traumatic events TF-CBT

27. Treatment is based on learning and cognitive theories and addresses • Distorted belief and attributions related to abuse • Provides s supportive environment in which children are encouraged to talk about their traumatic experiences • Helps the non abusive parents to cope effectively with their own emotional distress & develop skills to help support their children TF-CBT

28. TF-CBT integrates established treatment approaches: • Cognitive Therapy, which aims to change behavior by addressing a person’s thoughts or perceptions, particularly those thinking patterns that create distorted or unhelpful views. • Behavior Therapy, which focuses on modifying habitual responses such as anger and fear, to identified situations or stimuli. • Family Therapy, which examines patterns of interactions among family members to identify and alleviate problems. TF-CBT

29. TF-CBT uses well established cognitive behavioral therapy and stress management procedures originally developed for the treatment of fear, anxiety, and depression in adults. (Wolpe, 1969; Beck, 1976) • This protocol has adapted and refined these procedures to target the specific difficulties exhibited by children who are experiencing PTSD symptoms in response to sexual abuse, domestic violence or other childhood trauma. • Well established parenting approaches are also incorporated into treatment to guide parents in addressing their children’s behavioral difficulties. TF-CBT

30. Research results: • Shows results in various environments and cultural backgrounds • Appropriate for multiple traumas • Short-term treatment typically provided in 12-18 session for 50-90 minutes • Treatment is usually provided in outpatient mental health facilities, but has been used in hospital, group, home, school, community, residential and in-home settings • Individual and parent/child sessions are utilized TF-CBT

31. The goals of TF-CBT Therapy are: • Reduce the children’s negative emotional & behavioral responses to trauma • Correct maladaptive/unhelpful beliefs and attributions related to traumatic experiences, especially dealing with fault • Provide support and skills to help non-offending parents cope effectively with their own emotional distress TF-CBT

32. Protocol Components • P-Psycho-educational and parenting skills • R-Relaxation techniques • A-Affective expression & regulation • C-Cognitive coping and processing • T-Trauma narrative and processing • I-In-vivo exposure • C-Co-joint parent/child sessions • E-Enhancing personal safety and future growth TF-CBT

33. Target populations: • Children 3-18 years of age that have a history ofsexual abuse/exposure to trauma who • Experience PTSD • Show elevated levels of depression, anxiety, shame, or other dysfunctional abuse-related feelings, thoughts, or developing beliefs • Demonstrate behavioral problems, including age-inappropriate sexual behaviors • Non-offending parent or caregivers TF-CBT

34. Assessment: • PTSD, depressive and anxiety symptoms as well as sexually inappropriate behaviors and other behavior problems should be present in the assessment process to determine if TF-CBT can meet the needs of the client. TF-CBT

35. Children who’s primary problems include • Serious conduct problems • Other significant behavior problems that existed before the trauma • Children who are acutely suicidal • Adolescents who have a history of running away • Serious cutting behaviors • Children who engage in other para-suicidal behavior • These children need a stabilizing therapy approach such as dialectical behavior therapy (Miller,Tathus, & Linehan, 2007) • These important symptoms must be addressed first and foremost before TF-CBT can be utilized. Limitations for use of TF-CBT

36. TF-CBT is • Supported by outcome studies and recognized on inventories of model and promising treatment programs • 11 empirical investigations have been conducted on sexually abused or other traumatized children. • Findings consistently demonstrate it to be useful in reducing symptoms of PTSD as well as symptoms of depression and behavioral difficulties in children who have experienced sexual abuse and/or other traumas. Effectiveness of TF-CBT

37. In randomized clinical trials, comparing TF-CBT to other tested models and services such as supportive therapy, it resulted in significantly greater gains in fewer clinical sessions • Follow-up studies up to 2 years following conclusion of therapy have shown that these gains were sustained over time Effectiveness of TF-CBT

38. Children showing improvement typically experienced • Significantly fewer intrusive thoughts and avoidance behaviors • Were more able to cope with reminders and associated emotions • Showed reductions in depression, anxiety, dissassociation, behavior problems, sexualized behavior and trauma-related shame • Demonstrated improved interpersonal trust and social competence • Developed improved personal safety skills • Become better prepared to cope with future trauma reminders (Cohen, Deblinger, Mannarina & Steer, 2004) Results for children

39. Research also demonstrates a positive treatment response for parents • Parents often report reductions in depression, emotional distress associated with the child’s trauma, and PTSD symptoms • Parents also report enhanced ability to support their children • Systematic review of available research and evaluation studies have highlighted TF-CBT as a model program • TF-CBT is also a Promising Treatment Practice Results for Parents

40. Child Maltreatment 2012 US Department of Health and Human Services; Administration for Children and Families; Administration on Children, Youth, and Families; Children’s Bureau • Saunders, B.E., Berliner, L, & Hanson, R.F. (Eds.) (2003). Child Physical and Sexual Abuse: Guidelines for Treatment; Final Report: January 15, 2003. Charleston, SC: National Crime Victims Research and Treatment Center; Center For Sexual Assault and Traumatic Stress. • The Data Measures, Data Composites and National Standards to be Used in the Child and Family Services Reviews, 71 Federal Regulation 109,32973 (June 7, 2006) References: