Sources of Information

There are several sources of data related to the prevalence and incidence of physical and sexual abuse. There are two main sources of information about the prevalence of physical abuse, research using the Conflict Tactics Scale (e.g., Straus, Hamby, Finkelhor, Moore, & Runyan, 1998) and studies of adults reporting physical abuse during childhood (e.g., Briere & Elliott, 2003). Sexual abuse prevalence data derive from studies of adults and college students who report sexual abuse during childhood (Finkelhor, 1979; Russell, 1983). Although there are two primary sources of prevalence data for physical abuse, there are far more studies of sexual abuse survivors than of physical abuse survivors (e.g., London, Bruck, Ceci, & Shuman, 2005).

Incidence data are found in reports to public child welfare agencies, which are aggregated into a national data base (Children’s Bureau, 2016), and the National Incidence Studies (NIS) (Administration on Children and Families, 2010). Both of these incidence reports also include child neglect, the most common type of maltreatment, representing three-fourths of cases found in reporting data (Children’s Bureau, 2016) and 61% of cases in the NIS (Administration on Children and Families, 2010). The FBI also collects statistics on violent crimes, but reports using these data do not differentiate crimes against children and adults (Berliner, 2011; FBI Uniform Crime Reporting Statistics, 2012).

Prevalence of Child Physical Abuse

Prevalence rates for physical abuse vary depending upon whether the offender, that is, the parent, or the adult, who experienced physical abuse as a child, is asked about these acts. Parents report markedly lower rates than adults queried about their experiences as children.

The pioneering work of Straus and his colleagues in developing the Conflict Tactics Scale (CTS) was crucial in opening the eyes of professionals and the public about the prevalence of physical abuse in the United States (Straus, 1994; Straus & Mattingly, 2007). Moreover, the CTS has been used around the world, with literally scores of studies using it as a measure of interpersonal violence (Straus, 2007). The CTS has been used to gather data about domestic violence, child abuse, elder abuse, and physical abuse experienced by respondents during childhood. To assess for corporal punishment and child abuse, the Parent-Child CTS asks adult respondents to indicate tactics they have used to resolve conflicts with a child, methods ranging from appropriate, nonviolent strategies to violent and potentially lethal strategies. Methods that are considered abusive include the following: (1) shook a child two or younger; (2) hit some other part of the child’s body besides the bottom with a belt, hairbrush, stick; (3) hit the child with a fist or hit hard; (4) threw or knocked the child down; (5) beat up the child; (6) grabbed around the neck and choked the child; (7) burned or scalded the child on purpose; (8) threatened the child with a gun or knife (Straus et al., 1998). Prevalence of child abuse, as reported by parents, using various versions of the CTS is 4–5% of American parents (Straus et al., 1998; Straus & Mattingly, 2007).

Briere and Elliott solicited information about physical (and sexual) abuse from a geographically stratified, random sample of 1,442 adults in the general population, and obtained a response rate of 64.8% (Briere & Elliott, 2003). Of the respondents, 32.3% of women and 14.2% of men reported physical abuse before the age of 18.

Using a different methodology Goldberg and Freyd (2006) report similar results. They collected data on experiences of 12 types of childhood trauma, including “were severely attacked by someone close to you?” Theirs was a community sample of 397 women and 292 men. The response rate for being severely attacked by a person close to you was 26% for women and 18% for men.

Prevalence of Sexual Abuse

Using a broader definition that included non-contact behavior, David Finkelhor, a pioneer in the study of child sexual abuse, was the first researcher to alert professionals and the public to the pervasiveness of child sexual abuse. His initial research, which was both his doctoral dissertation and his first book (Finkelhor, 1979), was a study of students at six New England colleges and universities. Using a paper-and-pencil survey of undergraduate students, Finkelhor found that 19.2% of women and 8.9% of men had experienced sexual abuse during childhood.

Shocking as Finkelhor’s findings were to the professional community concerned about child well-being, his findings were exceeded in research by Diana Russell, another pioneer. Her first article appeared in 1983. This study involved a representative sample of women in the San Francisco area and employed face-to-face interviews, using as interviewers matched for gender and age with the respondents. Russell found that 38% of her sample experienced contact sexual abuse and 54%, when non-contact acts were included (Russell, 1983).

More recently, Bolen and Scannapieco undertook a meta-analysis of 22 studies with randomized samples (Bolen & Scannapieco, 1999; see also Bolen, 2001). In their introduction, they note that prevalence rates ranging from 2% to 62% have been reported. Based upon their work, they estimate female prevalence rate between 30 and 40% and male prevalence rate at more than 13%. They note that the small number of studies of males makes it difficult to arrive at a prevalence estimate for men (Bolen & Scannapieco, 1999). Similarly, in a meta-analysis of prevalence, 55 studies conducted between 2002–2009 from 24 countries, Barth and colleagues state prevalence estimates ranged from 8 to 31% for girls and 3 to 17% for boys. Nine girls and 3 boys out of 100 were victims of forced intercourse (Barth, Bermetz, Heim, Trelle, & Tonia, 2013).

Trends in Incidence of Child Maltreatment

Beginning in 1976, annual national statistics have been gathered on reports of child physical abuse and neglect. In 1988, the Children’s Bureau substantially revised the reporting system, now called National Child Abuse and Neglect Data System (NCANDS). Data are published annually in a volume, Child Maltreatment (Children’s Bureau, 2016).

National statistics demonstrate a dramatic increase in reports from 700,000 cases or 10 per 1,000 children in 1976, to the late 1990s when over 3 million children were reported or 47 per 1,000 children (Faller, 1999). Rates of reports continue to increase each year. In 2014, the most recent year for which data are available, there were 3.6 million reports representing 6.6 million children or 48.8 per 1,000 children, referred for all types of child maltreatment (Children’s Bureau, 2016).

As reporting rates have increased, substantiation rates have decreased. In the 1970s and 1980s, the substantiation rates were 40–50% (Faller, 1999). In the late 1980s, in order to manage the daunting number of reports, states developed screening criteria (Wells, Fluke, & Brown, 1995). In 2014, of the 3.6 million reports, 39.3% were screened out, that is, not investigated. Of the screened-in reports, approximately one-fifth were substantiated, or 702,000 children. Thus, of all children who were reported to child protective services, a little more than 10% were deemed to be victims of child maltreatment. Victims are approximately equally likely to be male or female. In terms of race, the largest number are White (44%), but African American (21.4%), Hispanic (22.7%), and Native American (1%) children are overrepresented. Child Maltreatment does not provide separate racial and gender statistics by type of maltreatment (Children’s Bureau, 2016).

The National Incidence Studies (NIS) are authorized by Congress as part of CAPTA, and are conducted at approximate 10-year intervals, the most recent being NIS 4, which was undertaken during 2005 and 2006, and whose results were published in 2010. NIS research targets a representative national sample of professionals working in agencies that serve children, known as “sentinel agencies,” and compares their reports of child maltreatment to substantiated reports from child protective services. In addition, because there have been four such surveys, rates of maltreatment and substantiation can be compared over time. NIS 4 involved 122 counties in which there were 126 child protection agencies. NIS includes two standards, a harm standard (severe maltreatment) and a broader endangerment standard. Because CAPTA definitions include both actual abuse and risk for abuse, both of these standards are relevant. NIS 4 estimated that 1.25 million children were maltreated in 2005–2006, or 1.8 times as many as were substantiated by child protection agencies. Of these children, 44% were abused and 61% were neglected (Sedlak et al., 2010). These are discrepant findings when compared to substantiated child welfare cases, where only about 25% involved abuse. According to the endangerment standard, close to 3,000,000 children were maltreated during 2005–2006 (Sedlak et al., 2010).

The first three NIS studies found no differences in patterns of maltreatment by race. However, NIS 4 found that rates of sexual and physical abuse for African American children according to the harm standard were higher than those for White children (Sedlak et al., 2010).

It is important to point out that both NCANDS and NIS gather data about situations in which the child’s caregiver is either the offender or is neglectful and does not prevent maltreatment or act protectively after maltreatment has occurred. Child Maltreatment 2014 reports that 78.1% of offenders were parents, but 3.7% were the unmarried partners of parents (Children’s Bureau, 2016). Although Child Maltreatment 2014 does not provide a breakdown of perpetrator relationship by type of maltreatment, practice indicates these unmarried partners are more likely to commit physical and sexual abuse than neglect. In terms of offender gender, 54.1% were women and 44.8% were men, but again, with no breakdown in terms of type of child maltreatment (Children’s Bureau, 2016).

A child can be physically abused outside of the family, for example, in a school setting or in a recreational setting. These cases would not be identified by either NCANDS or NIS, but might be reported to law enforcement. Under-identification of sexually abused children in national statistics poses a much larger problem. Bolen, who examined a spectrum of studies of sexual abuse, reports that 62 to 81% of offenders against females were extra-familial and 84 to 94% of offenders against males were extra-familial (Bolen, 2001). Similarly in an international meta-analysis, Stoltenborgh and colleagues found that approximately two-thirds of sex offenders against children were extra-familial (Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). The findings regarding offenders’ relationship to their child victims are important in planning and executing interventions to help the children, which is covered later in this article.

Incidence of Child Physical Abuse

According to Child Maltreatment, 2014, the proportion of children who were victims of physical abuse was 17% or 119,517 children. Children under the age of one year had the highest rate of physical abuse, and children under the age of three were the most likely to suffer fatal child abuse (Children’s Bureau, 2016).

According to the harm standard, NIS 4 data indicate that 58% of abused children were physically abused, or an estimated 323,000 children, 2.7 times the number substantiated by child protection agencies. According the endangerment standard, of the 835,000 abused children, 57% or 476,000 were physically abused (Sedlak et al., 2010).

Incidence of Child Sexual Abuse

According to Child Maltreatment, 2014, the proportion of children who were victims of sexual abuse was 8.3% or 58,283 children (Children’s Bureau, 2016). In 1976, the first year of aggregated reports, only 6,000 cases of sexual abuse were reported, a rate of .86 per 10,000 children, only 3% of all reports of maltreatment. By 1986, this figure had climbed to 132,000 cases, a rate of 20.89 per 10,000 children, and represented 15% of all cases of maltreatment. From the NCANDS data system, reports of sexual abuse from 1990 to 1995 remained about 15% of reports, when the proportion declined to 12.3% of the total reports of child maltreatment (Faller, 2003). The proportion and the number of cases of sexual abuse has continued to decline (Finkelhor & Jones, 2006). Despite these apparent declining numbers, sexual abuse should remain an abiding concern to social workers and other professionals because of its potential negative impact on children’s life courses.

According to the harm standard, NIS-4 found 24% of abused children were sexually abused, or an estimated 135,300 children (Sedlak et al., 2010). This number is 2.3 times the rate substantiated by child protection agencies. According to the endangerment standard, of the abused children, 22% or 180,500 children were sexually abused (Sedlak et al., 2010).

Investigation of Child Physical and Sexual Abuse

Social workers and other professionals employed as child protection and child welfare caseworkers are key professionals in investigation of allegations of physical and sexual abuse. In this endeavor, they work closely with other professionals (Child Welfare Information Gateway, 2013). Typically, the other professionals are health care providers who conduct the physical examinations of children who may have been abused; and law enforcement professionals, whose role is to determine if a crime has been committed.

In addition, increasingly, Child Advocacy Centers are hiring social workers as forensic interviewers. Child Advocacy Centers provide a child-friendly environment where the child is interviewed by a skilled professional, and other professionals with investigatory and case management duties (child protection workers, police, and prosecutors) observe the interview or review a video of it. The goals of Child Advocacy Centers are to minimize child trauma from the investigation by having the child interviewed, hopefully, only once, and to gather accurate information that can be used to protect the child and seek justice (National Children’s Alliance, 2016).

Although initially Child Advocacy Centers only interviewed and provided services to children who might have been sexually abused, more recently these centers conduct interviews of children who may have been physically abused or have witnessed violent crimes (National Children’s Alliance, 2016). Currently, there are 795 Children’s Advocacy Centers in the United States (National Children’s Alliance, 2016).

The usual goals of the child welfare investigative process are to determine if child abuse has occurred and, if so, whether the child is safe or there is future risk to the child. In addition, if the case is substantiated, the investigation will lead to a case management plan for the child and the family (Faller, in press).

Assessment of Physically and Sexually Abused Children

Social workers in voluntary agencies, in group practices, and in independent practice may work under contract with child welfare agencies or in other capacities on assessments. Often physically and sexually children and their families are referred by the child welfare agency to professionals in the community for evaluations. As already noted, the majority of sexual abuse involves offenders who are not part of the family (Bolen, 2001). In these circumstances, caregivers may seek assessments of sexually abused children, and law enforcement may refer children to assessment providers. In conducting assessments, social workers and other professionals may address the questions of whether abuse has occurred and child safety, but they are more likely to address the psychological impact of the abuse on the child and make specific treatment recommendations (Faller, in press).

In addition, social workers and other mental health professionals may be asked by the child welfare system and the courts to assess parents, both offenders and non-offenders, whose children have been abused. The goals of these assessments are to determine any parental responsibility for the child’s abuse, their parenting capacity, and their treatment needs.

Best Practices for Investigation and Assessment

Customary social work assessment methods are appropriate for evaluating situations of physical and sexual abuse. In addition, there are best practices that are unique to investigation and assessment of child abuse. These are forensic interviews of children and the use of abuse-specific standardized measures.

Forensic interviews. Whether social workers are child protection investigators or working in other capacities, the core of the evaluative process is interviewing the child. There are numerous guidelines and protocols for conducting these interviews (Faller, 2015; Newlin et al., 2015). Increasingly professionals who interview children about abuse are trained on several interview protocols and use strategies from them depending on the needs of the child (Newlin et al., 2015).

Although these interview structures vary in the number of phases of the interview, they have three core content areas: (1) the rapport-building phase, (2) the substantive phase, and (3) the closure phase (Faller, 2007; Newlin et al., 2015). During the substantive phase, the professional inquiries about abuse using open-ended probes and questions and attempts to obtain a narrative account from the child (Newlin et al., 2015). Care is taken not to ask leading questions or use interpretation. These child interviews are intended primarily to determine the facts, but interviewers can also gather information about the impact of the abuse on the child.

Use of standardized measures. Social workers and other mental health professionals working in Child Advocacy Centers and engaging in assessments of physically and sexually abused children should use standardized measures, which can supplement the interview process and provide information on the impact of the abuse on the child. Instruments that are the most widely employed and have the best research base are the Child Behavior Checklist (CBCL) (Achenbach, 2016), the Child Sexual Abuse Inventory (CSBI) (Friedrich, 1997), the Trauma Symptom Checklist for Children (TSCC) (Briere, 1996), and the Trauma-Symptom Checklist for Young Children (TSC-YC) (Briere et al., 2001).

The CBCL has two versions, one for children 1.5–5 (100 items) and another for children 6–18 (113 items). These are completed by the caregiver. There are also versions completed by the child and the teacher. The CBCL provides a Total Problems score and subscores for Internalizing Behaviors (1) Anxious/Depressed, (2) Withdrawn/Depressed, (3) Somatic Complaints, (4) Social Problems and Externalizing Behaviors ((a) Aggressive Behavior, (b) Thought Problems, (c) Attention Problems, (d) Rule-Breaking Behavior). Externalizing behaviors are especially common among children who have been physically abused (Achenbach, 2016).

The CSBI, as indicated by its title, is specific to indicators of sexual abuse. It is a 38-item inventory completed by the child’s caregiver and is normed for children, ages 2–12. It yields a Total CSBI score, a Developmentally Related Sexual Behavior Score (normal), and a Sexual Abuse Specific Items Score, with norms by age and gender for these scales (Friedrich, 1997).

The TSCC is a 54-item inventory completed by children ages 8 and older. It contains items related to (1) anxiety, (2) depression, (3) posttraumatic stress, (4) sexual concerns, (5) dissociation, and (6) anger. Respondents rate items 0 (not at all) to 3 (very often). It yields a Total Score as well as scores on the 6 subscales (Briere, 1996). It is useful for gathering information about the effects of both sexual and physical abuse.

The TSC-YC was developed by Briere and addresses the lack of full age range of the TSCC; and it is used to gather information on children, ages 3–12, from the child’s caregiver. It contains 90 items related to (1) posttraumatic stress—intrusion, (2) posttraumatic stress—avoidance, (3) posttraumatic stress—arousal, (4) posttraumatic stress—total, (5) sexual concerns, (6) anxiety, (7) depression, (8) dissociation, and (9) anger/aggression (Briere et al., 2001).

Case Management

Case management strategies for physically and sexually abused children have the goals of child safety, permanency, and well-being (Adoption and Safe Families Act (ASFA), 1997). Both the child welfare system and the child protection court will be involved in case management decisions (Child Welfare Information Gateway, 2013). When child protective services intervenes, if the child is not safe or cannot be made safe at home, the child is usually removed and placed with relatives or in foster care. Because the child welfare system also supports family preservation, the presumptive goal, except in very serious cases such as severe or chronic injury and sexual abuse (Adoption and Safe Families Act, 1997), is that removal will be temporary, and the family will be reunified when it becomes safe to return the child. Mindful of the importance of stability for children, ASFA and state child welfare statutes place time limits for the amelioration of the circumstances leading to child placement. A permanency planning hearing usually is required if the child has been in care for a year (Adoption and Safe Families Act, 1997). Depending upon case circumstances, the permanency goal for the child may be reunification with the family, termination of parental rights followed by a relative or non-relative adoption, or guardianship (Adoption and Safe Families Act, 1997; Child Welfare Information, 2013 Gateway).

In recent Practice Guidelines, the American Professional Society on the Abuse of Children (APSAC) advises evidence-based case management and service in child welfare cases (APSAC, 2014). These guidelines contrast the traditional approach to child welfare cases, which is described as both a “cookie cutter” and “kitchen sink” approach. Typical of the “cookie cutter” component is requiring generic counseling. The “kitchen sink” component is requiring a service for every family problem identified when the family is assessed by the child welfare system. The APSAC guidelines advise parsimony in the number of services because families can be overwhelmed by requirements to participate in many services, setting priorities in terms of what problems need to be addressed, and targeting specific problems with treatments that work for those problems (APSAC, 2014).

Treatment of Physically and Sexually Abused Children

Treatment for physically and sexually abused children is intended to address both the causes and the consequences of the abuse. Because in most instances of physical abuse and some instances of sexual abuse, the caregiver is the offender, treatment must also involve the abusive caregiver(s). In sexual abuse cases where the caregiver is not the offender, this adult, nevertheless, has an important role in the child’s treatment and may need treatment in her/his own right.

In terms of consequences for the child, the most common effect of physical abuse is aggressive and acting out behaviors (Runyon & Urquiza, 2011). Victims of physical abuse may also suffer from posttraumatic stress (PTS) and blame themselves for their abuse (Runyon & Urquiza, 2011). The most common sequelae of sexual abuse are posttraumatic stress disorder (PTSD) and posttraumatic stress (PTS) (Berliner, 2011). Some sexually abused children also have sexual behavior problems (Friedrich, 1997). Other fairly common effects are depression and self-blaming. Adolescents may engage in self-harm and substance use (NCTSN, 2013).

In recent years, research has documented the concurrence of several traumas: that is “poly-victimization” in abused children (Finkelhor, 2008). When children are “poly-victims,” they are more likely to have symptoms of trauma (Finkelhor, 2008), and treatment must address the spectrum of traumas or complex trauma (Courtois & Ford, 2009).

One of the positive developments in the last 20 years is the emergence of evidence-based treatments for both physically and sexually abused children. Thus, social workers and other professionals can help abused children (and their families) by employing evidence-based interventions. Social workers whose role is to support children’s treatment need to insist treatment strategies are empirically supported or at least promising practices (NCTSN, 2016). In schools and other non-clinical settings, social workers can play an important role in identifying an abused child’s behavior problems (e.g., aggression, affect dysregulation) as a result of trauma, and preventing negative labeling of the child.

Since evidence-based treatments for physical and sexual abuse are rapidly developing, social workers and others providing treatment need not only to study these treatments, but also to engage in continuing education about these treatments. All the evidence-based treatments described in this article are manualized. Many empirically supported treatments have established training programs and provide ongoing supervision to assure treatment integrity and to problem solve with therapists (e.g., NCTSN, 2012a, 2012b).

The National Child Traumatic Stress Network (NCTSN), which is funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), has played a leadership role, not only in supporting centers that provide services to traumatized children but also in developing a compendium of “Empirically Supported Treatments and Promising Practices” (NCTSN, 2016). NCTSN identifies core components of these interventions as follows: (1) motivational interviewing (to engage clients); (2) risk screening (to identify high-risk clients); (3) triage to different levels and types of intervention (to match clients to the interventions that will most likely benefit them); (4) systematic assessment, case conceptualization, and treatment planning; (5) engagement/addressing barriers to service seeking; (6) psychoeducation about trauma reminders and loss reminders; (7) psychoeducation about posttraumatic stress reactions and grief reactions; (8) teaching emotional regulation skills; (9) maintaining adaptive routines; (10) parenting skills and behavior management; (11) constructing a trauma narrative (to reduce posttraumatic stress reactions); (12) teaching safety skills; (13) advocacy on behalf of the client; (14) teaching relapse prevention skills; (15) monitoring client progress/response during treatment; and (16) evaluating treatment effectiveness (NCTSN, 2016).

These are generic components that focus on trauma, and most of the treatments supported by NCTSN can be used for a range of traumatic experiences. A number of these treatments are specifically appropriate for physically and sexually abused children. Many of the NCTSN treatments have been adapted to serve different cultures, and there are some treatments that are specific to cultural groups, for example, Native American/Alaskan Native and Latino populations (NCTSN, 2016). All of the treatments recommended in this article can be used with diverse populations.

Specific treatments for physical abuse. Treatment involving both children and their parents is appropriate when the child’s injuries are not severe and the child is two years or older. Physical abuse usually occurs in response to a child’s perceived or actual misbehavior. Evidence-based treatments for physical abuse have cognitive-behavioral components and involve the parent and the child to improve parent-child interactions. These treatments aim to reduce the coercion in the parent-child relationship (Runyon & Urquiza, 2011). Specific treatments identified by Runyon and Urquiza that improve the parent-child relationship are (1) Parent-Child Interaction Therapy (PCIT), (2) Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT), and (3) Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT). Some of these treatments also address posttraumatic stress. All three of these interventions appear in the NCTSN’s compendium.

Parent-Child Interaction Therapy (PCIT). PCIT is a 12–20 session treatment, and has been employed with children ages 2–12. The first half of the sessions is devoted to assisting the parent in playing cooperatively with the child and the second half to teaching parents to effectively control the child’s behavior using non-coercive methods. The therapist observes the sessions from behind a one-way mirror and actively intervenes, coaching the parent through a bug-in-the-ear of the parent. The goals during the child play sessions are to allow the child to take the lead in the play and to enhance positive interactions by teaching the parent “Praise, Reflection, Imitation, Description, and Enthusiasm” (PRIDE). During the second half of treatment, the parent is instructed and coached in a positive discipline program, including effective delivery of commands, positive parent responses for child compliance, and time-out for inappropriate behavior. Behaviors are charted during treatment so that the parent receives fairly immediate feedback (NCTSN, 2008)

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT). AF-CBT is a 20-session treatment for children, ages 5–17 years, who have experienced physical abuse or harsh/excessive physical discipline. It addresses parental coercive discipline, child trauma, and child behavior problems.

AF-CBT has child-directed components, caregiver/parent-directed components, and parent-child or family systems directed components. Child components are (1) engagement and goal setting; (2) psychoeducation about force/abuse; (3) disclosure of incidents involving hostility and physical force/abuse to help the child understand the context in which they occurred; (4) cognitive processing of automatic thoughts that could maintain aggressive behavior or family conflict; (5) training in affect identification, expression, and management skills (e.g., relaxation training, anger control); (6) social/interpersonal skills training to enhance social competence and development of social support plans; and (7) imaginal exposure and making meaning from the disclosure of traumatic events related to physical abuse/discipline.

For the caregiver/parent, these components are (1) engagement/rapport building that includes discussion of family of origin issues and current family circumstances; (2) psychoeducation on the impact of family abuse/conflict; (3) discussion of current referral reasons/child’s disclosure, and family contributors to coercive behaviors; (4) cognitive processing of caregiver’s automatic thoughts that may promote coercive interactions; (5) training in affect-regulation skills to manage reactions to abuse-specific triggers (e.g., escalating anger, anxiety, or depression); and (6) training in behavior management principles and practices/strategies (e.g., reinforcement and punishment) that serve as alternatives to using physical discipline.

Finally, for the parent-child and family relationship, these components are (1) treatment orientation and engagement; (2) clarification sessions to establish responsibility for the abuse (i.e., the caregiver); (3) focus treatment on the needs of the victims/family, and develop safety and relapse prevention plans, as needed; (4) communication skills training to encourage constructive and supportive interactions; (5) prosocial (nonaggressive) problem-solving skills training to minimize coercion, with home practice applications to help family incorporate them in everyday routines; and (6) graduation and review of skills learned/safety plans (NCTSN, 2012a).

Combined Parent-Child Cognitive Behavioral Therapy CPC-CBT). CPC- CBT is short term (16–20 90-minute sessions) for children, ages 3–18, whose caregivers have engaged in physical abuse or coercive parenting. Fewer studies of CPC-CBT have been completed than of PCIT and AF-CBT. The treatment addresses the child’s trauma from abuse; motivates parents to use effective, non-coercive parenting strategies; improves parent-child relationships; and stops the cycle of violence.

The treatment has four phases: (1) engagement and psychoeducation, (2) effective coping skill-building for parents, (3) family safety (developing a family safety plan), and (4) abuse clarification. During Phase 1, specific engagement and psychoeducation strategies employed in CPC-CBT are the following: (1) motivational interviewing/consequence review; (2) individualized goal setting; (3) providing violence psychoeducation including educating both parents and children on (a) different types of violence, (b) the continuum of coercive behavior, (c) the impact of violent behavior on children; (4) providing psychoeducation for parents about (a) child development, and (b) realistic expectations for children’s behavior; (5) addressing parental history of trauma exposure including its impact on (a) their relationships with their parents, and (b) their parenting approach with their own children. During Phase 2 or the coping skill-building phase, the therapist works collaboratively with the parent(s) to (1) develop adaptive coping skills, (a) cognitive coping, (b) anger management, (c) relaxation, (d) assertiveness, (e) self-care, and (f) problem solving; (2) assist parent(s) in remaining calm while interacting with their children; (3) develop nonviolent conflict resolution skills; (4) develop a variety of problem-solving skills related to child rearing; (5) develop a variety of non-coercive positive child behavior management skills; (6) learn the dynamics of their interactions with their children and what escalates anger and violence during these interactions and how to use skills to diffuse the situation; and (7) assist children in developing adaptive coping skills and self- management skills (e.g., emotional regulation, assertiveness, anger management). Phase 3 or developing a family safety plan includes the following strategies: (1) learning how to identify when parent-child interactions are escalating, (2) taking a cool-down period in order to enhance safety and communication in the family, (3) having parents and children rehearse the implementation of the family safety plan, and (4) introducing other safety components across the therapy. Phase 4 or the abuse clarification phase involves the following activities: (1) parent writing an abuse clarification letter in which the parent takes responsibility for the abuse to the child, (2) the child developing a trauma narrative about the abuse experienced, and (3) parents share their abuse clarification letter and the child reads the trauma narrative during conjoint sessions.

Specific treatments for sexual abuse. Although research indicates that victims of sexual abuse are more likely to receive treatment than victims of other types of maltreatment, not all victims of sexual abuse are traumatized by the experience (Berliner, 2011), which highlights the importance of a careful assessment. The preferred treatments for sexual abuse are cognitive behavioral. Trauma-focused cognitive behavior therapy (TF-CBT) is the most widely employed and has a superior research base to other treatments included on the NCTSN’s Empirically Supported Treatments and Promising Practices (NCTSN, 2012b). It is most effective when the child has a supportive caregiver who can be involved (Cohen, Mannarino, & Knudsen, 2005). Other treatments have been developed for children with complex trauma (i.e., “poly-victims”). Complex trauma treatment with the best evidence base is Integrative Treatment of Complex Trauma (ITCT). It has been widely employed and has one published pre- post-evaluation.

Trauma-focused cognitive behavior therapy (TF-CBT). Originally developed for treatment of sexual abuse, TF-CBT has been adapted to treat other kinds of trauma. It is appropriate for young people ages 3–21. It is a short-term treatment with 12–25 sessions, 60–90 minutes in length, the time divided between child, parent/caregiver, and parent-child. TF-CBT can address PTSD, depression, anxiety, externalizing behaviors, relationship and attachment problems, school problems, and cognitive problems, which may be associated with sexual abuse (NCTSN, 2012b).

Content for sessions includes didactic material and exercises focused on the following issues: (1) providing psychoeducation to children and their caregivers about the impact of trauma on children and common childhood reactions to trauma; (2) helping children and parents identify and cope with a range of emotions (e.g., anger, shame, fear); (3) developing personalized stress management skills for children and parents, such as deep breathing; (4) teaching children and parents how to recognize the connections between thoughts, feelings, and behaviors; (5) encouraging children to share their sexual abuse or other traumatic experiences either verbally, in the form of a written narrative, or in some other developmentally appropriate manner (e.g., in drawings); (6) helping children and parents talk with each other about the sexual abuse experiences; (7) modifying children’s and parents’ inaccurate or unhelpful trauma-related thoughts (e.g., the abuse was my fault); and (8) helping parents develop skills for optimizing their children’s emotional and behavioral adjustment (i.e., parenting skills) (TF-CBT.web, 2005).

Integrative treatment of complex trauma for adolescents (ITCT-A). ITCT addresses the effects of sexual abuse, but also of other traumas, especially traumas experienced at an early age (Lanktree & Briere, 2013; Lanktree et al., 2012). The adolescent version, which is on the NCTSN list, is suitable for multiply traumatized young people, ages 12–21. It has greater flexibility in terms of length of treatment than the other empirically supported treatments, with sessions ranging from 16–36. While the youth is in treatment, the clinicians assess the child every 2–3 months to determine progress in symptom reduction. ITCT can be delivered in individual and group format (NCTSN, 2015a). Treatment follows standardized protocols involving empirically based interventions for complex trauma. Core components of ITCT are (1) relational/attachment-oriented treatment, (2) cognitive therapy, (3) exposure therapy, (4) mindfulness skills development, (5) affect-regulation training, (6) trigger management, and (7) psychoeducation. Specific collateral and family therapy approaches are also integrated into treatment (NCTSN, 2015a).