Interventions for Physically and Sexually Abused Children
- Kathleen Coulborn FallerKathleen Coulborn FallerUniversity of Michigan
Social workers play a vital role in helping physically and sexually abused children. In order to play this role, they need knowledge about the nature of the problem: (1) legal definitions of physical and sexual abuse, (2) its incidence and prevalence, and (3) its signs and symptoms. Social workers have three major roles to play: (1) identifying and reporting child abuse to agencies mandated to intervene; (2) investigating and assessing children and families involved in child abuse; and (3) providing evidence-based interventions, both case management and treatment, to physically and sexually abused children.
This article will focus on helping physically and sexually abused children in the United States. This choice derives from the wide variation in recognition of and intervention for physically and sexually abused children around the world (Pereda, Guilera, Forns, & Gómez-Benito, 2009). Moreover, the body of knowledge about how these children can be helped is primarily limited to the developed world.
Topics relevant to the social work response to child physical and sexual abuse will be covered. These include (1) definitions of child physical and sexual abuse, (2) prevalence and incidence of physical and sexual abuse, (3) reporting physical and sexual abuse, (4) investigation and assessment of reports of physical and sexual abuse, and (5) interventions to assist physically and sexually abused children.
Definitions of Child Physical and Sexual Abuse
Both physical and sexual abuse are against the law. Definitions are found in both criminal and child protection statutes. A useful starting point for definitions of physical and sexual abuse is the federal statute, the Child Abuse Prevention and Treatment Act (CAPTA) (2010).
According to CAPTA, “the term child abuse … means, at a minimum, any recent act … on the part of a parent or caretaker, which results in death, serious physical or emotional harm, … or an act … which presents an imminent risk of serious harm” (CAPTA, 2010). Signs of physical abuse include the following: (1) bruises, blisters, burns, cuts, and scratches; (2) internal injuries, brain damage; and (3) broken bones, sprains, dislocated joints.
According to CAPTA, “the term ‘sexual abuse’ includes: (A) 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 purpose of producing a visual depiction of such conduct; or (B) the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children …” (CAPTA, 2010). Specific types of sexual abuse are the following: (1) non-contact behavior (e.g., voyeurism, exposure of private parts, sexual talk); (2) fondling of the private parts (genitals, breasts, buttocks); (3) digital, object, and penile penetration of the vagina or the anus; (4) oral sex (fellatio and cunnilingus, which may be required of the child or perpetrated on the child); and (5) sexual exploitation (prostituting the child or the use of the child in pornography) (Faller, 2003). Studies of sexual abuse may vary in which types are included in the definition, broader definitions including non-contact behavior.
For a situation of physical abuse to become a child protection matter, it must be inflicted by the child’s caregiver. If someone other than the caregiver abuses the child, this may become a child protection matter if the caregiver was negligent and permitted the assault. In contrast, in sexual abuse, CAPTA does not explicitly state that the child’s caregiver must be the offender. In practice, however, extra-familial sexual abuse is handled by law enforcement as a crime.
Prevalence and Incidence of Child Physical and Sexual Abuse
In this section, sources of information about the prevalence and incidence of physical and sexual abuse will be cited. Prevalence refers to the percentage or number of individuals who experienced physical or sexual abuse during childhood. Incidence refers to reports of physical or sexual abuse during a time frame, typically a year.
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).
Reporting Child Maltreatment
The first way that social workers can help physically and sexually abused children is by reporting cases to child protective services when there is reasonable cause to suspect or believe a child has been abused. In almost all 50 U.S. states and territories, social workers are mandated reporters of child maltreatment (Child Welfare Information Gateway, 2016b). Social workers need not be certain of abuse to justify a report. Moreover, both federal and state statutes provide protections for persons who report in good faith and penalties for professionals who fail to report (Child Welfare Information Gateway, 2016a). And child protection caseworkers are not allowed to reveal the identity of the reporting person during the course of the investigation.
Despite these protections and incentives, social workers and other professionals are sometimes reluctant to report to protective services (Kim, Gostin, & Cole, 2012; Zellman & Faller, 1995). Reasons for this reluctance include concern that the report will have a negative effect on the social worker’s relationship with the child or the family, worry that the child will be punished because of the report, skepticism about the quality of service provided by the child welfare agency, and concern that the report will not “do any good” (i.e., the case will not be substantiated and the family won’t receive any help) (Zellman & Faller, 1995). These are all legitimate concerns. That said, unless social workers are employed by the child welfare system, they are not in a position to provide child safety from abuse. Child protection workers are, as are law enforcement officials and the courts.
Physical abuse indicators include the following: injuries to a child in non-accidental injury sites, a child or caregiver’s implausible explanation for an injury, and a delay in seeking medical treatment for an injury; these are all red flags. Non-accidental injury sites include the face, the neck, the upper arms, ears, genitals, and buttocks (Reece, 2011). Similarly, bite marks and burns without plausible explanation are red flags (Reece, 2011). Finally, if a child discloses physically abusive acts by a caregiver, regardless of the presence of physical signs, that disclosure should trigger a report.
Sexual abuse rarely results in physical findings (Alexander, 2011). Child sexual abuse is usually signaled by the child’s statement or behavior. Research indicates that children rarely make false allegations of sexual abuse (Faller, 2007). If a child tells a social worker that she/he has experienced sexual abuse, a report to child protective services should be made. Other red flags for sexual abuse are sexualized behavior (Friedrich, 1997) and sexual knowledge (Brilleslijper-Kater, Friedrich, & Corwin, 2004) beyond what should be expected for the child’s developmental stage (Everson & Faller, 2012). Sexual behavior needs to be evaluated in terms of the behaviors that are high probability for sexual abuse (Child Sexual Behavior Inventory, 2012; Friedrich, 1997). Concerning behaviors include inviting others to engage in sexual activity, engaging in digital, anal, or vaginal penetration, and engaging in oral sexual acts. These concerning behaviors may be with self, other children, adults, or pets (Faller, 2003). Advanced sexual knowledge may be a sign of sexual abuse in young children. Such knowledge includes knowledge about the mechanics of vaginal, oral, and anal intercourse. Of particular concern is sensori-motor knowledge, for example. what intercourse feels like and what semen tastes like (Faller, 2007). Especially today, with the easy access to Internet materials about sexual activity, possible sources of sexual knowledge and sexual behaviors, other than sexual abuse, need to be assessed when considering a report.
Investigation and Assessment
The primary source of information used to determine physical abuse is a health care professional’s examination of the child’s physical injuries and condition. In contrast, the primary source of information used to determine sexual abuse is a professional’s evaluation of the child’s statements and behavior. Although social workers may play important roles in evaluating both physical and sexual abuse, they are more likely to have a central role in sexual abuse cases. In this section, differences between investigative and assessment roles and two strategies specific to gathering information about the likelihood of abuse and its effects will be described.
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).
Interventions to Help Physically and Sexually Abused Children
Interventions employed by social workers may involve both case management and treatment. Because most physical abuse cases involve the child’s caregiver as the offender, interventions are likely to involve the child welfare system and to involve both case management and treatment. In contrast, because most sex offenders against children are extra-familial (Bolen, 2001), professionals can usually count on a non-offending caregiver in the intervention.
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).
For social workers and other professionals to help physically and sexually abused children, they must contextualize these traumas by appreciating their legal definitions and by understanding the prevalence and incidence of child physical and sexual abuse. Moreover, they must be able to recognize the signs and symptoms of these types of abuse and make reports to child protective services as they are mandated to do by statute. Social workers may be charged with investigation and assessment of physically and sexually abused children in a variety of contexts, including as child welfare workers and as clinicians who work under contract with child welfare agencies. Interventions to help physically and sexually abused children can involve both case management and treatment. In both of these contexts, there is increasing focus on evidence-based and evidence-informed interventions. These include an array of treatments that have demonstrated efficacy and effectiveness for physically and sexually abused children.
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