Predictors of treatment outcome in sexually abused children☆
Introduction
SEVERAL STUDIES HAVE examined factors which contribute to symptom formation and resolution following child sexual abuse. Some have evaluated the impact of personal characteristics of the child, while others have focused on the impact of familial factors in this regard.
A number of authors have demonstrated that specific attributions and perceptions of sexually abused children effect the psychological symptoms they develop. In particular, personal attributions (self-blame) for the sexual abuse have been found to correlate with a number of behavioral and emotional difficulties in sexually abused children Hunter et al 1992, Morrow 1991, Spaccarelli 1995. The Children’s Attributions and Perceptions Scale was developed to specifically measure abuse-related attributions and perceptions, including feeling different from peers, blaming oneself for negative events, feeling one is not believed by others, and decreased trust of others (Mannarino, Cohen, & Berman, 1994). This instrument strongly predicted psychological symptom formation, both at the time of abuse disclosure and 12 months post-disclosure Mannarino and Cohen 1996a, Mannarino and Cohen 1996c. In addition to these factors, sexually abused children’s locus of control has been found to correlate with anxiety symptoms (Mannarino & Cohen, 1996c). To our knowledge, no studies have examined the impact of these child characteristics on treatment outcome following sexual abuse.
With regard to familial factors, Lynskey and Ferguson (1997) found in a longitudinal study that peer and family relationships (particularly paternal support) predicted psychological symptomatology in 18 year olds who had been sexually abused during childhood. Oates, O’Toole, Lynch, Stern, and Cooney (1994) demonstrated that familial dysfunction and poor maternal problem-solving abilities correlated significantly with behavioral problems in sexually abused children at an 18-month follow-up. Hanson, Saunders, and Lipovsky (1992) found a significant association between maternal distress and self-reported fear in sexually abused children. Lack of maternal support Everson et al 1989, Friedrich et al 1992b, Leifer et al 1993 and maternal depression (Kinard, 1995) have also been correlated with greater behavioral and emotional symptoms in sexually abused children. In a study of sexually abused preschool children (3–7 years old), the impact of demographic, developmental and familial factors on treatment outcome was examined. The strongest predictor of outcome at the time of treatment completion was the child’s parent or primary caretaker’s level of emotional distress related to the sexual abuse disclosure as measured by the Parent’s Emotional Reaction Questionnaire (PERQ) (Cohen & Mannarino, 1996). This was found to be true across two distinct treatment interventions.
It was not unexpected that preschool children’s response to treatment would be significantly impacted by their parents’ emotional state because of the their high degree of physical and emotional dependence on their caretakers; because school and peers generally are a minor influence compared to parents at this age; and because developmentally, preschoolers have limited cognitive ability to independently examine or reassess cognitive distortions, attributions or perceptions about the abuse. It is not clear whether older children’s response to treatment would be affected to such a degree by their parents’ abuse-related distress, or whether other factors such as parental support and the child’s own attributions and perceptions would have more influence on their response to treatment. We undertook the present study to address this issue. We hypothesized that all three of these factors (parental emotional reaction to the sexual abuse, parental support of the child, and the child’s attributions and perceptions) would significantly predict treatment outcome, independent of the type of treatment provided.
Section snippets
Overview
The methodology used in this project has been described in detail previously (Cohen & Mannarino, 1998). Briefly, 49 sexually abused children aged 7–14 years and their nonoffending primary caretakers completed a 12-week treatment course of either sexual-abuse specific cognitive-behavioral therapy (SAS-CBT) or nondirective supportive therapy (NST). Treatment condition was randomly assigned and monitored for adherence to the assigned therapeutic model through the use of intensive training and
Overview
The assessment instruments were divided into two general categories. The first category was outcome measures, that is, instruments which assess the child’s level of psychological symptomatology at different points in the study. The second category of instruments measured possible mediating factors in symptom persistence and treatment response in sexually abused children and adolescents.
The outcome measures were chosen for use in this study in two ways. First, instruments which have been
Results
Correlational analyses were conducted to analyze the relationships between the hypothesized mediating factors and the outcome measures at posttreatment across the two treatment groups. Results of these analyses are summarized in Table 2.
The CAPS Feeling Different scale significantly correlated with the TSC-C Depression and PTSD scales as well as with the STAIC Trait scale. The CAPS Trust scale significantly correlated with the TSC-C Depression and PTSD scales. The CAPS Personal Attributions
Discussion
This study attempted to explore what factors predict treatment outcome in sexually abused 7- to 14-year-olds. It demonstrated that the Children’s Attributions and Perceptions Scale was a strong predictor of treatment outcome on several instruments. The FACES-III Adaptability scale and parental support as measured by the PSQ were also predictive of outcome.
The CAPS Perceived Credibility and the FACES-III Adaptability scales significantly predicted outcome on the TSC-C Anxiety scale, together
Acknowledgements
The authors gratefully acknowledge Ann Marie Kotlik, Mary McCracken, L.S.W., Julia Peters, M.S., and Karen Stubenbort, M.S., M.S.W., who contributed greatly to all aspects of this project. We also thank our consultants, Lucy Berliner, M.S.W., and Esther Deblinger, Ph.D., for their ongoing assistance and support, and David Brent, M.D., who graciously provided us with a prototypical treatment manual for nondirective supportive therapy.
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This study was funded by the National Center on Child and Abuse Neglect, Grant #90-CA-1545.