Practitioner’s Guide to Evidence Based Psychopathology
Amy Hoch-Espada, Psy.D., Erika Ryan, Ph.D. & Esther Deblinger, Ph.D.
University of Medicine & Dentistry – School of Osteopathic Medicine
New Jersey Child Abuse Research, Education, and Service (CARES) Institute
Child Sexual Abuse
What is child sexual abuse?
Child sexual abuse refers to sexual activity with a child where consent is not or cannot be
given reflecting an unequal power relationship (Berliner, 2000; Finkelhor, 1994; Berliner &
Elliott, 2002). This broad definition includes sexual contact such as direct genital touching, oralgenital contact, anal and/or vaginal penetration as well as non-contact abusive acts such as
voyeurism, exposure, and involvement in or exposure to pornography.
Basic Facts about Child Sexual Abuse
Finkelhor (1994) found that in a retrospective review of studies approximately 25% of
women and 5 – 15% of men in the United States and Canada experienced contact sexual abuse as
children. Additionally, Widom and Morris (1997) found that over 30 % of adults with
documented histories of sexual abuse failed to report those experiences when questioned,
suggesting that Finkelhor’s findings may be an undersestimate of actual rates of childhood
sexual abuse. Data on childmaltreatment is collected from Child Protective Services in each
state and reported by the US Department of Health and Human Services. Sexual abuse reports
made up 11.5% of 2.8 million reports of suspected abuse across the country (US Department of
Health and Human Services, 2000). According to Kolko (2002) these figures are likely an
underestimate of the prevalence of abuse given that they are based solely on cases reported to
child protective agencies.
One reason these figures may be an underestimate of the prevalence of sexual abuse is
that the definition of sexual abuse varies across states, agencies and researchers. The figures
based on reports to child protection agencies are limited to those instances of abuse perpetrated
by an individual in a caregiver role. Furthermore, it’s unclear if estimates also include sexual
abuse perpetrated by children and adolescents. There are alarming statistics that suggest that
between 20 and 30% of sexual abuse is committed by adolescents and between 5 and 16%
committed by children (Adler & Schutz, 1995, Bagley & Shewchuk-Dann, 1991; Margolin &
Craft, 1990; Brown, 2004).
Research has examined the impact of sexual abuse in primarily two ways. One body of
literature is retrospective in nature, often focusing on adult females, while the other reports
examine the effects of child sexual abuse on children who have recently suffered sexual abuse.
Studies with adult females have reported that a history of childhood sexual abuse is related to
later psychological difficulties that include anxiety, depression, and substance use (Cunningham,
Pearce & Pearce, 1988, Fry, 1993; Law, 1993). A variety of sexual difficulties such as
promiscuity, sexual dysfunctions, sexual dysphoria and avoidance of sexual activity have also
been reported by women with a history of sexual abuse (Thakkar, 2001; Finkelhor & Brown,
1985; Fry, 1993). Studies have also reported significant increased risk or revictimization in
adulthood (Chewning-Korpach, 1993; Wyatt, Guthrie & Notgrass, 1992). Several investigators
have also demonstrated a history of child sexual abuse impacting on adult physical health,
including increased gynecological problems, digestive problems, pelvic pain, and headaches
(Cunningham, Pearce & Pearce, 1988; Feltti, 1991; Walker, Caton, Hansom, Harrop-Griffiths,
Holm, Jones, Hickok & Jemelka, 1992).
Children who have suffered sexual abuse appear to be at increased risk for experiencing
PTSD, depression, sexually reactive behavior, and general behavior problems (Deblinger,
Lippman & Steer, 1996; AACAP, 1998; Finkelhor & Brown, 1985; McCleer, Deblinger, Henry
& Orvashel, 1992). Children also exhibit somatic problems, such as stomaches, headaches, and
skin rashes (Dubowitz, Black, Harrington & Vershoore, 1993). Furthermore, recent research
suggests that chronic PTSD experienced as a result of childhood abuse may have negative effects
on brain development (DeBellis, Baum, Birmaher, Keshavan, Eccard, Boring, et. al. , 1999).
It should, however, be noted that a significant proportion of children who have suffered
sexual abuse demonstrate highly resilient responses and experience minimal after effects
(Kendall-Tackett, Williams & Finkelhor, 1993). As a result, researchers have actively examined
factors that might explain the highly divergent impact of sexual abuse on the functioning and
well being of children. While several studies have documented that the child’s relationship to
the perpetrator and the invasiveness and forcefulness of the abuse appears to have some bearing
on the child’s post-abuse adjustment, these characteristics are not amenable to change, and may
not be as significant in influencing recovery as the reaction and supportiveness of nonoffending
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parents. In fact, recent studies consistently suggest that greater levels of parental support and
acceptance appear to be associated with more positive child outcomes (Cohen & Mannarino,
1998; Deblinger, Steer & Lippmann, 1999).
The expansive literature, documenting the potentially devastating emotional and
behavioral impact sexual abuse may have on children, highlights the critical need for
psychotherapeutic interventions for this population that are demonstrably effective. In fact, over
the last decade, considerable progress has been made with respect to the development and
evaluation of evidence based interventions for children who have suffered sexual abuse. Since
1990, a series of pre-post investigations and randomized controlled trials have documented the
efficacy of the trauma-focused cognitive behavioral therapy (CBT) approach to be described here
in both individual and group therapy formats (Deblinger, McLeer & Henry, 1990; Deblinger,
Stauffer & Steer, 2001; Deblinger, Lippmann & Steer, 1996; Cohen & Mannarino, 1996, 1998;
King, et al., 2000). The findings of these investigations have not only demonstrated the superior
benefits of trauma-focused CBT as compared to the nondirective supportive therapy, community
based treatments as well as the passage of time, but the results have also highlighted the
important role nonoffending parents can play in the treatment process. Moreover, it should be
noted that one and two year follow up studies have established that symptom improvements in
response to trauma-focused CBT appear to be long lasting (Cohen & Mannarino, 1998;
Deblinger, Lippmann & Steer, 1996). More specifically, the findings of the most recent and only
multi-site treatment outcome investigation in the field to date revealed that children randomly
assigned to trauma-focused CBT as opposed to children assigned to client centered therapy
showed greater improvement with respect to PTSD, depression, behavior problems, shame and
feelings of perceived credibility and interpersonal trust (Cohen, Deblinger, Mannarino & Steer,
2004). Participating parents demonstrated similar superior benefits in response to traumafocused CBT in terms of general levels of depression, abuse-specific distress, parental support
and skills in responding their children’s behavioral and emotional needs. Although there have
been some outcome investigations examining alternative abuse-specific treatments, several
recent critical reviews of the empirical literature have clearly established this trauma-focused
CBT model as the treatment of choice at this time for children who have suffered sexual abuse
and their families (Saunders, Berliner, & Hanson, 2003; http://modelprograms.samhsa.gov.)
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Assessment
What is Involved in Effective Assessment?
Given the range of difficulties children may experience subsequent to sexual abuse, a
thorough pre-treatment assessment can better inform the course of treatment. However, this
assessment should not serve as an investigative evaluation. A forensic evaluation is warranted
when: children are unable to provide a clear disclosure; allegations emerge in a custody dispute;
allegations are recanted; or sexual abuse is suspected but has not been substantiated (Lippmann,
2002). Please see references under Key Readings for a more comprehensive description of
forensic evaluations of sexual abuse.
Before initiating a pre-treatment assessment, clinicians should have clarity regarding the
allegations of sexual abuse. This would include substantiation of the abuse through child
protective services, law enforcement, medical examination or independent forensic evaluation.
The pre-treatment assessment should include both interview and self and other report
standardized measures to assess symptomatology specific to the experience of sexual abuse
including assessments of PTSD, depression, anxiety, behavior problems, sexualized behavior as
well as feelings of shame, responsibility and distrust of others. For adolescents you should also
assess substance abuse, dissociation, suicidality, and self-injury.
Given the importance of caregiver involvement in treatment, one also needs to evaluate
the caregiver’s overall psychosocial adjustment with respect to depression, other severe
psychopathology, substance abuse as well as their level of emotional distress specifically related
to the child’s sexual abuse. Other helpful areas to assess include parental feelings of guilt, fear,
shame, embarrassment and available resources for social support. Because the caregiver will be
involved in implementing behavior management strategies at home, parenting skills should also
be assessed.
Successful implementation of this model necessitates a level of child and caregiver
stability in their own emotional and behavioral functioning as well as their external environment.
For example, severe psychopathology, ongoing family violence, imminent placement change,
and active suicidality should be taken into consideration prior to initiating trauma-focused
treatment. When these difficulties are present, the clinician may recommend other courses of
action and/or treatment so that the above difficulties can be addressed or stabilized prior to the
initiation of trauma-focused treatment.
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Treatment
What Treatments are Effective?
The expansive literature, documenting the potentially devastating emotional and
behavioral impact sexual abuse may have on children, highlights the critical need for
psychotherapeutic interventions for this population that are demonstrably effective. In fact, over
the last decade, considerable progress has been made with respect to the development and
evaluation of evidence based interventions for children who have suffered sexual abuse. Since
1990, a series of pre-post investigations and randomized controlled trials have documented the
efficacy of the trauma-focused cognitive behavioral therapy (CBT) approach to be described here
in both individual and group therapy formats (Deblinger, McLeer & Henry, 1990; Deblinger,
Stauffer & Steer, 2001; Deblinger, Lippmann & Steer, 1996; Cohen & Mannarino, 1996, 1998;
King, et al., 2000). The findings of these investigations have not only demonstrated the superior
benefits of trauma-focused CBT as compared to the nondirective supportive therapy, community
based treatments as well as the passage of time, but the results have also highlighted the
important role nonoffending parents can play in the treatment process. Moreover, it should be
noted that one and two year follow up studies have established that symptom improvements in
response to trauma-focused CBT appear to be long lasting (Cohen & Mannarino, 1998;
Deblinger, Lippmann & Steer, 1996). More specifically, the findings of the most recent and only
multi-site treatment outcome investigation in the field to date revealed that children randomly
assigned to trauma-focused CBT as opposed to children assigned to client centered therapy
showed greater improvement with respect to PTSD, depression, behavior problems, shame and
feelings of perceived credibility and interpersonal trust (Cohen, Deblinger, Mannarino & Steer,
2004). Participating parents demonstrated similar superior benefits in response to traumafocused CBT in terms of general levels of depression, abuse-specific distress, parental support
and skills in responding their children’s behavioral and emotional needs. Although there have
been some outcome investigations examining other abuse-specific treatments, several recent
critical reviews of the empirical literature have clearly established this trauma-focused CBT
model as the treatment of choice at this time for children who have suffered sexual abuse and
their families (Saunders, Berliner, & Hanson, 2003; http://modelprograms.samhsa.gov.)
5
It is noteworthy that some of the basic elements found in the trauma-focused CBT interventions
are incorporated in many of the treatment approaches described in the clinical literature. Authors
from a variety of theoretical orientations report that some type of trauma-focused process is
important to effective treatment with victims of trauma (Benedek, 1985; Terr, 1990; Pynoos &
Nader, 1988; Friedrich, 1996).
What are Effective Therapist Based Treatments?
TF-CBT consists of individual child and caregiver sessions and joint child-caregiver
sessions over approximately twelve 60-90 minute sessions. Generally, the model is considered
short-term but it can be expanded based on the needs of the family. Legal involvement,
reunification with the perpetrator, non-supportive caregiver(s), active suicidality and self-injury
might warrant extended treatment. However, difficulties such as family conflict, school
problems and diagnostic complexity can be addressed in a more general treatment approach.
The model is short-term because it reinforces a strength-based, success-focused approach
to treatment. Often, clinicians feel that sexual abuse requires long-term treatment, especially
when it coexists with other child and family problems. However, research has shown short-term
treatment, that remains abuse-focused, is successful in alleviating significant PTSD, depression
and behavior problems. Additionally, a short-term, strength-based approach counteracts
common attributions of self-blame, responsibility and hopelessness (ruin), teaching children that
the abuse was not their fault; that they can be successful and they can move beyond the sequalae
of abuse, including therapy. A guiding principle of the model is to facilitate open
communication between the child and caregiver. Therefore, in the first session, children and
parents are informed of this approach and explained that information will be shared with one
another unless specifically requested otherwise.
For ease of presentation, the model will be described as having separate components;
however, in practice, implementation of the components (e.g. coping skills, gradual exposure,
psychoeducation, sex education, personal safety) are integrated across sessions. Trauma-focused
work (including gradual exposure) begins in session one with identification and discussion about
feelings associated with the trauma. It is important to note the necessity for a collaborative
relationship between the therapist and client. Despite a structured treatment format, the
foundation of treatment is built on an empathic and empowering therapist-client relationship.
This type of relationship may in and of itself be healing for children and caregivers who not only
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have been betrayed by the perpetrator of the abuse but also may feel helpless negotiating the
larger legal and child protective systems. For a more comprehensive description of the treatment
model, please see Treating Sexually Abused Children and Their Nonoffending Parents
(Deblinger & Heflin, 1996) or Trauma-Focused Cognitive Behavioral Therapy for Children and
Parents (Cohen, Mannarino & Deblinger, 2003).
Child Sessions
Individual child sessions begin by focusing on developing skills that will be necessary
throughout the course of treatment. These skills include a variety of coping skills meant to
address typical problem areas such as anxiety, anger, and interpersonal difficulties. It’s often
useful to start with a skill like emotional expression which provides a baseline of a child’s ability
to accurately identify, label and communicate a range of both positive and negative feelings.
This skill can be taught in a variety of ways including playing feeling charades, using feeling
posters or cards, discussions and roleplays which facilitates rapport-building. Another key skill
that every child should be taught is cognitive coping. The child is taught how feelings, thoughts
and behaviors are connected. Clinicians can teach children that the way they talk to themselves
can make them feel better or worse. Depending on a child’s presenting problems, including
sleep difficulties, fears, aggression or peer victimization, one would provide relaxation training,
visualization, anger management, and/or assertiveness training.
After a sufficient skill base has been established, the next major goal of treatment is to
continue the gradual exposure piece in a more structured way by creating a trauma narrative. A
rationale for the importance of a trauma narrative should be provided to both children and
caregivers. A common analogy one may use to illustrate this point is to compare developing a
trauma narrative to cleaning out a painful wound. For example, if you fall off your bike and cut
your leg you may be tempted to avoid cleaning and caring for the injury which may hurt and take
time away from being with friends. If left untreated, the injury may become infected and even
more bothersome. However, while it may be temporarily painful to open up the wound and
clean it out, it will then be able to heal. Although there may be a scar which will occasionally
remind one of the injury, it will no longer hurt.
The findings of field research conducted by Sternberg and colleagues (1997, 1999)
demonstrated that when suspected victims of child sexual abuse are encouraged to provide
detailed narratives about neutral events, this “practice” experience enhances their ability to
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provide detailed accounts of their abusive experiences. Building on this approach, therapists are
encouraged to utilize this neutral event practice exercise to begin the gradual exposure process as
it communicates an expectation for the child to provide detailed information about events from
beginning to end. In addition, the therapist may encourage children to incorporate into these
neutral narratives what they were feeling and saying to themselves during the event being
described. By beginning the more structured GE process in this manner, children provide a
baseline that reflects their developmental level in terms of their abilities to provide verbal detail
and express feelings and thoughts, while also enhancing their skill in expressing abuse-related
narratives. The therapist should create a preliminary hierarchy of abuse-related events ranging
from least to most anxiety-provoking. Examples of common abuse-related events include: the
first time the abuse happened; the last time; the first person they told; telling child protection/law
enforcement; medical exam; counseling; court and the worst experience. Therapists may
enhance children’s feelings of control by giving them a choice between two events to discuss or
two activities to engage in during each session. Therapists should be careful not to assume what
part of the sexual abuse experience is the most traumatizing for the child. It is possible that
discussing the legal repercussions or the disclosure is more distressing than the physical act of
abuse. More than one event may be discussed and processed in a session given the child’s
comfort level and time.
One approach that facilitates childrens’ narratives is to create a “book” about their
traumatic experience. Each abuse-related event can become a “chapter” in the book. The
therapist should create a calm, quiet atmosphere, free of interruptions so the child can be “in the
moment” as much as possible. The clinician should explain that he/she will be the secretary and
record their words which facilitates the primary goal of allowing the child to tolerate and cope
with his/her distress associated with remembering the event. Another advantage to the therapist
recording the child’s thoughts and feelings is to identify dysfunctional beliefs about the abuse.
These abuse-related beliefs should be processed with the child after completion of the narrative.
Interrupting as little as possible, the therapist may need to prompt for thoughts, feelings
and sensations associated with the event. In addition, if the child stops talking and/or the
narrative is very short, the therapist may need to use prompts such as “What happened next?
Then what? I wasn’t there so tell me more about that.” The therapist should predict for the child
that he/she will not be able to write as quickly as he/she thinks so the child will have to talk
8
slowly to allow the therapist to keep up. Going slowly forces the child to tolerate his/her feelings
longer and allows the therapist to repeat back what is said, facilitating desensitization to
distressing thoughts, feelings and memories. The child’s narrative is reread on several occasions
including after finishing each chapter; after writing additional chapters and at the book’s
completion.
In order to keep the child engaged, the development of the trauma narrative may take
many forms. Therapists are encouraged to be creative and utilize children’s strengths and
interests. For example, narratives may take the form of drawings, poetry, songs, posters,
audiotapes, puppet shows, and talk/radio shows.
The next treatment component is psychoeducation which includes general information
about child sexual abuse, age-appropriate information about sex and sexuality and personal
safety skills. Once again it should be noted that psychoeducation can precede GE and
processing. For example, it may be particularly helpful to introduce general information about
child sexual abuse prior to developing the trauma narrative. Children can use information they
learned from this component to dispute dysfunctional beliefs about the abuse during the
cognitive processing phase. Similarly, if a child is particularly avoidant discussing their abuse
experience, providing age-appropriate sex education first may increase their comfort level
regarding sexually explicit material.
Parent Sessions
The individual treatment with the caregivers mostly parallels the work done with the
child. Thus, coping skills, including emotional expression/regulation, cognitive coping,
relaxation, and anger management, provide a base for being able to process their child’s sexual
abuse experience. As the child is writing the trauma narrative, the therapist begins sharing it
with the caregiver with the goal of helping them process their own thoughts and feelings about
the experience.
Similar to the child’s treatment, particular components are woven across sessions based
on the family’s need. Because children who have experienced trauma are at increased risk for
developing behavioral and/or emotional problems, caregivers are provided education about
behavior management. The therapist works with the caregivers to apply the behavior
management strategies to the particular problems displayed by their child. For the majority of
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families, increasing the caregiver’s use of global and specific praise is an effective behavioral
tool for changing behavior as well as for improving the caregiver-child relationship.
Joint Sessions
In order to ensure successful joint sessions, the child and caregiver should be prepared in
their individual session time by reviewing the task for the joint session and role playing praise
and positive reinforcement. Although the activities for joint sessions will vary depending on the
family and increase in difficulty as treatment progresses, the goals of open communication and
positive interactions remain the same. Initial joint sessions may revolve around discussion about
general sexual abuse information or sex education with the goal of later joint sessions
progressing to discussing and processing the child’s personal sexual abuse experience. The joint
sessions should serve as a model for how caregivers and children can continue to discuss any
difficult topic outside of the realm of treatment. It is important to note that joint sessions are
counterindicated if a caregiver is unable to respond to the child’s trauma narrative in a supportive
manner. This therapist would make this determination based on the caregiver’s response during
individual sessions.
Challenges
As mentioned previously, this approach is meant to be short in duration. It is unlikely
that every challenge the family faces will be addressed. The goal is to provide skills to the
family which are fine-tuned during the course of treatment so that they move beyond therapy and
independently apply them to future challenges.
The involvement of a supportive caregiver is ideal, however, it is not always possible and
children can complete this form of treatment alone assuming that the legal guardian has provided
consent. If unavailable for participation, the legal guardian also may consent to the participation
of another important individual in the child’s life. Since children seem to greatly benefit from
having a supportive adult participate, other individuals whose participation may be considered
include older siblings, grandparents, foster parents, other relatives or close family friends. Nonoffending caregivers who express a desire to help the child but who also express ambivalence
about the child’s disclosure or who are struggling with ongoing feelings for the perpetrator may
respond well to this approach with extended sessions.
The therapist’s commitment to this treatment approach as well as their own level of
discomfort may pose a challenge to treatment progress. It may seem counterintuitive to
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encourage a child to continue an activity that causes him/her visible distress, yet discontinuing
trauma-focused work actually reinforces the child’s avoidance. The success of gradual exposure
is dependent on detailed and often graphic descriptions of the traumatic experience. Therefore,
the therapist needs to be able to tolerate the child’s distress and be aware of his/her own reactions
to the descriptions and the impact they may place on the child. Ultimately, the most powerful
motivator for therapists, initially adopting this approach, may be objective symptom
improvements as well as the not uncommon spontaneous reports from children and parents who
express that talking about the sexual abuse helped them feel stronger and closer as a family unit.
Conclusions
There are two overarching premises to this treatment approach. First, several studies
have demonstrated (Cohen, et al., 2004) that children are not likely to initiate discussions about
their abuse or focus on abuse-related difficulties without the structure and guidance of the
therapist. Therefore, this approach requires the therapist to take a directive role with the
caregiver and child to provide abuse-related information and focus on the family’s traumatic
experience. Part of this directive role necessitates modeling comfort and open communication
about difficult topics such as sexual abuse and sexuality.
Second, the involvement of a non-offending caregiver has been routinely demonstrated to
positively impact outcome for children (Deblinger, et al, 1996). The relationship the child has
with their caregivers greatly outweighs the therapeutic relationship. Therefore, it is the role of
the therapist to work collaboratively with the caregiver and empower them to act as a therapeutic
and supportive resource for the child even after therapy is terminated.
Finally, it is recognized that the field is still very much in its infancy in terms of our
understanding of how to best respond to the psychosocial needs of children and their families in
the aftermath of trauma. Thus, continued research is needed to further clarify the critical
ingredients of treatment and to increase the availability and accessibility of evidence based
models such as the one described above. In fact, efforts are underway to develop more effective
means of disseminating trauma-focused CBT, while also adapting the model to enhance the
growth and adjustment of children facing a wide array of traumatic experiences.
What is Effective Medical Treatment?
To treat PTSD symptomatology, the clinical literature describes the use of various
medications (Famularo, et. Al, 1988; Harmon & Riggs, 1996). Yet, no psychopharmacological
11
intervention in the literature has been rigorously evaluated for its efficacy. No controlled
randomized trials addressing the impact of psychiatric medications on PTSD in children and
adolescents have been done. It is recommended that professionals choose
psychopharmacological interventions for children experiencing PTSD (e.g. SSRI’s, imipramine)
based on co-morbid symptoms such as depression, anxiety and ADHD (AACP, 1998).
What are Effective Self-Help Resources?
*It Happened to Me: A Teen’s Guide to Overcoming Sexual Abuse by Wm. Lee Carter, Ed.D.
*A Guide for Teen Survivors: The Me Nobody Knows by Barbara Bean & Shari Bennett
*How Long Does It Hurt? By Cynthia L. Mather
*An Educational Book About Body Safety by Lori Stauffer, Ph.D. & Esther Deblinger, Ph.D.
*My Body is Private by Linda Walvoord Girard
*Please Tell! Published by Hazelden
*When Your Child Has Been Molested: A Parent’s Guide to Healing and Recovery, Revised
Edition by Kathryn Brohl
Useful Websites:
www.aacap.org/publications/facstfam/sexabuse.htm
www.ncptsd.org/facts/specific/fs_child_sexual_abuse.html
www.apa.org/html/ojjdp/jjbul2001_1_1/contents.html.
www.apsac.org
www.nccanch.acf.hhs.gov/
www.nctsnet.org
www.modelprograms.samhsa.gov/template_cf.cfm?page=model&pkProgramID=90
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Table 1.
Example of one 90-minute early session
Goals
Child –
Individual
Session
• Establish rapport
• General discussion about child’s
interests
• Obtain a baseline narrative about
the child’s experience of a neutral or
positive event
• First have child describe a neutral
event in detail to set example, then
explain why they are coming to
treatment specific to the abuse
• Build emotional expression skills
• Provide education about child
sexual abuse
Caregiver –
Individual
Session
Joint Session
Activities
Time
30-40 minutes
• Feelings charades, feelings games,
make a list of feelings, books, etc.
• Play a (question/answer) game about
child sexual abuse and/or read a book
about child sexual abuse
• Provide treatment rationale – instill
hope
• Highlight the importance of a
supportive caregiver in outcome
• Provide education about child
sexual abuse
• Discuss factual information about
child sexual abuse
• Introduce behavior management
principle of praise
• Teach global and specific praise. Use
examples and role plays
• Demonstrate open communication
about child sexual abuse
• Strengthen caregiver child
relationship
• Card game (question/answer) about
child sexual abuse information
30-40 minutes
10-15 minutes
• Mutual exchange of praise
20
21
Table 2.
Example of one 90-minute session from mid-treatment
Goals
Child –
Individual
Session
• Review rationale for
gradual exposure
• Review child’s gradual
exposure work from prior
sessions
• Reduce distress associated
with the abusive experience
• Continue to add additional
“chapters” to child’s book by
providing choices of topics to
focus on
• Elicit abuse related
thoughts and feelings
• Process and dispute
dysfunctional thoughts
• Reduce distress associated
with the child’s abusive
experience
Caregiver –
Individual
Session
Activities
• Elicit abuse related
thoughts and feelings
• Process and dispute
dysfunctional thoughts
Time
30-40
minutes
• Reinforce education about
child sexual abuse when
disputing dysfunctional
beliefs
• Prepare for joint session
with caregiver. Help child
generate questions for
caregiver and practice praise
for the caregiver
• Share the child’s gradual
exposure work
• Assist in applying cognitive
coping skills to combat
dysfunctional beliefs
• Prepare for joint session
with child. Role play
caregiver’s comments to the
selected “chapter” of the
child’s book as well as praise.
30-40
minutes
• Assist caregiver in
managing child’s behavior at
home
Joint Session
• Promote open
communication about the
child’s experience of abuse
• Provide an opportunity for
the caregiver to model
comfort when discussing the
abuse
• Strengthen relationship
• Child shares a “chapter”
from gradual exposure book
• Mutual exchange of praise
10-20
minutes
22
23
24
Table 2.
Example of one 90-minute session from mid-treatment
Goals
Child –
Individual
Session
• Review rationale for
gradual exposure
• Review child’s gradual
exposure work from prior
sessions
• Reduce distress associated
with the abusive experience
• Continue to add additional
“chapters” to child’s book by
providing choices of topics to
focus on
• Elicit abuse related
thoughts and feelings
• Process and dispute
dysfunctional thoughts
• Reduce distress associated
with the child’s abusive
experience
Caregiver –
Individual
Session
Activities
• Elicit abuse related
thoughts and feelings
• Process and dispute
dysfunctional thoughts
Time
30-40
minutes
• Reinforce education about
child sexual abuse when
disputing dysfunctional
beliefs
• Prepare for joint session
with caregiver. Role play
sharing the “chapter” from the
child’s book as well as praise
for the caregiver
• Share the child’s gradual
exposure work
• Assist in applying cognitive
coping skills to combat
dysfunctional beliefs
• Prepare for joint session
with child. Role play
caregiver’s comments to the
selected “chapter” of the
child’s book as well as praise.
30-40
minutes
• Assist caregiver in
managing child’s behavior at
home
Joint Session
• Promote open
communication about the
child’s experience of abuse
• Provide an opportunity for
the caregiver to model
comfort when discussing the
abuse
• Child shares a “chapter”
from gradual exposure book
• Mutual exchange of praise
10-20
minutes
25
• Strengthen caregiver-child
relationship
26