Cognitive Behavioral Therapy in Child Sexual Abuse Treatment


Psychological and physical traumas have a negative impact on people regardless of their variety and consequences. The fact of their existence is a dark spot on the reputation of humanity. They influence various groups of people, depending on their age, sex, or profession. The separate group of traumas, which is characterized by sexual nature, is widespread and causes many destructive effects.

The effects are more pronounced when the victim of this kind of trauma belongs to the most unprotected group of society – children. The consequences of this kind of trauma can have lifetime critical influence and cause various psychiatric disorders. Moreover, child sexual abuse has a destructive effect on society in general. That is why child sexual abuse is the kind of trauma that should be considered an inadmissible phenomenon in a civilized society.

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Prevalence of the Trauma

First, it is necessary to examine how much this problem is pervasive as well as its emplacement. However, there are some complications, which do not allow specialists to obtain accurate results. The number of cases of child sexual abuse will never be known because of several reasons (Johnson, 2004). The reasons may include the inability of a victim to report properly about an event and provide details. Some of the children do not realize that they have become victims of improper actions because of the lack of knowledge in such an area.

Furthermore, the imperfection of the data-gathering techniques can decrease the accuracy of the research results. In spite of these complications, researches provide the following statistics. In Europe, 33 – 8 % of females and 10-9% of male adolescents have reported that they experienced sexual abuse at least once in the lifetime (Johnson, 2004). In the USA, 78% of the child population were the victims of this trauma, which is equal to 879 000 individuals (Johnson, 2004). About 42-3% of women became a victim of non-contact abuse in Australia and 35-7% experienced a contact one (Johnson, 2004).

The lowest rates are observed in Greenland. It is estimated that 8% of women population and 3% of men have experienced sexual abuse in this region (Johnson, 2004). UNICEF’s fact sheet on this problem states that it is the kind of the abuse, which occurs in every country of the world, and represents an issue, which recognizes no social, economic, cultural boundaries (Sabella, 2016). Therefore, according to statistics, thousands of children are under the threat of becoming a victim of sexual abuse around the world annually.

Complex Trauma

There is a need to clearly define the issue of child sexual abuse. This term includes several sexual activities, such as attempted intercourse, oral-genital contact, touching of the genitals directly or through the clothes, demonstrating images and videos of a sexual character, and child exploitation in prostitution (Putnam, 2003). Furthermore, conversations of sexual nature also belong to the abuse.

Specialists divide traumas into two categories – simple and complex. Complex traumas are the kind of traumas, which are characterized by the increasing impact over time and repeated nature in many cases. Child sexual abuse appertains to complex traumas because of some significant factors. One of these factors is the effects of the trauma on the children and their families. It can damage relationships in the family and cause harm to a child’s psychological and physical health. The child can develop anxiety disorders or even the Post Traumatic Stress Disorder and behavioral problems. Child sexual abuse is considered to powerfully contribute to adult psychopathology (Mullen, Martin, Anderson, Romans, & Herbiso, 1996).

Moreover, it can cause damage to the society in general. An abused child will most likely not be able to become successful in his/her education. In such a way, he/she will become an adult, who cannot work to the best of his/her abilities (The National Child Traumatic Stress Network). This has a negative impact on the economy. It is logical that such an adult will not create his/her own family. Wyatt and colleagues found that women, who had experienced abuse in childhood, are most likely to have relationships with the shorter duration and greater amount of the sexual partners (Fergusson, Boden, & Horwood, 2008).

This affects the demographic situation and the general level of morality. Probably, an adult who was harmed in childhood will develop psychological deviations. The worst case is when childhood trauma turns a person into a criminal or someone who is able to do with children the same things, which happened to him/her in his/her early years of life.

Vulnerable Groups, Symptoms, and Reactions to the Trauma

The number of victims differs, depending on the age, gender, disabilities, and social status of the child. Girls have 2.5 to 3 times higher risk than boys to become a victim of this kind of abuse (Putnam, 2003). About 75 – 82 % of the victims are females. The risk of sexual abuse elevates with age (Putnam, 2003). Researches show that among all the victims, 10% of children were aged between 0 and 3, 28.4% of children were from 4 to 7 years old, while ages 8 to 11 account for about a quarter of cases (Putnam, 2003). In the third of cases, 35.9%, of children were 12 years old and older. Moreover, the age factor may vary with gender differences. The risk is higher during the earlier years and keeps longer for the girls (Putnam, 2003).

The disability is one more factor that raises the risk of being involved in child sexual abuse. Disabilities have the most significant effect on the risk increase, as they produce difficulties in communication and dependency. They include mental retardation, blindness, and deafness. Data analysis shows that the disability factor depends on gender as well. The amount of the boys, who experienced child sexual abuse, is noticeably bigger among those, who have a physical disability compared to others (Putnam, 2003). One more risk factor is socioeconomic status. It is assumed that social position does not influence the number of children experiencing this trauma. However, a number of child sexual abuse cases are reported to Child Protective Services from families of lower socioeconomic status (Putnam, 2003).

The race and ethnic factors do not seem to raise the risk of being involved in the abuse. However, these factors influence the symptoms of trauma (Putnam, 2003). The family composition has a huge influence on the increase of the risk. The presence of a stepfather doubles the risk of child sexual abuse for girls (Putnam, 2003). Moreover, it includes the probability of being abused not only by the stepfather but also by the other male. Some researches claim that parental impairments, such as maternal illnesses, alcoholism, extended absence, conflicts, social isolation, and cruel punishments are serious risks for sexual abuse (Putnam, 2003).

Symptoms of the abuse are very diverse depending on the strength of the impact this trauma has on children. There is a huge amount of factors, which are responsible for that. These are the age and gender of a victim, his/her ethnic and racial background, the personality of the penetrator, and the type of sexual abuse. However, it is possible to outline the most common symptoms. Indicators of the history of sexual abuse are inappropriate sexual knowledge or interest, and acting out sexually (Sabella, 2016). A lot of sexual activities and behaviors are part of the child development being natural for children. However, some studies have found out that abused children get engaged in more sexualized activities compared to the non-abused ones (Hornor, 2010).

In general, girls embody internalizing behavior, such as eating disorders and depression, while the externalizing behaviors, such as heavy drinking and delinquency, are more typical for boys (Hornor, 2010). The fear of adults, specific places, or activities, which is produced by the feeling of shame and confusion is the sign of abuse (Sabella, 2016). In addition, if older children behave like younger ones, which includes bed-wetting or thumb sacking, it is the sign of the abuse.

Reactions to the trauma differ a lot too, depending on age, gender, and other influential circumstances. The most frequent reactions to the abuse are fear, nightmares, clinging behavior, general misbehavior, and poor school performance. If the abused child does not get help and support from his/her parents and specialists, he/she will be under the risk of developing mental disorders. Many studies connect the child sexual abuse with psychiatric disorders, such as Post Traumatic Stress Disorder, suicidal ideation, borderline personality disorder, depression, and substance abuse (Hornor, 2010).

The cases of reported psychiatric problems during a lifetime are much higher for the people, who have experienced abuse, than for those, who have not. In the case of abused women, this rate is 56%, while in the case of men, it equals 47%. At the same time, the rates for the non-abused women are 32% and for men -34% (Hornor, 2010).

Sexual abuse can lead to the development of Post Traumatic Stress Disorder (PTSD). There is a list of the criteria for PTSD, which was offered by the American Psychiatric Association. It includes such parameters as the experience of the traumatic event that leads to the real threat of self-injury, helplessness, horror, agitated and disorganized behavior for children (Hornor, 2010). Scientists identify it as the permanent re-experience of the traumatic event by the repetitive dreams of the event, the repetitive play of the event, nightmares, and intense psychological distress (Hornor, 2010). This type of disorder can result in behaviors, which are pernicious for the victim’s life. Commonly, PTSD develops only in several months or even years after the traumatic event.

Depression can develop in pre-adolescent children, adolescents, and adults, who have become a victim of sexual abuse (Hornor, 2010). The risk of the development of depression increases when a child grows up for both boys and girls. Depression causes such effects as an increase in appetite, weight gain, and hypersomnia. The experience of child sexual abuse increases the possibility of suicide throughout life. The risk of it is significantly higher for the abused boys than the abused girls (Hornor, 2010).

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Impacted Communities and Systems

As stated above, families, which are characterized with the absence of one of the parents, or the presence of the maternal illnesses or alcoholism, the presence of the stepfather, or presence of the parent, who has experienced a child sexual abuse in his childhood, increase the risk of this kind of trauma. That is why specialists and nurses should be aware of how to provide help and professional support in case of necessity.

Strategies of Intervention Plan

Not all of the children, who had experienced child sexual abuse, develop psychiatric problems or disorders (Putnam, 2003). According to researches, 40% of children have a few or even no symptoms at all. However, the biggest part of the victims suffers from the consequences of the trauma throughout their lifetime. Specialists and psychotherapists develop treatment programs to minimize the damage caused by the trauma and to help the victim to return to normal life.

Child sexual abuse is the area, where many rigorous researches devoted to the treatment measures were carried out. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is one of the ways of treatment with the strongest evidence base for childhood trauma and maltreatment currently covering all types of childhood traumas (Olafson, 2011). However, originally it was oriented on the victims of the child sexual abuse.

TF-CBT is a component-based approach, where the central component is the creation of the narrative about the trauma experienced by the child, using language, poetry, dancing, or artwork (Olafson, 2011). Furthermore, it offers psychoeducation about the child sexual abuse and other traumas for parents and children, as well as coping and stress reduction strategies. The session ends with the child-parent sharing of the child’s safety plan and trauma narrative (Olafson, 2011). Moreover, parent session includes training in the implementation of simple and effective sexual behavior rules.

The TF-CBT module includes three phases. During the first phase, the sessions are supposed to enhance children’s affective, biological, and behavioral self-regulation with the skills-building components. This phase also includes the improvement of the parental skills of the child support, and enhancement of the caregiving components (Mannarino et al., 2012). The first phase is aimed at influencing the child’s reminders of the trauma.

The second phase is called the trauma narrative. During this step of the treatment, the child cognitively processes his/her personal trauma experience. Finally, the last phase is dedicated to the planning of the child’s safety. These phases combine behavioral management training and family therapy (Mannarino et al., 2012). The first of them is aimed to identify and cover the undesired behaviors with the use of cognitive therapy, which is oriented towards understanding and changing unwanted thoughts and feelings (De Vries, Peak, & Lawson, 2014).

TF-CBT was the only treatment, which earned the status of being “well supported and efficacious” in a review of a 24 child treatment founded by the Office of Victims of Crime (Saunders, Berliner, & Hanson, 2003). Furthermore, it gained the reputation of being “well established” from Silverman and colleagues. Abused children, who were treated with the help of the TF-CBT, manage to successfully overcome depression, shame, PTSD, and behavior problems compared to others. Parents also showed greater success in dealing with depression, providing support for the child, coping with abuse-specific distress, and undergoing effective parenting practices (Olafson, 2013). The effectiveness of the TF-CBT is illustrated by the one-year follow up, which showed that improvements in children and parents continued (Olafson, 2013).

Another treatment model, which is considered as effective as the previous one by many studies, is cognitive-behavioral therapy (Cohen & Mannarino, 1996). There are some variants of this model. The first variant is focused on the child only, while the second one is focused on the parents only, and the third is focused on both parents and child. The last one is a standardized care model. The researches among 100 abused children showed that all groups achieved significant improvement. However, the first model, where the child is the only focus of the treatment, proved to be the most effective (Greenspan, Moretzsohn, & Silverstone, 2013).

CBT includes cognitive and behavioral therapies and has a strong impact on resolving anxiety and mental disorders (Cully & Teten, 2008). The main idea of the therapy is that it is difficult to change the emotional state directly, so there is a need to change thoughts and behaviors, which produce stressful emotions. This model of treatment helps to establish the skills of identifying how situations and thoughts influence emotions in order to improve the disagreeable emotions.

The CBT model includes four stages, which are called the Assessment stage, Cognitive stage, Behavior stage, and Learning stage. Each of them has its specialized tasks. The first phase of the treatment is responsible for the installation of the trusting relationships between the victim of the abuse and the therapist. During this stage, the therapist can tell about the program of the future treatment and ask the child about his/her personal assessment of the event that happened to him/her. The Cognitive stage is aimed at helping the child to control his/her thoughts through the events in the past. The CBT does not focus on the past.

Instead, it uses it for the understanding of the current thinking process. The child and therapist explore together the way of the patient’s thinking investigating the reasons for producing it. The child can be offered to write down his/her thoughts every day. During the third phase of the CBT, the abused child should learn how his/her thoughts influence his/her behavior. At this stage, the therapist helps to manage the symptoms and improve the behavior. At the Behavior stage, the child is offered to communicate with new people in some new ways. The Learning stage is the final phase of the CBT.

However, the treatment does not stop at this stage. Through the CBT, the child should learn how to change the attitude to him/herself and how to manage the symptoms and behave in different situations. Such an organization of the treatment helps abused children to overcome his/her negative experience along with its consequences.

There are many studies dedicated to finding out how much CBT is effective in terms of dealing with the consequences of child sexual abuse. There is evidence of the improvement of the behavioral problems, decreasing the sexual behavior, managing with the PTSD symptoms, and dealing with depression, anxiety, and fear (Greenspan et al., 2013). Moreover, there is evidence of the improvement of coping and safety skills and trust. Children, who were treated with the help of CBT, acquired the ability to shift feelings of shame and guilt. In addition, CBT helps to overcome aggression. In such a way, the abuse-centered CBT is considered by some studies to be the best-documented type of treatment for children, who experienced a child sexual abuse (Putnam, 2003).

Empirically and clinically, it was found out that there are many potential barriers to accessing the treatment of abused children. They can be divided into several groups. These are practical treatment barriers, family-related treatment barriers, individual treatment barriers, and sexual abuse specific barriers (Holm & Hansen, 2007). The practical barriers include the low socioeconomic status of the family, transportation problems, lack of time, and the number of children in the family. The family barriers include the level of family stress, social isolation of the parents, and family health problems. The history of physical abuse, the mother’s supportiveness of treatment, custody conflict between family members also belong to this group of the barriers.

The desire of the family to repress unpleasant memories of the abused child with the aim of saving a respectable reputation stands on the way of the child’s treatment. The individual section includes treatment acceptability, self-defeating behaviors, and cultural differences. Furthermore, it depends on age, gender, and culture. Statistics claim that younger victims are less likely to disclose their emotions. The reason for that is the lack of communication skills of the younger children (Esposito, 2005). However, they are inclined to disclose their feelings in other non-verbal ways.

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Researches show that girls are more likely to disclose their emotions in the cases of being abused than boys. This is explained by the fear of boys to be recognized as the homosexuals because they are often abused by other males (Esposito, 2005). Certain cultural terms, such as modesty, virginity, women’s honor, shame, and taboo can become the barriers of the treatment. The last group of the potential treatment barriers includes the parental history of sexual abuse, continued parental relationships with a penetrator, and parental level of child behaviors. The trusting relationship with the penetrator contributes to the reluctance to talk about the abuse. In this situation, the abused child is afraid of not being trusted and feeling guilty.

In addition, loyalty to the penetrator contributes to the silence of the victim. Researches claim that individuals who are well known by the child (Esposito, 2015) commit about 90% of the cases of child sexual abuse. In such a way, all of these cases are under the threat of staying unknown and the child is likely not to get the appropriate help and support.


Child sexual abuse is trauma, which affects children of all ages and genders around the world. It causes temporary and long-termed consequences. These are physical traumas and various psychiatric disorders, such as depression, Post Traumatic Stress Disorder, suicidal thoughts, and anxiety. Due to its destructive effects on the life of the individual and society, the specialists continue to develop various treatment programs and conduct studies to minimize the damage caused by the abuse to help the victims to return to normal life.

The most popular among the treatment measures are Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Therapy. These models are used to overcome the potential barriers during the treatment and to change the thinking and behavior of the abused children.

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