Child sexual abuse II: treatment

Barry Nurcombe, Sally Wooding, Peter Marrington, Leonard Bickman,

Gwenneth Roberts

Objective: To evaluate the scientific literature concerning the treatment of child

sexual abuse.
Method: A critical review of the scientific literature.
Results: There are only nine published research studies in which subjects were
randomly assigned to an index treatment or treatments and a comparison treatment
or no-treatment control group. In seven of the studies, the index treatment exceeded
the control or comparison group in regard to treatment outcome; in two studies it did
not. The successful treatments involved group therapy, combined individual and
group play therapy and cognitive behaviour therapy.
Conclusions: Treatment should be based on an explicit conceptual model of the
psychopathology of sexual abuse. The University of Queensland Sexual Abuse
Treatment Project, which is based on a transactional model, is described.
Key words: child sexual abuse, treatment.

Australian and New Zealand Journal of Psychiatry 2000; 34:92–97

Finkelhor and Berliner [1] have reviewed published
research into the treatment of sexual abuse. Casting
their net very broadly, they were able to locate 29
studies that used pre- and post-standardised measures
to assess change in the sexually abused child or parent
following treatment. Sample sizes varied widely
(from five to 156), as did age range (from 3 to 18
years) and sex of subjects (13 involved female sub-
jects only; two included only male subjects; and 14,
Barry Nurcombe, Professor of Psychiatry and Director (Correspon-
dence); Sally Wooding, Co-investigator; Gwenneth Roberts, Research
Manager
Child and Adolescent Psychiatry, University of Queensland,
Mental Health Centre, Royal Brisbane Hospital, Herston,
Queensland 4029, Australia.
Email: bnurcombe@psychiatry.uq.edu.au
Peter Marrington, Senior Therapist
P.A.C.T. (Protect All Children Today), Child Witness Court
Support Clinic, Woodridge, Queensland, Australia
Leonard Bickman, Professor of Psychology and Professor of Public
Policy
Peabody College of Vanderbilt University, Nashville, TN, USA
Received 12 March 1999; accepted 14 July 1999.
both sexes). Seventeen studies were uncontrolled and
five were quasi-experimental. Only seven of the
studies reviewed by Finkelhor and Berliner involved
random assignment to an experimental treatment
program and a comparison or control group.
The methods of treatment employed in these
studies varied considerably: music therapy, drama
therapy, structured or psychodynamic group
therapy, family therapy, individual or group
cognitive–behaviour therapy, stress-inoculation
and graded exposure therapy, psychodynamic indi-
vidual psychotherapy, multifaceted therapy, crisis
intervention, non-directive supportive therapy, and
‘mixed, unspecified’ treatments. The standardised
measures used in these studies to estimate the effect
of treatment varied widely; for example, the follow-
ing variables were assessed: self-confidence,
depression, anger, emotional pain, hostility, anxiety,
posttraumatic stress disorder, avoidance, dissocia-
tion, sexual concerns, self-esteem, self-concept,
social competence, locus of control, maternal
depression, parental psychopathology, family con-
flict and parental practices.
 B. NURCOMBE, S. WOODING, P. MARRINGTON, L. BICKMAN, G. ROBERTS
Of the 17 uncontrolled studies, 13 found signifi-
cant improvement from pretest to post-test. Of the
five quasi-experimental studies, three found that the
experimental program had produced a more
favourable outcome on post-test than a comparison
or no-treatment group. Of the seven fully controlled
studies, four demonstrated the superiority of one
treatment over its comparison or no-treatment
control group. The controlled studies (together with
two more recently published) will be described in
more detail in this paper.
Controlled studies
Three [2–4] of the nine controlled studies we could
find have not been published other than in
Dissertation Abstracts. They will be described first.
Baker [2] compared the effect of a 10-week indi-
vidual psychotherapy program (n = 15) with that of a
6-week group therapy intervention (n = 24) on
female outpatient abuse victims, 13–17 years of age.
Standardised measures of self-concept, anxiety and
depression were employed. The results of group
therapy exceeded those of individual therapy with
regard to self-concept but not anxiety or depression.
Burke [3] compared the effect of a 6-week struc-
tured group therapy program (n = 12) with that of a
waiting list no-treatment control group (n = 13).
Subjects were female outpatients, 8–13 years of age.
At the end of treatment and at follow up, the treat-
ment group exhibited less psychopathology than the
control group on standardised measures of emotional
distress, anxiety and depression.
Perez [4] compared the effects of a 12-week indi-
vidual play therapy program (n = 18), a 12-week
group play therapy program (n = 21), and no-
treatment (n = 16) on outpatient subjects of both
sexes, 4–9 years of age. Both treatment groups
exceeded no-treatment in regard to standardised
measures of self-concept and internalised locus of
control, but there were no significant differences
between the effects of the two treatment groups.
Verleur et al. [5] compared the effect of a 6-month
sex-education group therapy program (n = 16) with
that of a matched no-treatment control group (n = 14)
on female subjects, 13–17 years of age, who had
been placed by the court in a residential treatment
facility. The children in group therapy had more
favourable scores at 6 months with regard to self-
esteem and knowledge of sexual anatomy, physiology,
venereal disease and birth control.
Monck et al. [6] randomly assigned referred out-
93
patient children 4–16 years of age, of both sexes, to
one of two treatment programs of 9 to 12 months’
duration: family treatment, consisting of regular
family meetings at 4–6 week intervals (n = 25), or
family treatment plus group therapy (n = 22). In group
therapy, family members separately attended weekly,
6 to 20-week groups specific to their role in the family,
sex, and age. All families received community
network support. Subjects were assessed at baseline
and 12 months using standardised measures of behav-
iour at school, general symptomatology, depression,
self-esteem, and perceived competence. There were no
statistically significant differences between the
outcome measures of the two treatment programs.
Berliner and Saunders [7] compared a 10-week
sexual-abuse-specific structured educational group
therapy program (n = 48) with a similar program to
which were added stress inoculation and graded
exposure (n = 55). The subjects referred were out-
patients, of both sexes, aged 4–13 years. The pro-
grams were modified appropriately for 4–6, 7–10,
and 11–13 year olds. In both groups, each week’s
session was devoted to a different topic (e.g. express-
ing feelings about the abuse, the offender, family and
friends; the impact of disclosure; self-esteem; body
awareness and sexuality; and prevention and termi-
nation of unwanted contact). In the second program,
stress inoculation, progressive relaxation exercises,
the ‘quieting reflex’, thought-stopping skills, and
graduated exposure were added to the structured edu-
cational program. Both treatment programs were man-
ualised, and all treatment sessions were audio-taped
and checked in order to ensure treatment fidelity. The
outcome was assessed at pretest, post-test, 12 months,
and 2 years with six standardised instruments related
to general fears, fears related to sexual abuse, anxiety,
social competence, general symptomatology, depres-
sion and sexual behaviour. Participants in both groups
improved significantly in anxiety, depression, general
symptomatology and sexual behaviour, but not in
general or abuse-related fearsor social competence.
However, there were no significant differences
between the two groups in the magnitude or rate
of improvement on any of the measures. A subset of
children (5–15%) deteriorated over the 2 years, while
another subset did not improve. Berliner and Saunders
raised the question of whether children who are
asymptomatic at pretest should be treated.
Deblinger et al. [8] randomly assigned 100 fam-
ilies of school-aged abused children of both sexes to
one of three 10-week treatment conditions (child
only, mother only, or child and mother together) or
94 CHILD SEXUAL ABUSE II: TREATMENT
to a community control condition. In the three treat-
ment conditions, cognitive–behaviour therapy targeted
posttraumatic stress disorder. Treatment outcome
was assessed at pretest and post-test with standard-
ised measures of general symptomatology, anxiety,
depression, posttraumatic stress disorder and parent-
ing practices. Children in the treatment program that
involved both mother and child demonstrated greater
reduction of externalising behaviour, depression,
and posttraumatic stress disorder symptoms. The
child-only treatment resulted in greater improvement
in the symptoms of posttraumatic stress disorder
whereas the mother-only treatment selectively miti-
gated the depression and externalising behaviour of
the child. This study appeared in the literature fol-
lowing Finkelhor and Berliner’s review [1].
Cohen and Mannarino [9] compared the effect of
a 12-week, abuse-specific, structured, cognitive–
behaviour therapy program (n = 33) with that of a
12-week, non-specific, non-directive supportive pro-
gram (n = 28). Subjects were referred outpatient chil-
dren of both sexes aged 3–6 years, who had been
sexually abused. The cognitive–behaviour therapy
program involved both parent and child. Parental
objectives involved resolving the following issues:
ambivalence concerning belief of the child; parental
feelings toward the perpetrator; attributions concern-
ing the abuse; feelings that the child is damaged; man-
agement of inappropriate child behaviour, fear and
anxiety; and the parent’s experience of abuse (if
appropriate). The child’s objectives concerned: safety;
assertiveness; learning the distinction between appro-
priate and inappropriate touching; abuse attributions;
resolution of feelings toward the perpetrator; reducing
regressive behaviour; and coping with fear and
anxiety. The cognitive–behaviour interventions
employed included cognitive reframing, thought
stopping, the use of positive images, contingency
reinforcement, parental training and problem-solving.
The contrasted non-specific treatment program was
designed to provide support, build rapport, and
encourage the expression of feeling through empathy,
reflective listening, supportive statements and clarifi-
cation. Clinicians were trained specifically in one or
other program. Both treatment programs were manu-
alised and the fidelity of treatment implementation
checked by audio-tape. Subjects were assessed at
baseline, at completion of treatment, and at 12-month
follow up, using standardised measures of social com-
petence and general symptomatology, sexualised
behaviour, and a parental count of the frequency of
episodes of problematic behaviour during the previous
week. There were significant differences in outcome
between the effects of the two treatment programs:
cognitive–behaviour therapy was superior in regard to
its effect on total symptomatology, internalising symp-
toms, sexualised behaviour and weekly-recorded
problematic behaviour.
Cohen and Mannarino [10] have recently com-
pared the effectiveness, for adolescents, of a 12-week
cognitive–behaviour program (n = 30) with that of a
12-week non-specific therapy program (n = 19).
Subjects were outpatients of both sexes aged 7–14
years, referred within 6 months of having experi-
enced independently validated sexual abuse. Treat-
ment outcome was assessed before and after
treatment with standardised measures of symptoma-
tology and social competence, anxiety, depression,
and sexual behaviour. The cognitive–behaviour
therapy program targeted depression; anxiety; the
connections between thoughts, feelings and behav-
iour; and inappropriate behaviour associated with the
abuse. The cognitive–behaviour therapy program
also addressed parental emotional distress and guilt,
the capacity of the parent to provide adequate support
to the child and parental behaviour management.
Both treatment programs were manualised, and the
fidelity of implementation monitored by audio-tape.
Therapists switched programs at the midpoint of the
study. The cognitive–behaviour program exceeded
the non-specific program in regard to depression and
social competence but not sexual behaviour, sympto-
matology, or anxiety. The drop-out rate from this
study was high (40%), particularly from the non-
specific therapy group, and may have been respon-
sible for the somewhat disappointing results.
Recommendations
After their review of treatment research in child
sexual abuse, Finkelhor and Berliner [1] came to the
following conclusions. Some abused children, despite
treatment, either do not improve or get worse. The
optimal duration of treatment is unclear, and the
drop-out rate a serious problem. Given the diversity
of psychopathology following child sexual abuse, it
is unlikely that one kind of treatment will suit all. It is
unclear whether (or which) asymptomatic children
should be treated. Boys are harder to treat than girls.
Finally, intrafamilial sexual abuse usually occurs in a
setting of personal, familial and community problems
all of which may need therapeutic intervention.
Finkelhor and Berliner [1] recommended the fol-
lowing directions for future research. There is a need
 B. NURCOMBE, S. WOODING, P. MARRINGTON, L. BICKMAN, G. ROBERTS
for properly controlled studies, with sufficiently
large sample size, followed for a sufficiently long
time. The index treatment or treatments should be
specified, abuse-specific and implemented with high
fidelity to the design of the treatment. Pre- and post-
follow up measures are required, from a variety of
sources, tapping the full range of abuse-related phen-
omena. The non-offending parent needs treatment as
well as the child. Sexualised behaviour, aggression,
impulsivity and depression probably require targeted
intervention because, although these behaviours
may arise from the abuse experience, they are self-
perpetuating. Finally, treatment should be based on
an explicit conceptual model of the psychopathology
of child sexual abuse. The treatment program to be
described next addresses all these recommendations.
The University of Queensland program for
the treatment of child sexual abuse
The University of Queensland (UQ), in collab-
oration with Protect All Children Today (PACT)
(Queensland), has been funded by the National
Health and Medical Research Council (NHMRC) to
develop treatment programs and evaluate the impact
of treatment for child sexual abuse. As our therapists
are trained community clinicians, this is not a
laboratory-based efficacy study but, rather, a clinic-
based action research effectiveness study.
Conceptual model
The UQ/PACT Project is based on a modification of
Spaccarelli’s [11] transactional model described
in the previous paper. In this model (see figure 1),
antecedent factors operating prior to the abuse (e.g.
Figure 1. A conceptual model of the
pyschopathology of child sexual abuse.
95
exposure to domestic violence, physical abuse or
neglect) interact with abuse stressors (e.g. the propin-
quity of the abuser, the frequency and duration of
abuse, genital penetration and coercion or threat)
and post-disclosure stressors (e.g. quality of parental
support, psychopathology in the non-offending parent
and the necessity to testify in court). All these factors
influence the child’s mediating factors (potentially
generating maladaptive attitudes to the self and
others, a traumatic state, affect dysregulation, disin-
tegration of the self-system, and maladaptive coping
style). It is through the mediating factors that child-
hood outcome (in terms of adaptive functioning and
symptomatology) and adult outcome (adult adaptive
functioning and symptomatology) are determined.
As treatment intervention cannot affect antecedent
or abuse-related factors, it must target post-disclosure
stressors and mediating factors, for example: (i) the
quality of parental support; (ii) parental attributions
about the abuse; (iii) parental psychopathology
(especially reactivated conflict concerning past
sexual abuse) as reflected in parental coping style;
(iv) the stress of the child of testifying in court; (v)
maladaptive attitudes toward the self (e.g. of being to
blame for the abuse, of being bad or damaged or of
being powerless); (vi) maladaptive attitudes to others
(e.g. that others cannot be trusted or that they must be
placated sexually); (vii) traumatic state (as manifest
in posttraumatic stress disorder); (viii) dysregulation
of affect, impulse and self; and (ix) maladaptive
coping style (particularly denial, suppression, avoid-
ance, dissociation, externalisation and inappropriate
tension-reduction).
Successful treatment, therefore, should be reflected
in an improvement in, or alleviation of, the above
problems, together with the adoption by the child of
a more adaptive coping style (i.e. disclosure, support-
seeking and cognitive restructuring).
Sample
Subjects are victims of substantiated cases of
sexual abuse, of either sex, 6–16 years of age,
referred from the police or child protection (SCAN)
teams in south-east Queensland. Exclusion criteria
are as follows: children with verbal IQ less than 70;
those who are not living with a caregiver; those who
are expected to testify in court; those who continue to
live at home with the offender; and those whose
experience of sexual abuse occurred over 2 years
before referral. We plan to recruit 200–300 families
over an 18-month period.
96 CHILD SEXUAL ABUSE II: TREATMENT
Treatment programs
This study compares two contrasting, 18-week,
manualised treatment programs: a cognitive–
behaviour therapy program and a family therapy
program.
The cognitive–behaviour therapy program pro-
gresses in three 6-week phases. In Phase I, Relaxation,
Reframing and Stress Management, child and family
are oriented to the program, encouraged to externalise
and reframe their problems, informed about the
relationship between stress and symptomatology,
assisted to express and differentiate their emotions and
trained in the identification and expression of feelings
and the use of relaxation. In Phase II, Resolving
Anxiety and Depression, child and parent separate.
The program is modified as appropriate for 6–11 and
12–16 year old subjects. The child undertakes stress
inoculation and graduated imaginal exposure, con-
trolling tension through relaxation, thought stopping,
positive imagery, alternative behaviours, contin-
gency reinforcement, assertiveness and problem
solving. Dysfunctional thoughts are challenged and
alternatives explored. The child keeps a journal and
completes homework assignments. During Phase II,
the parent is assisted to support the child and to
encourage him or her to complete homework assign-
ments. The parent is educated concerning the origin
of anxiety and depression and its behavioural man-
agement. In Phase III, Resolving Residual Problems,
parent and child come together to address issues
relating to sexualised behaviour and anger manage-
ment via both behaviour therapy and cognitive
therapy techniques. The importance of helpful
thoughts and alternative behaviours is stressed.
The family therapy program is derived from
cybernetics-based and structural family therapy. It,
too, has three 6-week phases. Phase I, Relaxation,
Reframing and Stress Management, is similar to the
first phase of the cognitive–behaviour therapy
program. In Phase II, Parenting Issues and Family
Functioning, child and parent stay together while the
principles of effective parenting (such as consistency
and encouragement) are imparted and implemented.
In Phase III, Application and Consolidation, child
and parent raise any further problems they wish to
change, and these are dealt with through externalisa-
tion, reframing and relaxation.
The two programs differ in that the family therapy
program keeps child and parent together throughout
the 18 weeks, whereas the cognitive–behaviour
program separates them in Phase II. The cognitive–
behaviour therapy program uses graded imaginal
exposure in Phase II and a combination of cognitive–
behaviour therapy techniques and behaviour modi-
fication in Phases II and III. In contrast to the
cognitive–behaviour therapy program, the family
therapy program does not ask the child to examine
traumatic memories and their associated affects and
does not use cognitive–behaviour techniques to deal
with such issues; instead, if the child’s traumatic
memories emerge in the course of treatment, they are
dealt with by externalisation, reframing and stress
management.
Theoretically, the cognitive–behaviour therapy
program should have an impact on outcome superior
to that of the family therapy program because it
directly addresses sexual trauma by the use of
specific therapeutic techniques.
Clinicians
The clinicians who implemented the two programs
have been recruited from 14 different child and youth
mental health clinics and from three non-government
agencies in south-east Queensland. Each clinician
is trained in a 3-day workshop to implement one of
the two programs. Treatment fidelity will be assessed
by random audio-tape audit of different therapeutic
sessions.
Evaluation
At baseline, 18 weeks, and 12 months the follow-
ing domains are assessed: parental psychopathology;
the parent’s reaction to the child’s disclosure of
abuse; the child’s social competence and general
symptomatology; dissociation; posttraumatic symp-
tomatology; anxiety; depression; sleep disturbance;
hyperactivity; aggressiveness; sexualised behaviour;
attitudes to self, others and the abuse; attachment;
self-esteem; and defensive style. Between Phases II
and III, in order to select the foci of Phase III, we
check whether or not the child is still exhibiting sex-
ualised, aggressive, or impulsive behaviour.
Conclusion
An analysis of research into the treatment of child
sexual abuse suggests that there is, as yet, no convinc-
ing evidence that any treatment is effective.
Contemporary opinion that cognitive–behaviour
therapy represents the treatment modality of choice is
based on two controlled studies [9,10], conducted in a
 B. NURCOMBE, S. WOODING, P. MARRINGTON, L. BICKMAN, G. ROBERTS
labaoratory setting, with children aged 4–6 and 7–14
years, respectively, whose progress was assessed by a
relatively limited evaluation system, and on a third
controlled study [7] that focused primarily on whether
child or parent should be treated alone or together. In
a fourth controlled study [6] with a wider age
range (4–13 years), it could not be demonstrated that
cognitive–behaviour therapy provided benefits
beyond those accrued by educational group therapy.
As Finkelhor and Berliner [1] point out, aside from
the preferred modality of intervention, the desired
duration and frequency of therapy are unclear. Other
uncertainties concern the context of treatment.
Should therapy be conducted in an individual, family
or group context? Is it essential (or even desirable) in
all cases for the child to explore his or her memories
concerning the abuse experience? When (if ever)
should treatment be offered to an asymptomatic
child? How should parental psychopathology (partic-
ularly emotional disturbance arising from unresolved
conflict concerning past sexual abuse) be dealt with?
Should parental problems be part of the child’s
therapy or should the parent be referred elsewhere for
treatment? How should the therapist deal with the
child’s past or present exposure to emotional neglect,
lack of intellectual stimulation, physical abuse, or
domestic violence: problems that often precede or
accompany sexual abuse? Can children with
impaired verbal intelligence benefit from psycho-
dynamic psychotherapy or cognitive–behaviour
therapy? If not, how can the children be prepared in
order to benefit from verbally oriented therapy?
Finally, how should the index treatment be con-
trolled? If a no-treatment or ‘usual services’ control
group is ethically or politically unacceptable, is it
possible or desirable to compare the index treatment
with another treatment that is more than a ‘dummy’?
Questions abound. As has already been said, sexual
abuse is an experience, not a disorder. Its manifesta-
tions and contexts are quite diverse. For these
reasons, it is not likely that a ‘one size fits all’ treat-
ment will work. We seek the criteria that will deter-
mine how the central model of treatment should be
modified to suit the individual case. In the long term,
the clinician’s task will be to select treatment goals
for the particular case and to design an individu-
alised, multifaceted, evidence-based treatment
program. This is a technically different task from that
associated with designing an experimental treatment
program and pitting it against a control or compari-
97
son treatment. However, it will not be possible to
design individualised treatment plans until it is
known what generic treatments work best for which
children with which problems.
Finally, it is not clear whether laboratory research
can be translated into effective community treatment.
Can community clinicians co-operate in multi-centre
trials of treatment programs? If they do, it is essential
that they adopt the constructive skepticism that char-
acterises the best researchers, and constrain their
natural individualism in order to preserve the fidelity
of the treatment being tested. No easy matter.
Acknowledgement
The preparation of this paper has been funded in part
by the National Health and Medical Research Council
project number 990201, ‘Child Sexual Abuse:
Evaluation of a Multimodel Treatment Program’.
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