Title: A Meta-analytic Investigation of Therapeutic Modality Outcomes for Sexually Abused Children and Adolescents: An Exploratory Study
Authors: Melanie D Hetzel-Riggin, Amy M Brausch and Brad S Montgomery
Institutions: Departments of Psychology at Western Illinois University and Northern Illinois University
The purpose of the study was to analyse 28 peer-reviewed and published outcome studies of treatment for sexually abused children and adolescents. The researchers compared the effectiveness of different psychological treatments (individual, cognitive behavioural and so on), and considered the effectiveness of these treatments in addressing what they term “secondary problems” (such as behaviour problems or psychological distress). They also took into account contextual factors such as child characteristics, abuse characteristics and the quality of studies included in the review.
This study supports the view that many psychological interventions can be of some benefit. In general terms, better outcomes for children and adolescents were indicated after psychological treatment, although the mental health of many who did not receive treatment also improved, indicating high levels of resilience. Different types of therapy were clearly beneficial for different types of difficulties.
Most effective in the case of behavioural difficulties were cognitive-behavioural, abuse-specific and supportive therapy, either individually or in groups. For children whose main problems were concerned with social functioning, play therapy seemed the most effective. Cognitive behavioural, family and individual therapy seemed to be the most effective for psychological distress, and for poor self-image, abuse-specific, cognitive-behavioural and group therapy came out as the most suitable.
The authors conclude that decisions about what form of therapy is best should be decided on the basis of the child’s main presenting secondary problem. They found that the ethnicity of the sample, the presence of intrafamilial abuse and length of therapy were all relevant to how effective therapy was. Non-Caucasians fared best and, overall, longer-term therapy was associated with better outcomes.
A higher percentage of intrafamilial abuse indicated that therapy would be less successful. Age, gender and therapist training did not come out as significant, but the authors did suggest a need for further research to investigate the relationship between forms of treatment and secondary problem outcomes.
LIMITATIONS OF THE STUDY
The researchers used appropriate statistical methods to compare effect sizes that’s to say, the degree of improvement each therapy offered. However, although effect sizes related to child and adolescent outcomes were included, those regarding parent behaviour and health were left out. These could, therefore, have influenced outcomes in a way that was not picked up.
Some of the study sample sizes were small for statistical purposes, making their results more difficult to interpret. A further limitation is that some studies gave only a vague description of the therapy involved and many of the children, who were technically not receiving treatment, were in fact assigned to community services, so could have had some treatment outside that provided by the research team.
This leaves it unclear how far it is possible to support the claim that children not receiving treatment show signs of improved mental health. Many studies did not give enough information about sample characteristics such as age and gender. And there was considerable difference in the number of studies amassed relating to different forms of therapy for example more than a dozen were on cognitive behavioural therapy while only a few reported on play therapy.
There is much material describing the positive benefits of different therapeutic approaches with sexually abused children. However, treatment of child sexual abuse is a complex arena and debate persists about whether formal therapeutic intervention can exacerbate rather than relieve its symptoms.
Thomas Oellerich’s 2002 article published in Sexuality and Culture sets out the debate. In view of the controversy over whether formal therapeutic treatment is helpful, strong factual evidence is needed. However, there are few studies that systematically analyse the effectiveness of different treatments.
The research by Hetzel-Riggin and colleagues adds to the small literature base comparing different treatments. The most relevant previous study on which it builds is a 10-year research update review of treatment for child sexual abuse by Frank Putnam published in 2003. Putnam’s review concluded that cognitive-behavioural therapy with the child and a non-offending parent was the most effective treatment option, although he acknowledged that too few studies of other types of therapy exist. Hence the evidence base is insufficient to determine their precise effectiveness.
This 2007 meta-analysis by Hetzel-Riggin and colleagues is particularly helpful for three reasons first, it amalgamates the findings of a large number of studies and considers various types of therapy second, it considers treatment relevant to the effects of sexual abuse, recognising that presenting difficulties vary, rather than focusing on treatment for sexual abuse as a generalised category third, it attempts to analyse the relevance for treatment of contextual factors such as age, ethnicity and abuse characteristics. This review is genuinely helpful to practitioners having to make judgements in individual cases.
Angie Hart is professor of child, family and community health at the University of Brighton, and academic co-director of its community university partnership programme.
LINKS AND RESOURCES
● This account is based on an article in Child Abuse & Neglect, 2007, Vol 31, pages 125-141. Other articles mentioned are a “Ten-year research update review of child sexual abuse” by Frank Putnam published in the Journal of the American Academy of Child and Adult Psychiatry (March 2003 vol 42, number 3). Thomas Oellerich’s article, “The case against the routine provision of psychotherapy to children/adolescents labeled ‘sexually abusede_SSRq” was published in Sexuality and Culture, Volume 6, number 2, in April 2002.
● The NSPCC is undertaking research in this area. Fresh Start offers an opportunity for researchers to work closely with professionals working at the NSPCC, as well as external projects and agencies.
● The University of Birmingham has a centre for forensic and family psychology.
● Childline is at www.ChildLine.org.uk
Various factors, including the intense emotion and stress surrounding the issue of sexual abuse, may lead practitioners to focus on sexual abuse as a general category to which treatment should be applied. Given the lack of availability of rapid-response child and adolescent mental health services in some areas, social workers seeking specialist therapy for children on their caseload can find themselves accepting any therapy they can get, rather than finding that which is best.
Court-ordered therapy can also fall into the trap of insisting that children who have been sexually abused are routinely offered therapy without being specific about what type of therapy is best offered. The review emphasises the worth of at least trying to match therapeutic approach to the issues that the child or family is dealing with, rather than simply focusing on the matter of sexual abuse. It seems that adopting this strategy will facilitate therapeutic effectiveness.
For children displaying severe behavioural difficulties, cognitive-behavioural, abuse-specific and supportive therapy either individually or in groups could each be useful approaches to pursue. Practitioners working with children who find it difficult to function socially might seek out play therapy as first port of call. On the other hand, cognitive-behavioural, family and individual therapy seemed to be the most effective for psychological distress and for poor self-image, abuse-specific, cognitive-behavioural and group therapy came out as most suitable.
In recent years there has been much emphasis on cognitive-behavioural therapy as a treatment of choice for issues relating to sexual abuse. This may be because other forms of therapy have not had as much research undertaken on them, and so the evidence base is not there to back them up. However, while cognitive behavioural approaches were over-represented in this review, the authors did find evidence to suggest that a wide range of therapeutic approaches are helpful, depending on the presenting difficulty. Applying the findings of the review should help service managers and commissioners ensure the availability of different therapeutic approaches in local child and adolescent mental health services, since it is clear that one size definitely does not fit all.
Practitioners working with children where there is a high degree of intrafamilial abuse should be alerted to the review findings that these are the most challenging cases to treat. Hence priority should be given to them in relation to finding the best therapeutic fit with their presenting difficulties. Longer-term therapy was associated with better outcomes this is a point that managers and commissioners should consider when planning services since the trend is often towards shorter interventions.
To treat or not to treat
The worth of routine prescription of therapy for children who have been sexually abused has been questioned. Some argue that the therapy “industry” has little to offer children who have been sexually abused and that many get better with no formal interventions. The study discussed here does go some way to support this contention in that many of the children who did not receive therapy found their symptoms abating anyway.
However, the review does provide evidence to suggest that for children whose functioning is severely affected by sexual abuse, formal therapeutic intervention is helpful.
While ideally a therapeutic approach should be tailored to the presenting difficulties, practitioners who are faced with little choice of precise form of therapy can find some solace in the review findings. For children whose mental health is severely affected by sexual abuse, it does seem that some therapeutic input is better than none, even if its precise orientation doesn’t match research definitions of what is most effective.
Hence from a social work perspective, it is worth remembering that the therapeutic work undertaken within the social work role may well be sufficient to deal with many of the presenting difficulties associated with sexual abuse, certainly in less severe cases.
This article appeared in the 23 August issue under the headline “The impact of therapies”