Development of a Brief Psychological Trauma Intervention for Child Sexual Abuse in India.

Despite the alarming increase in incidences of child sexual abuse (CSA) in India, intervention research remains preliminary and generic. Although Cognitive Behavior Therapy (CBT) has been found to be consistently effective in addressing the adverse consequences of CSA, none of the cultural adaptations of CBT have been evidenced in India so far. Hence, the present study was conceived to develop a CSA-focused brief CBT intervention for children between 7 and 13 years of age. Intervention development progressed through four steps: 1) a systematic review of literature; 2) a qualitative study, including focused group discussions, conducted with 19 mental health professionals; 3) development of the intervention; 4) expert evaluation and finalization. We developed the intervention with three key elements: restoring the child's functioning, assisting the child in processing, and managing trauma effectively and initiating the process of growth. The intervention predominantly followed the CBT framework while integrating culturally specified techniques. The intervention contains 8 modules and 18 sub-modules structured around three phases of intervention. The intervention is spread across a minimum of 6 required sessions and a maximum of 12 session held twice weekly for approximately 90-120 min duration. A list of 35 activities corresponding to each phase and sub-module of the present intervention has been designed as an intervention workbook. In conclusion, the newly developed intervention is a manualised, culturally competent, psychological intervention developed within the CBT framework for children aged 7-13 years with experience of CSA. The next phases include piloting intervention for feasibility.

Mental imagery in adolescent PTSD patients after child abuse: a comparison with matched healthy controls.

BACKGROUND: Intrusive mental imagery (MI) plays a crucial role in the maintenance of posttraumatic stress disorder (PTSD) in adults. Evidence on the characteristics of MI in adolescents suffering from PTSD is sparse. The aim of this study was to thoroughly assess MI in an adolescent sample suffering from PTSD after the experience of childhood sexual abuse and/or childhood physical abuse (CA). METHODS: Thirty-two adolescents with a primary diagnosis of PTSD after CA and 32 adolescents without any mental disorder and without a history of CA, matched for age and gender, completed questionnaires assessing the characteristics of negative and positive MI, as well as images of injury and death that lead to positive emotions (ID-images). RESULTS: The PTSD group reported significantly more frequent, more vivid, more distressing and more strongly autobiographically linked negative MI compared to the control group. Although positive MI was highly present in both groups (PTSD: 65.6%; controls: 71.9%), no significant differences emerged between the two groups regarding the distinct characteristics of positive MI. The frequency of the ID-images did not significantly differ between the two groups (PTSD: 21.9%; controls: 9.4%), although the ID-images were more vivid in the PTSD group. DISCUSSION: Negative MI appears to be crucial in adolescent PTSD, whilst positive MI are unexpectedly common in both the PTSD and the control group. The role of positive MI as well as that of ID-images remain unclear. Specific interventions for changing negative MI that are tailored to the developmental challenges in adolescents with PTSD should be developed. TRIAL REGISTRATION: Some of the PTSD patients in this study were also part of a randomized controlled trial on Developmentally adapted Cognitive Processing Therapy (D-CPT). This trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787 , 18 March 2013.

Five year cost savings of a multimodal treatment program for child sexual abuse (CSA): a social return on investment study.

BACKGROUND: Specialized mental health services for the treatment of Child Sexual Abuse (CSA) are generally expensive and labour intensive. They require a trauma-informed approach that may involve multiple services and therapeutic modalities, provided over the course of several months. That said, given the broad-ranging, long term negative sequelae of CSA, an evaluation of the cost-benefit analysis of treatment is clearly justified. METHODS: We performed a Social Return on Investment (SROI) analysis of data gathered as part of the treatment program at the Be Brave Ranch in Edmonton, Canada to determine the value-for-money of the services provided. We endeavoured to take a conservative, medium-term (5 year) perspective; this is in contrast to short term (1-2 year) effects, which may rapidly dissipate, or long term (15-20 year) effects, which are likely diffuse and difficult to measure. As such, our analysis was based on an average annual intake of 100 children/adolescents (60:40 split) and their families, followed over a five-year timeframe. Financial proxies were assigned to benefits not easily monetized, and six potential domains of cost savings were identified. RESULTS: Our analyses suggest that each dollar spent in treatment results in an average cost savings of $11.60 (sensitivity analysis suggests range of 9.20-12.80). The largest value-for-money was identified as the domain of crisis prevention, via the avoidance of rare but costly events associated with the long term impacts of CSA. Somewhat surprisingly, savings related to the area of criminal justice were minimal, compared to other social domains analysed. Implications are discussed. CONCLUSIONS: Our results support the cost effectiveness of the investment associated with specialized, evidence-based early interventions for CSA. These approaches alleviate severe, negative outcomes associated with CSA, resulting in both economic savings and social benefits. These findings rest upon a number of assumptions, and generalizability of these results is therefore limited to similar programs located in comparable areas. However, the SROI ratio achieved in this analysis, in excess of $11:1, supports the idea that, while costly, these services more than pay for themselves over time.

Creative Interventions for Preparing and Disclosing Trauma Narratives in Group Therapy for Child Sexual Abuse.

Group therapy is a widely utilized and empirically supported treatment for victims of child sexual abuse (CSA). An important aspect of trauma-focused groups for CSA is the composition and presentation of a trauma narrative as part of a gradual exposure process. One challenge in the creation of a trauma narrative in group is the contagious avoidance that may be present if group members are reluctant to engage in the development of a trauma narrative. Creative group therapeutic interventions can assist in mitigating avoidance, a hallmark of posttraumatic stress disorder (PTSD), by reducing resistance to constructing and processing the trauma narrative in CSA group treatment. Additionally, creative expressive arts interventions are a developmentally tailored approach to trauma narratives for young children with limited language as well as for traumatized youth who do not have words accessible to describe their CSA. This manuscript presents a wide array of creative therapeutic activities that can be utilized for creation and processing of the trauma narrative and facilitating cohesion and coping in group therapy for CSA. Using these expressive arts techniques can support youth in preparing for the trauma narrative and providing a space to process their CSA.

A Comprehensive Pediatric Acute Sexual Assault Protocol: From Emergency Department to Outpatient Follow-up.

OBJECTIVE: Close medical follow-up after pediatric acute sexual assault is recommended and may mitigate adverse consequences and decrease long-term comorbidities. The objectives are to (1) examine adherence to a comprehensive outpatient medical follow-up protocol after evaluation in the emergency department in a pediatric population and (2) identify characteristics associated with patient adherence to inform the utilization of a medical follow-up protocol after pediatric acute sexual assault. METHODS: A retrospective medical record review was conducted of patients younger than 18 years presenting to the emergency department from January 1, 2010, to December 31, 2013, with a discharge diagnosis suggestive of sexual assault/abuse. We examined differences in demographics, assault characteristics, and medical/legal needs of patients who were evaluated in follow-up versus patients who were not. RESULTS: Of 182 patients, 60.4% completed follow-up appointments with the child protection center. Younger patients had follow-up rates higher than older patients (70.2% vs 50%; odds ratio [OR], 0.42). For patients where child protective services or law enforcement were called, follow-up rates were 74.2% and 64.7%, respectively (OR, 2.5; OR, 3.1). All patients with anogenital injuries on initial examination were seen in follow-up. The majority of patients who followed-up were accompanied by a caregiver/relative (95%). CONCLUSIONS: (1) Caregivers should be integrated into the evaluation to facilitate compliance with follow-up; (2) child abuse specialists may be consulted to facilitate specific interventions and recommendations; (3) professionals should work as a multidisciplinary team; and (4) the patient's psychological status should be evaluated, and mental health interventions recommended.

Attention Problems and Comorbid Symptoms following Child Sexual Abuse.

Treatment utilization following child sexual abuse (CSA) is essential in combatting the various negative consequences of CSA. Youth may present to treatment for CSA with symptoms that cut across multiple diagnostic presentations that impact their ability to successfully engage in treatment. In particular, children who have difficulties with attention may have unique treatment needs following CSA. The purpose of this study was to examine how attention problems interplay with comorbid symptoms and how these clinical presentations impact treatment outcomes for youth who have been sexually abused. Participants included 323 families presenting to treatment for CSA. Youth were 7 to 19 years old, 78.5% female, and 76.6% identified as Caucasian/White. Results indicated that 22.9% of the youth presented with clinically elevated attention problems as collected through parent-report of the Child Behavior Checklist (CBCL). Results demonstrated that child survivors of CSA who presented with attention problems self-reported more psychological concerns (e.g., symptoms of depression, anxiety, and post-traumatic stress). At post-treatment, attention problems, interpersonal problems, and thought problems were significantly reduced for youth initially presenting with attention problems. Further implications for treatment following CSA and unique needs for youth with attention problems are discussed.

[Inpatient Treatment of Complex PTSD Following Childhood Abuse: Effectiveness and Predictors of Treatment Outcome]. / Stationäre Therapie der komplexen PTBS in Folge körperlicher oder sexualisierter Gewalt in der Kindheit: Wirksamkeit und Prädiktoren des Behandlungsverlaufs.

BACKGROUND: There is a lack of studies investigating the effectiveness of inpatient trauma-focused psychotherapy of complex post-traumatic stress disorder. The first aim of this retrospective investigation was to analyze the course of PTSD. Second, possible predictors of treatment response were investigated. METHODS: 150 inpatients of Clinic St. Irmingard with complex PTSD following childhood physical and childhood sexual abuse were assessed regarding childhood abuse, PTSD symptomatology, mindfulness, dissociation and general psychopathology. Differences in pre and post scores were analyzed using regression analyses. A classification tree was used to identify predictors of response. RESULTS: The significant reduction of PTSD symptoms corresponded to a large effect (d=1.8) and a reponse rate of 52% according to the reliable change index (p<0.05). Effect sizes for other symptoms were medium to large (0.5

Are one-stop centres an appropriate model to deliver services to sexually abused children in urban Malawi?

BACKGROUND: The Republic of Malawi is creating a country-wide system of 28 One-Stop Centres (known as 'Chikwanekwanes' - 'everything under one roof') to provide medical, legal and psychosocial services for survivors of child maltreatment and adult intimate partner violence. No formal evaluation of the utility of such services has ever been undertaken. This study focused on the experiences of the families served at the country's first Chikwanekwane in the large, urban city of Blantyre. METHODS: One hundred seven families were surveyed in their home three months after their initial evaluation for sexual abuse at the Blantyre One Stop Centre, and 25 families received a longer interview. The survey was designed to inquire what types of initial evaluation and follow-up services the children received from the medical, legal and social welfare services. RESULTS: All 107 received an initial medical exam and HIV testing, and 83% received a follow-up HIV test by 3 months; 80.2% were seen by a social welfare worker on the initial visit, and 29% had a home visit by 3 months; 84% were seen by a therapist at the initial visit, and 12% returned for further treatment; 95.3% had an initial police report and 27.1% ended in a criminal conviction for child sexual abuse. Most of the families were satisfied with the service they received, but a quarter of the families were not satisfied with the law enforcement response, and 2% were not happy with the medical assessment. CONCLUSIONS: Although a perception of corruption or negligence by police may discourage use of service, we believe that the One-Stop model is an appropriate means to deliver high quality care to survivors of abuse in Malawi.

Normal Anal Examination After Penetration: A Case Report.

BACKGROUND: Physical findings are rare after anal penetration. Furthermore, children delay in disclosing or are reticent to discuss penetration. CASE REPORT: A 12-year-old boy presented to medical care multiple times over a several-week period complaining of abdominal pain, bloody diarrhea, and poor appetite. On colonoscopy, he was found to have a cylindrical foreign body (measuring 7 cm tall and 7 cm in diameter) in his rectum, which had been present for at least 2 weeks. He initially denied knowing how the object got into his rectum and later stated that he inserted it himself out of curiosity. One week after the object was removed, follow-up examination using video colposcopy revealed a completely normal anal examination; the patient had a normal anal examination despite known anal penetration and removal of the object. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Children can have a normal anal examination despite anal penetration, and do not always disclose anal penetration. The aforementioned concepts can be applied to situations related to child sexual abuse in the emergency department, where physical examinations are frequently normal and children delay in disclosing the abuse. When there is concern for sexual abuse, even in the absence of a disclosure or examination findings, patients should be referred for a child abuse pediatrics evaluation if available.

Characteristics and treatment of internet child pornography offenders.

In the realm of sexual offenses, there has been a decrease in hands-on offenses, but an increase in online offenses against children. The current issue is whether online and offline sexual offenders are alike or differ. This literature review investigates the differences among individuals who have committed child pornography offenses, individuals who have committed contact offenses against children, and individuals who have committed both. This review discusses the various typologies that have been proposed of those who have committed online offenses against children, the diagnostic implications of having committed child pornography offenses, and the current state of treatment and prevention of individuals who have committed online sex offenses against children. The studies examined were found from psychology databases, listserv links, and references of those collected articles. Only articles in English were included in the review. Overall, Internet child pornography offenders (ICPOs) tend to score significantly differently from contact offenders on various psychological measures. These findings may imply that ICPOs have different treatment needs than contact offenders.

Interventions that Foster Healing Among Sexually Exploited Children and Adolescents: A Systematic Review.

Sexual exploitation of children and adolescents is a pressing, yet largely under-recognized form of child abuse. The goals of this review were to identify interventions that have been implemented with sexually exploited children and adolescents and to better understand their effectiveness for fostering healing with this population. Our systematic search generated 4,358 publications of which 21 met our inclusion criteria. Based on their objectives and delivery, we organized the interventions into five categories: (a) focused health and/or social services, (b) intensive case management models, (c) psychoeducational therapy groups, (d) residential programs, and (e) other. Most programs were gender-specific, targeting girls and young women with just one being for boys and young men only. Studies reported on a range of outcomes including psychosocial outcomes, risky behaviors, trauma responses, mental health, protective factors, and public health outcomes. Despite differences in delivery, most of the interventions did, to some degree, appear to foster healing among sexually exploited children and adolescents. Findings from this review have implications for researchers, policy and program developers, and frontline practitioners who, through partnerships with one another, can advocate for the creation of evidence-informed, purpose-built, and thoughtfully delivered interventions.

Compassion-Focused Therapy as an Intervention for Adult Survivors of Sexual Abuse.

Child sexual abuse can have long-term negative impacts across psychological, physical, and interpersonal domains. Some of the common issues for survivors of sexual abuse include shame and self-blame, attachment-based difficulties, avoidant coping strategies, and reduced capacity for self-compassion. Compassion-focused therapy is a transdiagnostic intervention that specifically responds to these concerns. Compassion-focused therapy was originally developed for clients who experience high levels of shame and self-criticism and aims to strengthen the soothing and affiliative system through the cultivation of compassion. This article will highlight the theoretical alignment between some of the common issues and impacts associated with experiences of sexual abuse, with the core underlying principles of compassion-focused therapy. This includes (a) the capacity of the therapy's evolutionary framework to reduce perceptions of self-blame, (b) the cultivation of compassion to respond to feelings of shame, (c) acknowledgment of the role of early attachment experiences and facilitation of corrective affiliative experiences, (d) regulation of the threat-based system following trauma, and (e) provision of an alternative to avoidant-based coping by responding to distress with compassion. It is proposed that the theoretical framework and core focus and aims of compassion-focused therapy are highly applicable for survivors of sexual abuse and therefore holds significant promise as a treatment option for this client group.

Betrayal of the Body: Group Approaches to Hypo-Sexuality for Adult Female Sufferers of Childhood Sexual Abuse.

Hypo-sexuality, self-reported hypoactive sexual desire and/or sexual aversion, is a common symptom experienced by women who were victims of childhood sexual abuse. This symptom may be distressing to the patient herself, and may place strain on her romantic relationships in adulthood. Unfortunately, this problem often remains undiscussed between patient and provider, in part due to the provider's lack of comfort or knowledge regarding how best to address this issue. In this article, we explore several strategies that providers may employ in a group setting in order to help women realize their sexuality while minimizing untoward side effects such as feelings of guilt or shame, or flashbacks. We highlight the merits of each technique, and provide insights from clinical experience to guide practitioners to help their patients facing this difficult issue.

Child-Parent Relationship Therapy with Extra-Familial Abused Children.

Sexual abuse by a perpetrator outside of the family is the most prevalent form of child sexual abuse. It is associated with serious consequences for both the child and his family. Surprisingly, however, the issue of extra-familial sexual abuse has received very little research and clinical attention. The purpose of the current study was to explore the effectiveness of Child-Parent Relationship Therapy (CPRT), which uses nondirective play therapy tools, among parents of extra-familial abused children and their parents. In order to do so, data was collected from 51 parents who participated in CPRT, at three points in time: pretreatment stage, at the beginning of the first meeting; and in the post treatment stage. The data included the parents' reports via three questionnaires: Parenting Stress Inventory (PSI), Compassion Fatigue Self-Test (CFST), Child Behavior Checklist (CBCL). Overall, the results indicated a decrease in internalizing and externalizing symptoms among the children, as well as in parenting stress and in parental secondary trauma symptoms. This study contributes to the literature on interventions with victims of extra-familial child abuse and their parents. Specifically, the results highlight the benefits and importance of involving both parents and children in therapeutic interventions for victims of extra-familial child sexual abuse, with particular emphasis on the benefits of Child-Parent Relationship Therapy.

Adults with Pedophilic Interests in the United States: Current Practices and Suggestions for Future Policy and Research.

Adults with pedophilic interests are often viewed by the public as a homogenous subgroup based on what we know from those who sexually offend against children. The stigma associated with child sexual abuse may serve to deter such behaviors but may also interfere with the person's stability and willingness to seek assistance in managing pedophilic interests. This article contrasts the sex offender response and prevention efforts typically employed in the U.S. (i.e., containment, registration, and notification policies and public education programs) with treatment programs aimed at preventing child sexual abuse in Germany, Belgium, and Canada. Five major areas are identified that should be further examined with regard to implementing preventative outreach and treatment programs in the U.S.: barriers to outreach and treatment programs, how to expand or reframe current preventative educational programs, implementation of such programs in light of current mandating reporting policies, promising treatment approaches for pedophilic interests among non-offenders, and ethical concerns relevant to preventative psychological interventions.

[Healthcare situation for children, adolescent and adult victims of sexual violence in Germany : A critical overview]. / Versorgungssituation von Kindern, Jugendlichen und Erwachsenen mit sexuellen Gewalterfahrungen in Deutschland : Ein kritischer Überblick.

In Germany, since 2010 the debate regarding sexual assault victims, additionally due to extensive activities of the independent commissioner for questions regarding sexual abuse of children (Unabhängiger Beauftragter für Fragen des sexuellen Kindesmissbrauchs, UBSKM), has received increased attention from the public and the healthcare system. Sexual violence is a burdening experience regardless of age and can have a lasting impact on the physical, psychological and/or social life of victims. Empirically, it has been found that more than half of the adult population suffering from mental disorders have experienced sexual abuse in childhood and adolescence. In some of the affected the impact of the trauma experienced, which is often accompanied by neglect and physical violence, can negatively influence the course of disease. Early counseling and therapeutic support for affected children and adolescents should be taken more into account and focus on optimizing treatment for this patient group. This article discusses the prevalence of sexual violence, possible health and social consequences and the treatment situation of affected children, adolescents and adults in various areas of the help/aid system. In doing so, a discrepancy between scientific findings, recommendations from statutory health insurance companies (GKV), the current healthcare situation and the real needs of the affected are made clear.

[Treatment structures for men with pedosexual problems]. / Versorgungsstrukturen für Männer mit pädosexueller Problematik.

Pedophilia is defined as a persistent or dominating sexual preference for prepubescent children characterized by persistent thoughts, fantasies, urges, sexual arousal and behavior. Less than 50% of all child abusers fulfill the diagnostic criteria and an even smaller part exclusively has a preference for children. Following psychiatric classification systems, pedophilia must be distinguished from child sexual abuse. Outpatient treatment and treatment in forensic psychiatry clinics, sociotherapeutic facilities and in correction facilities are different aspects of prevention. So-called grey area projects (Dunkelfeldprojekte) are special facilities of primary and secondary prevention. The aim is to prevent sexual abuse by reducing and controlling of risk factors.

Predicting Time Spent in Treatment in a Sample of Danish Survivors of Child Sexual Abuse.

The aim of this study was to identify significant predictors of length of time spent in treatment. In a convenience sample of 439 Danish survivors of child sexual abuse, predictors of time spent in treatment were examined. Assessments were conducted on a 6-month basis over a period of 18 months. A multinomial logistic regression analysis revealed that the experience of neglect in childhood and having experienced rape at any life stage were associated with less time in treatment. Higher educational attainment and being male were associated with staying in treatment for longer periods of time. These factors may be important for identifying those at risk of terminating treatment prematurely. It is hoped that a better understanding of the factors that predict time spent in treatment will help to improve treatment outcomes for individuals who are at risk of dropping out of treatment at an early stage.

[The post-traumatic nightmare or the ghost of past trauma]. / Le cauchemar post-traumatique ou le fantôme du trauma.

The post-traumatic nightmare is the reliving of traumatic scenes during sleep and is linked to post-traumatic stress disorder. Unlike other forms of dreams, it can happen at any stage of sleep, invasively, and makes the person relive their traumatic scenario, which can plunge them into a state of terror and shock. Post-traumatic nightmares thereby maintain and reactivate the traumatic memory. However, narration techniques can lead to a marked improvement and even the disappearance of these nightmares.