1. The Impact and Treatment of Child Sexual Abuse Judith A. Cohen, M.D. Medical Director Center for Traumatic Stress in Children and Adolescents Allegheny General Hospital Drexel University College of Medicine Pittsburgh, PA jcohen1@wpahs.org

2. Impacts of Child Sexual Abuse ABC’S: Affect Behavior Biology Cognition Social School

3. Affective Impacts Sadness Anxiety (with increased motor activity) Anger (with behavioral regulation problems) Loss of affect (flat, no feelings) Affective regulation problems: 0 to 60 Dissociation

4. Behavioral Impacts Avoidance: don’t talk, think about it Traumatic reenactment: sexualized behaviors Behavior problems: aggression, don’t listen, poor attention, poor concentration (“ADHD”) Self-injurious behaviors, e.g., cutting Substance abuse Risk-taking

5. Biological Impacts Significant changes in: Stress-related neurotransmitters Hypothalamic-pituitary-adrenal axis (cortisol) Brain structure and function (emotion regulation; hemisphere communication) Immune function

6. Cognitive Impacts Maladaptive cognitions including: Self-blame Blame of non-offending parent Diminished self-worth Feeble person in dangerous world Malevolent intent; loss of social contract All are associated with worse MH outcomes

7. Social Impacts Loss of trust (betrayal) Increased family stress/conflict (especially if perpetrator was family member) Associate with deviant peers Media attention  loss of privacy, gossip Risky or inappropriate behaviors  may lose status or reputation

8. School Impacts Poor concentration/attention Disruptive behaviors in school Decline in grades More missed days of school Higher rate of school drop out Trauma reminders may occur in school  may be helpful to change schools

9. Mental Health Diagnoses Diverse mental health diagnoses including: Posttraumatic Stress Disorder Depressive disorders Anxiety disorders Behavioral disorders (e.g. ODD; ADHD) Substance use disorders Bipolar disorder; ADHD may be misdiagnosed

10. Medical Problems Diverse medical problems including significantly increased rates of: Pulmonary disease (asthma, bronchitis) Headache GI problems Allergy and immunologic problems Health care usage

11. “Asymptomatic” Victims Some children are highly resilient Gene X environment (exposure) interaction Other protective factors: Parental support Adaptive cognitions Active coping skills Lack of diagnosis does not mean SA was benign

12. Long Term Problems One time assessment is “hit or miss” Severe problems often have “sleeper effect” Adult studies show significantly greater Depression and suicide PTSD Substance abuse Medical problems Early death

13. Effective Treatment Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): strongest evidence of efficacy TF-CBT components: PRACTICE acronym

14. TF-CBT Components: PRACTICE P: Psychoeducation; Parenting skills R: Relaxation Skills A: Affective Expression and Modulation Skills C: Cognitive Coping Skills T: Trauma Narrative and Processing I: In Vivo Mastery of Trauma Reminders C: Conjoint Child-Parent Sessions E: Enhancing Safety and Future Development

15. Promise Video The Promise of Trauma Focused Treatment for Child Sexual Abuse: www.nctsn.orgwww.nctsn.org Developed by the NCTSN for stakeholders— Judges, parents, CPS, teachers, GAL To recognize elements of effective treatment: COPING SKILLS TALK DIRECTLY ABOUT SEXUAL ABUSE INCLUSION OF PARENTS/CAREGIVERS

16. Standards for Effective Treatment/ Best Practices Treatment plan: must include how treatment will address individual child’s problems Coping skills to address ABC’S Trauma narration: directly talking about CSA to address avoidance/CSA reminders Include parents/caregiver if feasible to: decrease parental distress improve parental support and attunement optimize child and family outcomes

17. Recognizing Appropriate Providers Evidence-based treatments have specific training requirements, certification will be available TF-CBT Certification: Licensed practitioner completing: Free 10 hour web-based training in TF-CBTWeb: www.musc.edu/tfcbt www.musc.edu/tfcbt 2 day training + 6 months of twice monthly consultation calls or year long Learning Collaborative Complete 5 TF-CBT cases with standardized assessment instruments Pass written test assessing clinical competence

18. Benchmarks for Determining Progress Treatment plan: required by MH treatment Each progress note should reflect how treatment is addressing treatment plan What to reasonably expect: TF-CBT significantly improves PTSD in 12-16 sessions Other problems (e.g., behavior problems, attachment issues) often take longer to address (20-25 session for children in foster/RTF settings).

19. Reunification Issues: Sibling Abuse Sibling/older youth=40% of perpetrators MH guidelines for returning to home: SAFETY FIRST Victim and parent have completed TF-EBT Perpetrator acknowledges perpetration, understands harm, has attempted restitution (e.g., apologized) Family has effective, realistic safety plan Victim shows ability to use learned safety skills Perpetrator publicly reinforces this safety plan

20. CSA with Intimate Partner Violence IPV victim (mother) charged with failure to protect child from father who abused child IPV=power imbalance; if mother didn’t know about SA  further victimize mother and child But child protection is essential Do you remove the child or order mother to keep father out of the home? Watchful Shepherd: http://watchful.org: no episodes of IPV or SA when WS was in place.http://watchful.org

21. Resources NCTSN webinars: How to Create a Trauma Informed Program to Help Young Children in Juvenile Court The Courts Cant Stop Child Trauma if They Don’t Know About It: How to Question Alleged Child Victims NCTSN product: Caring for Kids: What Parents Need to Know about Sexual Abuse

22. Summary Impacts of CSA are diverse No “Child Sexual Abuse Syndrome” Effective treatment includes coping skills, directly talking about CSA, including parents EBT have clear standards for training therapists and will soon certify therapists Working together we can enhance children’s safety after child sexual abuse.

23. Maya Angelou: “The world is changed one child at a time.” Thank you for all you do for traumatized children.