Royal Hospital for Sick Children, Edinburgh
University of Birmingham
Royal Hospital for Sick Children, Edinburgh, UK
Correspondence: Dr Fiona Forbes, Child and Family Mental Health Servie, Royal Hospital For Sick Children, 3 Rillbank Terrace, Edinburgh EH9 1LL,UK.Tel: 0131 536 0520; Fax: 0131 536 0545; e-mail: fiona.forbes{at}lpct.scot.nhs.uk
Declaration of interest None. The study was funded by the Chief Scientist Office, Scottish Executive Health Department.
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ABSTRACT |
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Aims To assess the level of psychopathological symptoms in parents and children following disclosure of sexual abuse and the changes following a parental treatment intervention.
Method Parents completed standardised rating scales about their own and their childs symptoms. These were repeated following the intervention.
Results Thirty-nine parents of 31 children completed scales at the baseline assessment; 18 repeated these following interventions. Initially, parents reported high rates of psychopathological symptoms in themselves and their children, which were reduced following the intervention.
Conclusions This study confirms the high rates of psychopathological symptoms found in parents of children following disclosure of sexual abuse. Children clinically identified for intervention had higher measured levels of psychopathological symptoms. Targeted treatment interventions are needed.
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INTRODUCTION |
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METHOD |
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A team
The A team offers an early intervention service for non-abusing parents of
children who have disclosed sexual abuse; this work is the focus of the
current pilot research project. The service is provided in a collaborative and
supportive framework, and has the following components:
Based on this information, and on an assessment of the parental response to intervention, a decision is reached together with parents and carers regarding whether the child needs to be assessed for possible therapy and hence referred to a therapist in the B team. The experience of the team to date is that approximately half of the children do not require therapy at this stage. Most research has focused on non-abusing mothers, but the early intervention service is offered to both (non-abusing) parents and carers.
B team
The B team offers an assessment and treatment service for children who have
been sexually abused and who are suffering significant mental health problems
as a result.
C team
The C team offers a consultation service to professionals working with
children with sexually inappropriate or sexually abusive behaviour, and an
individual assessment and treatment service for the children.
Sample selection
Child sexual abuse was defined as sexual exploitation of a child by another
person or persons. The Community Child Health Department of the Royal Hospital
for Sick Children in Edinburgh is the central referral point for requests for
medical evaluations of children who disclose or are suspected to have
experienced sexual abuse. The Departments clinical database was used to
identify families eligible for the study from referrals made between 1 January
2001 and 31 October 2001. A total of 115 children were identified from this
database. The study included all non-offending carers (male and female) aged
18 years and over of victims of sexual abuse aged under 14 years. Carers under
the age of 18 years, non-English speakers, and those who had visual impairment
or learning disabilities were excluded, as were children living in residential
units. The study was approved by the research ethics sub-committee of Lothian
Primary Care NHS Trust.
Recruitment process
For the eligible children, the following information was sought from the
database as well as from hospital records: age, gender, date of referral, and
the contact details of the social worker who carried out the initial
investigation. The identified social work office was then contacted to request
information about the suitability of the family for recruitment into the
study. The research assistant then approached the carers, explained the study,
and sought their agreement to participate.
Procedure during study
The carers were seen at recruitment (baseline), at cessation of contact
(post-intervention) and 3 months later (follow-up). At the first contact,
information was sought from the carers regarding their age, relationship to
child, family composition, education and employment status, health, and
previous direct or indirect experience of sexual abuse. On every occasion,
measurements were made on both carer and child.
Instruments
Carers
The Brief Symptom Inventory (BSI;
Derogatis & Spencer, 1982) is a 53-item inventory which evaluates psychological symptoms experienced
within the previous week. It includes a measure of the overall level of
distress, the Global Severity Index (GSI); the pattern of symptoms in nine
domains; the Positive Symptom Total (PST) and a further summary measure, the
Positive Symptoms Distress Index (PSDI).
The Parent Emotional Reaction Questionnaire (PERQ; Cohen & Mannarino, 1996a) is a 15-item instrument developed to measure parental emotional reactions (fear, guilt, anger) to the knowledge that their child has been sexually abused. Scores have been found to significantly predict symptoms in sexually abused schoolchildren (Cohen & Mannarino, 1996a). Internal consistency has been calculated at 0.87, with a 2-week testretest reliability of 0.90.
Children
Each carer completed the Child Behavior Checklist (CBCL;
Achenbach & Edelbrock,
1983). This instrument was developed as a descriptive rating
measure to assess both adaptive competencies and behaviour problems for use
with carers of children aged 418 years. Scores can be calculated for
overall behaviour, and for internalising and externalising sub-scales.
Carers also completed the Child Sexual Behavior Inventory (CSBI; Friedrich et al, 1992), which covers 42 items relating to sexual behaviour. The frequency with which the child has shown each behaviour within the previous 6 months (from never to at least once a week) is rated. The CSBI is the only empirical scale that specifically examines sexual behaviour in children. Norms are available from three groups: parents of normal children, parents of psychiatric out-patients and parents of sexually abused children.
Statistical methods
A major aim of the study was to obtain estimates of means, variances and
changes in both parent and child scores with a view to designing a randomised,
controlled trial of the parental intervention. Further considerations related
to interrelationships between the child and parent scores, changes in these,
treatment of the children and issues of caseness. The design of the study
afforded an opportunity to perform various significance tests of differences
between groups at baseline, differences in scores between baseline and
post-intervention, relationships between potentially explanatory variables and
prepost differences, and correlational structures. For continuous
variables, descriptive statistics presented are means and standard deviations,
while t-tests (paired or independent as appropriate) and F
tests are used for comparisons between groups. Pearson correlations are
reported along with significance levels (P values). For discrete
variables frequency tables are presented, but statistical tests are
inappropriate because of the small numbers involved.
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RESULTS |
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Details of abuse
Sixteen children had suffered sexual abuse from within their own family;
only one child had been abused by a stranger. The majority of the abusers were
male. Three children were abused by females (this included one child also
abused on separate occasions by a male). Four children were abused by two
abusers, not necessarily at the same time.
Seven children suffered a single abuse episode; 2 suffered two episodes; 9 were abused over periods of 29 months; 13 were abused over periods of 17 years.
All 31 children had been touched inappropriately in the genital region; 12 had to engage in masturbatory acts; 5 suffered attempted penetration; 13 suffered vaginal and/or anal penetration (digital and/or with object and/or penile). At least 2 children were photographed in a pornographic fashion. Clearly, several children suffered a range of abusive acts.
Referrals to child assessment and treatment team
Fifteen of the 31 children were referred to the B treatment team.
Parents and carers
Demographic data
Thirty-nine parents and carers were recruited to the study (in the case of
nine children, two carers each were recruited, and one carer was associated
with two children). Nine were men, 30 women, and all were White, with an age
range of 2049 years. All but four were the biological parent of the
child, two being adoptive parents and two other relatives. The modal number of
other children at home was one (21 parents). Fourteen of the parents had a
history of psychiatric illness.
Baseline measures
All parents provided baseline measurements prior to their first appointment
with the team. Two children and their parents/carers were not subsequently
referred to the team. Figure 2
shows baseline measures on the sub-scales of the Brief Symptom Inventory
together with the summary measures GSI and PSDI. Normative data are also
plotted for female psychiatric inpatients, out-patients and normal individuals
(Derogatis, 1993), as the great
majority of the parent sample were women (this is a conservative procedure as
male norms are in general less than female). The PST is an order of magnitude
greater than those plotted in Fig.
2: for the parent group the mean PST was 29.44 compared with norms
of 30.35 for in-patients, 31.81 for out-patients and 12.86 for
non-patients.
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Other baseline comparisons of the measures with published norms are given in Table 1. For variables related to children, both parents measures are included at this stage.
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Caseness at baseline
The scales can be used to provide an operational definition of
caseness in the parent (BSI) and child (CBCL) respectively.
Using the criteria for caseness set out by Derogatis
(1993), all but one parent
would be classified as a case. The one parent not so classified was male and
scored zero on all BSI sub-scales except paranoid ideas where a
score of 1 was registered, about the 65th percentile for normal men. Of the 31
children assessed at baseline, 22 satisfied the caseness criterion of a CBCL
score of 50 or over.
Baseline comparisons
Parents
Unbalanced two-way analyses of variance were performed on each of the
parent measures, using gender of child, subsequent treatment of child and the
interaction as model terms. There was a consistent and (apart from the PERQ
score) statistically significant association between subsequent treatment of
the child and higher parental scores. Abuse of male children was associated
with higher carer scores. Group means are presented in
Table 2.
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Children
For these comparisons children for whom scores of two carers were available
were allocated the mean score of the two values for each variable. Paired
t-tests and calculation of correlation coefficients indicate both
high correlations and no significant disagreement between the scores of the
carers within each pair. Analyses of variance were performed with the above
model (child gender and treatment) on the four child-related variables. The
only significant associations observed were between subsequent treatment and
scores on the CBCL internalising sub-scale and, perhaps predictably, the CBCL
total (Table 3). Boys show
higher scores than girls on all variables, as indeed do boys in the
normal population. There is some skewness in the distributions
of scores, most notably for the CSBI. Applying distribution-free tests did not
alter the conclusions regarding statistical significance. No significant
relationship was observed between the childrens baseline rating scores
and the characteristics of the abuse, the abuser and the duration of the
abuse.
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Parentchild correlations
The basic principle of the intervention examined by this research is that
child well-being is connected with parental response and well-being.
Accordingly, correlations between parent and child variables at baseline and
change in scores from baseline to post-intervention were calculated.
Table 4 shows that all
correlation coefficients are positive as expected, and all except the
correlations between CSBI and PST, and between CSBI and PERQ (given in
parentheses in Table 4), are
statistically significant.
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Changes in scores
Changes from baseline to post-intervention assessment were examined for all
scores and also for childs caseness. The mean time
between the relevant interviews was 5.5 months (s.d.=2.4) and the maximum and
minimum gaps were 9 months and 10 weeks, respectively.
Parents
Altogether 18 sets of pre- and post-intervention parental scores were
available, relating to 16 children (as mentioned above, one parent was
responsible for two children, and two carers were recruited in the case of
three other children). Paired t-tests were conducted on GSI, PST,
PSDI and PERQ scores (Table 5). None of these changes was statistically significant, but apart from the PST
score all showed a reduction in parental distress.
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Children
Data for 16 children were available pre- and post-intervention. When a
child was scored by two carers the average of the two scores was taken. Eight
of the 16 children were treated by the B team. All the treated children
satisfied the CBCL caseness criterion at baseline, as did five of the eight
untreated children. Post-intervention changes were towards non-caseness. Two
of the treated children and two of the children who did not receive direct
treatment achieved non-case scores.
Table 6 gives means and paired t-tests of differences on the four measures employed comparing baseline with post-intervention. The signs of mean changes indicate improvement on all variables, but statistical significance is only achieved for the score on the CSBI.
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Table 7 displays correlations between change scores for children and parents. Changes in scores on the CSBI do not correlate with parental score changes, but CBCL scores do. Despite the small numbers two of the correlation coefficients were statistically significant, and several of the others approached statistical significance.
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Follow-up
Follow-up information was obtained for nine parents of six children
approximately 3 months after the end of the intervention. There was no
evidence of deterioration in either children or parents.
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DISCUSSION |
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Following treatment intervention by the team, there was a reduction in parental distress and degree of psychopathology. Numbers were too small to reach statistical significance and there was no control group. Despite this, it is unlikely that the parental distress which in all but one had reached clinically significant levels would have resolved spontaneously. This aspect will be addressed directly in the proposed randomised, controlled trial.
The teams clinicians correctly identified those children most likely to need treatment. Part of the treatment intervention for parents involves helping them support and empathise with their child and reaffirming previous healthy parenting skills. It also includes discussion of any emotional or behavioural problems in the child and whether or not these can be addressed solely by the parents. If this is not possible the childs difficulties are too severe, or the parents are continuing to have significant problems in coping it is agreed that the child will be assessed for possible therapy. In the research group, 16 of the children were not referred for assessment the clinicians, in collaboration with the parents, deemed this unnecessary. Fifteen of the children did go on to be assessed and receive therapy. Analysis of the baseline scores of the parents and children in this group revealed them to be much higher than in the non-referred group.
Implications for subsequent trial design
An important aim of this research was to obtain information to help design
a randomised, controlled trial of the parental intervention. The results
indicate that reductions occur in scores on all scales for parents, but
although the baseline scores for almost all parents are in ranges similar to
those of psychiatric patients, the well-being of the child is a key aim of the
intervention. Accordingly, we considered power calculations relating both to
parents and children. The correlational and change results suggest that the
PERQ score may be variable in practice, and although it has been used
elsewhere no published norms appear to be available. The correlation of change
in PERQ with change in CBCL internalising score indicates that it should be
retained as a secondary outcome. Of the BSI scores the PST does not take
severity into account, while the GSI is recommended for use as part of the
caseness criterion. Accordingly, GSI is a suitable primary outcome measure for
parents.
Scores on the CSBI were only slightly higher than normal values at baseline. Despite the large t value for change in CSBI, we feel that two conclusions follow: first, that it is not appropriate to use CSBI as a primary outcome, and second, that our analysis might not be applicable to a population of abused children with high CSBI scores.
Correlations between parent and child changes in scores suggest that we should restrict attention to the CBCL total score and the CBCL internalising score as primary outcomes for the children (further details available from the authors upon request.)
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Bulik, C. M., Prescott, C. A. & Kendler, K. S.
(2001) Features of childhood sexual abuse and the development
of psychiatric and substance use disorders. British Journal of
Psychiatry, 179,
444449.
Cohen, J. A. & Mannarino, A. P. (1996a) Factors that mediate treatment outcome of sexually abused pre-school children. Journal of the American Academy of Child Adolescent Psychiatry, 34, 14021410.
Cohen, J. A. & Mannarino, A. P. (1996b) A treatment outcome study for sexually abused pre-school children: initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 4250.[Medline]
Cohen, J. A. & Mannarino, A. P. (2000) Predictors of treatment outcome in sexually abused children. Child Abuse and Neglect, 24, 983994.[CrossRef][Medline]
Deblinger, E., Lippmann, J. & Steer, R. (1996) Sexually abused children suffering posttraumatic stress symptoms: initial treatment outcome findings. Child Maltreatment, 1, 310321.
Deblinger, E., Steer, R. & Lipmann, J. (1999a) Two-year follow-up study of cognitivebehavioural therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse and Neglect, 23, 13711378.[CrossRef][Medline]
Deblinger, E., Steer, R. & Lipmann, J.
(1999b) Maternal factors associated with sexually
abused childrens psychosocial adjustment. Child
Maltreatment, 4,
1320.
Derogatis, L. R. (1993) BSI Brief Symptom Inventory: Administration, Scoring and Procedures Manual (4th edn). Minneapolis, MN: National Computer Systems.
Derogatis, L. R. & Spencer, P. (1982) The Brief Symptom Inventory (BSI): Administration, Scoring and Procedures ManualI. Baltimore, MD: Clinical Psychometric Research.
Everson, M. D., Hunter, W. M., Runyon, D. K., et al (1989) Maternal support following disclosure of incest. American Journal of Orthopsychiatry, 59, 197207.[Medline]
Finkelhor, D. & Berliner, L. (1995) Research on the treatment of sexually abused children: a review and recommendations. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 14081423.[Medline]
Friedrich, W. N., Grambsch, P., Damon, L., et al (1992) The Child Sexual Behavior Inventory: normative and clinical comparisons. Psychological Assessment, 4, 303311.[CrossRef]
Hiebert-Murphy, D. (1998) Emotional distress among mothers whose children have been sexually abused; the role of a history of child sexual abuse, social support and coping. Child Abuse and Neglect, 22, 423435.[CrossRef][Medline]
Kendall-Tackett, K. A., Williams, L. M. & Finkelhor, D. (1993) Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164180.[CrossRef][Medline]
Manion, I. G., McIntyre, J., Firestone, P., et al (1996) Secondary traumatisation in parents following the disclosure of extrafamilial child sexual abuse: initial effects. Child Abuse and Neglect, 20, 10951109.[CrossRef][Medline]
Received for publication July 10, 2002. Revision received November 15, 2002. Accepted for publication December 9, 2002.
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