The present study reviews the extant literature on the treatment of sexually abused adolescents to identify the treatment methods available, their relative effectiveness, and the factors to consider in the design of a treatment program to address the individual needs of the client. Adolescent sexual abuse refers to the use of children aged 12 to 18 years for sexual pleasure by an adult (Barnett, Miller-Perrin & Perrin, 2011, p. 197). The exact prevalence of adolescent sexual abuse is unknown because of the high variability of findings from prevalence studies, but up to one in five women and one in ten men have experienced sexual abuse at least once during childhood (Sanchez-Meca, Rosa-Alcazar & Lopez-Soler, 2011, p. 67). According to Barnett, Miller-Perrin & Perrin (2011, p. 226), girls are more prone than boys are to sexual abuse by a close family member. Sexual abuse has many adverse effects on the victim including trauma, depression, low self-esteem, physical injury, sleep problems, and drug abuse. Therefore, sexually abused children need treatment to restore their physical, psychological, and behavioral health, yet at least half of child sexual abuse cases go unreported.
A search in Academic Search Premier yielded four studies (Avinger & Jones, 2007; Sanchez-Meca, Rosa-Alcazar, & Lopez-Solar, 2011; Springer & Misurell, 2012; Kemp et al., 2014) that qualified for review. To qualify for selection, the study had to (a) address the issue of treatment of sexually abused adolescents as its central subject, (b) a scholarly article published in a peer-reviewed journal complete with a research problem statement, methodology, data collection, and analysis, discussion of findings and references. The four studies addressed different aspects of sexual abuse treatment. For instance, Avinger & Jones (2007) was a qualitative review of 10 previous studies on group treatment of adolescent girls aged 11-18 while Sanchez-Meca, Rosa-Alcazar, & Lopez-Solar (2011) conducted a meta-analysis of psychological treatment of sexually abused children and adolescents. The remaining two studies (Springer & Misurell, 2012; Kemp et al., 2014) were empirical studies on equine facilitated therapy and game therapy for sexually abused adolescents respectively.
Findings: Treatment Methods
The reviewed literature identified several treatment methods for sexually abused adolescents. They include group therapy using trauma-focused cognitive behavior therapy, psychodynamic therapy, humanistic therapy, combined treatment (skills training + education +psychotherapy) (Avinger & Jones, 2007; Sanchez-Meca, Rosa-Alcazar, & Lopez-Solar, 2011), Equine facilitated therapy (Kemp et al., 2014) and game therapy (Springer & Misurell, 2012). Trauma-focused cognitive behavior therapy (CBT) involves helping clients to communicate and process their traumatizing experiences by a technique called cognitive restructuring (Avinger & Jones, 2007). Through this technique, the affected person develops new ways of thinking about their trauma and coping with it. Therefore, coping skills training and exposure therapy are important elements of trauma-focused CBT.
The combined therapy for sexually abused children includes a skills training component (relaxation training, social skills training, anxiety management, and problem-solving skills training) and a psychotherapy component to help the client to process the cognitive and emotional effects of sexual trauma (Sanchez-Meca, Rosa-Alcazar & Lopez-Soler, 2011). Combined therapy may also include education to increase the client’s awareness of various aspects of sexuality such as sexual physiology and contraceptive use. Psychodynamic therapy involves helping abused children to process sexual trauma through experience or the stimulation of senses. Equine facilitated therapy involves the use of horses to provide feedback to victims of sexual abuse about their emotional states and train them to control their emotions and behavior (Kemp et al., 2014). As experiential learning, it differs from most other psychotherapy techniques that rely on therapists or fellow humans for feedback. Finally, game therapy is a modification of trauma-focused CBT to include play activities that enable sexually abused children to learn the various skills needed to process trauma in a healthy manner (Springer & Misurell, 2012).
The choice of treatment modality and the design of a treatment program vary with treatment goals. The main treatment goals for sexually abused adolescents include alleviating depression and anxiety symptoms, improving self-esteem, addressing problem behaviors, and responding to other symptoms such as posttraumatic stress, sleep problems, and emotional disorders(Avinger & Jones, 2007; Sanchez-Meca, Rosa-Alcazar & Lopez-Soler, 2011; Kemp et al., 2013).
Analysis: Efficacy of Treatments
The reviewed studies indicate that the different treatment approaches have varying effectiveness across different outcome measures or treatment goals. Evidence indicates that trauma-focused CBT is quite effective in reducing symptoms of posttraumatic stress disorder commonly found in sexually abused children such as irritability, aggression, hyper-arousal, nightmares, and flashback (Avinger & Jones, 2007; Kemp et al., 2014). However, many studies that Avinger & Jones (2007) reviewed lacked control groups and thus their results were only preliminary. In addition, all the studies included in Avinger & Jones (2007) excluded individualized treatment methods and thus it is difficult to determine the exact role of group aspects in determining the efficacy of the methods investigated. According to Sanchez-Meca, Rosa-Alcazar & Lopez-Soler (2011), trauma-focused CBT is more effective in group therapy than in individualized therapy. Although both Avinger & Jones and Sanchez-Meca et al. did not explain the reasons for the disparity in outcomes between the group and individualized treatments, Avinger & Jones (2007) suggested that peer factors such as feedback might inspire active participation in the treatment program.
In their meta-analysis of the efficacy of psychotherapy for sexually abused children and adolescents, Sanchez-Meca, Rosa-Alcazar & Lopez-Soler (2011) found that trauma-focused CBT is the most commonly used treatment for most outcome measures including depression, anxiety, self-esteem, and problem behaviors. Trauma-focused CBT is often combined with other treatments such as supportive therapy and play/game therapy to increase its efficacy in alleviating anxiety and trauma symptoms (Avinger & Jones, 2007; Sanchez-Meca, Rosa-Alcazar & Lopez-Soler, 2011; Springer & Misurell, 2012). Sanchez-Meca, Rosa-Alcazar & Lopez-Soler (2011) found that cognitive behavior therapy is more effective when accompanied by other treatments such as psychodynamic therapy and education than when it is the only treatment. According to Avinger & Jones (2007), trauma-focused CBT, psychodynamic and humanistic therapies are quite effective in improving self-esteem in sexually abused children in group-treatment settings. However, Sanchez-Meca, Rosa-Alcazar & Lopez-Soler, (2011) found that some clients might deteriorate if group treatments fail to address their specific needs. Using an individualized treatment approach, Springer & Misurell (2012) found that game therapy based on cognitive behavioral therapy principles is effective in reducing symptoms of trauma and anxiety in a teenage girl who was sexually abused at ages eight and nine. However, Springer & Misurell tested the game-based therapy on one participant only, which means that the results may not apply to all adolescents
Out of the four studies examined only Kemp et al. (2014) utilized an animal-assisted therapy model for sexually abused adolescents. Animal-assisted therapy is not only unique because of the use of an animal to provide feedback to the client but also it uses experiential learning and non-verbal communication tools that are mostly lacking in other treatment approaches. Kemp et al. (2014) argued that experience-based treatments are more appropriate for sexually abused adolescents because they find it difficult to trust adults and maintain appropriate conduct necessary to benefit from the therapist’s verbal guidelines. In addition, Kemp et al. noted that verbal therapies face the additional limitation of cultural bias. With this in mind, Kemp et al. hypothesized that equine-assisted therapy would be effective in reducing the symptoms of sexual abuse because the horse provides genuine and timely feedback to the client under all circumstances, thanks to the horse’s innate ability to detect mood and behavior changes in humans. The study reported significant reductions in the symptoms of sexual abuse in all the participants regardless of age, ethnicity, and gender. Similar results had been obtained in non-animal assisted therapies. For example, Sanchez-Meca, Rosa-Alcazar & Lopez-Soler (2011) found no statistically significant effect of age and gender on the efficacy of psychotherapy treatments for sexual abuse. However, the mean effect size increased with being older, female, and abused by a close family member. Despite suggesting that equine-assisted therapy would overcome human limitations such as subjective judgment of thoughts and emotions, Kemp et al. (2014) failed to compare the efficacy of their method with that of human-based methods. Nevertheless, Kemp et al. (2014) demonstrated that animal-assisted therapy is equally effective for all clients regardless of ethnicity and other characteristics, results that deviated from those of Sanchez-Meca, Rosa-Alcazar & Lopez-Soler (2011) who reported that non-Caucasians seemed to respond better to treatment than Caucasians.
Cognitive behavior therapy (CBT) and its modifications (mainly trauma-focused CBT) is the most commonly used therapeutic treatment modality for adolescent victims of sexual abuse. Trauma-focused CBT is the most preferred treatment for sexually abused children because of its effectiveness in reducing a wide range of symptoms including depression, anxiety, avoidance symptoms, low self-esteem, and behavioral problems. The benefits of trauma-focused CBT increase significantly when it is combined with other treatment methods, especially supportive therapy. Although most studies report positive results on the efficacy of psychological treatments for sexually abused adolescents numerous aspects related to sample, methodological and interpretational limitations render it difficult to make concrete decisions regarding the efficacy of most treatment modalities. For instance, only a few studies use control groups—four out of the 10 studies reviewed by Avinger & Jones (2007) and 7 out of the 44 studies reviewed by Sanchez-Meca, Rosa-Alcazar & Lopez-Soler (2011). In addition, the influence of personal factors such as age, ethnicity, and gender is unclear and ranges from no effect (Kemp et al. 2014) to statistically insignificant effect (Sanchez-Meca, Rosa-Alcazar & Lopez-Soler, 2011). Furthermore, animal-assisted therapy for children who have been sexually abused remains underutilized.
Sexual abuse affects many aspects of the psychological and behavioral health of adolescents resulting in depression, anxiety, low self-esteem, emotional problems, posttraumatic stress symptoms, and numerous other symptoms that may vary with personal characteristics, and thus the search for effective treatments is worth the cost. Since the evidence indicates that treatment is far much better than no treatment at all, the next most important step is to understand the specific ways in which the various treatment methods work in order to increase their effect sizes. Such understanding demands the use of effective assessment tools and careful design of treatment programs to incorporate all the elements required to address each symptom of sexual abuse. While multidimensional treatments involving trauma-focused CBT, education and other supportive therapies appear to be the best approach so far, animal-assisted therapy and play therapy should be explored further because of their potential to overcome human-related barriers such as cultural incompatibility and overreliance on verbal feedback.
Avinger, K. A., & Jones, R. A. (2007). Group treatment of sexually abused adolescent girls: A review of outcome studies. American Journal of Family Therapy, 35(4), 315-326. doi: 10.1080/01926180600969702
Barnett, O. W., Miller-Perrin, C. L., & Perrin, R. D. (2011). Family violence across the lifespan: An introduction. Thousand Oaks: SAGE Publications.
Kemp, K., Signal, T., Botros, H., Taylor, N., & Prentice, K. (2014). Equine facilitated therapy with children and adolescents who have been sexually abused: A program evaluation study. Journal of Child & Family Studies, 23(3), 558-566. doi:10.1007/s10826-013-9718-1
Sanchez-Meca, J., Rosa-Alcazar, A. I. & Lopez-Soler, C. (2011). The psychological treatment of sexual abuse in children and adolescents: A meta-analysis. International Journal of Clinical Health & Psychology, 11(1), 67-93.
Springer, C., & Misurell, J. R. (2012). Game-based cognitive-behavioral therapy individual model for child sexual abuse. International Journal of Play Therapy, 21(4), 188-201. doi: 10.1037/a0030197