**2. Impact of child sexual abuse**

There are emotional, behavioral, developmental, relational, physical and sexual sequela of CSA, especially if the child did not receive timely and efficacious interventions and/or the child was not believed nor supported when they disclosed the CSA. The effects of CSA are often dependent on severity and frequency of the CSA as well as the developmental level of the child. Additionally, many CSA survivors have been victims of ongoing and complex trauma and the effects are cumulative and likely to overwhelm the child's coping resources. Emotional impacts can include depression, anxiety, posttraumatic stress symptoms, and angry outbursts, among others [4]. Externalizing behavioral symptoms can include regressions in toileting, temper tantrums, sleep difficulties and nightmares, provocative sexual behaviors, substance abuse, defiance and noncompliance [5]. CSA increases an individual's risk for both minor and major health problems including cancer and diabetes [6]. Relational consequences can include indiscriminant attachments which put victims at further risk, and also withdrawal and mistrust. Mistrust is empirically common if the child experienced betrayal trauma where the perpetrator was a known and trusted individual [7]. Sexual sequela can include sexual acting out behaviors, hypersexuality, poor body boundaries as well as an aversion and fear of affection and sexual behaviors.

The child's relationship with the perpetrator or offender of the sexual abuse impacts symptom presentation and also disclosure. The majority of sexual abuse victims know their perpetrator [3, 7], often making it difficult for the child to disclose due to feelings of loyalty to the family or the perpetrator. The lack of disclosure often results in the sexual abuse continuing over an extended period of time and the youth not receiving needed interventions, which may exacerbate their symptoms and the negative effects of CSA [8].

## **3. CSA interventions for youth**

There is a need for empirically supported, targeted, and child directed interventions for victims of CSA [9]. These interventions should be trauma informed, provided within the context of a strong and supportive therapeutic relationship and include psychoeducation about CSA, coping skills, exposure through a trauma narrative and safety planning. Several of the most widely utilized interventions for CSA victims and their nonoffending caregivers are presented in this chapter.

#### **3.1 TF-CBT**

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an empirically supported treatment model for CSA developed to address PTSD symptoms and trauma in children and adolescents [4, 8, 10, 11]. Studies conducted in the last 25 years have provided consistent support for TF-CBT as the superior therapy for sexually abused children and other traumatized children when compared to non-directive or child-centered supportive therapy, as it provides essential support structures for both caregivers and children [11]. TF-CBT treats children and adolescents, ages 3 to 17, by addressing the negative effects of trauma including processing of traumatic

#### *Intervention Strategies for Promoting Recovery and Healing from Child Sexual Abuse DOI: http://dx.doi.org/10.5772/intechopen.97106*

memories, addressing and overcoming problematic thoughts, and building coping and interpersonal skills. This short-term manualized treatment is typically provided in eight to 16 weekly 90-minute sessions, extending to as many as 25 sessions for individuals suffering from complex trauma [4, 8]. The TF-CBT treatment model was developed not only to address PTSD and depression and anxiety symptoms, but also underlying problematic distortions of thought regarding self-blame for trauma, ideas and expectations for safety, and constructs of trust in others and the world [10, 11].

The core components of TF-CBT can be summarized with the PRACTICE acronym, P: psychoeducation and parenting skills, R: relaxation skills or managing physiological reactions to trauma, A: affective modulation skills or managing affective responses to trauma, C: cognitive coping skills that build connections between thoughts, feelings, and behaviors, T: trauma narrative and processing, I: in vivo mastery of trauma reminders, C: conjoint child-caregiver sessions, and E: enhancing safety and future development [4, 8].

A primary curative component of TF-CBT is creation and processing of the trauma narrative (T) [4, 8, 10, 11]. This is the middle third of the duration of therapy, where the therapist and traumatized client focus increasingly on the specific traumas experienced. As the therapist and client progress through the components of the PRACTICE model, the therapist increases gradual exposure and helps the client and caregivers implement the skills learned to prepare them to cope with the inevitable full exposure of trauma reminders that accompany the trauma narrative [4, 8]. The trauma narrative and processing component is essential in the exposure therapy aspect of this treatment model, as it allows the child to extinguish negative emotions and reactions associated with the trauma by wiring new pathways of associations to the traumatic memories and eliciting positive and resilience-focused feelings such as pride and strength [8, 10].

In the trauma narrative and processing component, the youth develop a narrative about their CSA that includes specific traumatic circumstances, cognitions, feelings, behaviors, and other trauma-related experiences. For many of these youth, it is difficult to create a fully integrated trauma narrative, as they may only conjure up fragmented and non-linear pieces of their complex trauma memories [8]. Traditionally, these trauma narratives manifest in the form of written books about the youth and their specific trauma. The youth will complete their trauma narrative, usually ending with a chapter of what they have learned about themselves, relationships with others, worldviews, and expectations of the future, and then have the opportunity to share their narrative with their caregiver [10]. Trauma narratives can both highlight maladaptive core beliefs, and facilitate the integration of thoughts and feelings related to trauma [10]. Trauma narratives have been shown to reduce a child's fear and anxiety related to their abuse and decrease avoidant behaviors related to trauma [4, 8, 10, 11].

#### **3.2 Play therapy**

Play is the language of children and play based therapy for CSA is a developmentally attuned and expressive intervention that can facilitate emotional and behavioral regulation and healing from CSA [12]. Children who have been sexually abused frequently have difficulty with verbal recollection and expression of their traumatic experiences both due to the neurobiological impact of trauma on language centers in the brain and the developmental level of the child [13, 14] and play interventions can be familiar and less threatening. Additionally, complex trauma interferes with typical brain development, plus traumatic memories are often stored in the brain's implicit memory, which results in memories of sexual abuse

being stored in areas of the brain and body that are frequently challenging to access through verbal methods [15]. Through play therapy, children use symbolic representation to explore feelings and thoughts. Play therapy can include dolls, puppets, action figures and stuffed animal play for sexual abuse disclosure, which creates distance and an alternative to the children directly discussing their traumatic experiences, as they act it out through play. Play can be incorporated into other treatment modalities, such as play based construction of a trauma narrative in TF-CBT, and is particularly important for younger children who may not have the cognitive and language skills to fully express their feelings through talk therapy [16].

Play therapy for CSA can be directive and focused on the CSA or nondirective and child centered, focused on building rapport and establishing safety in the therapeutic relationship [12]. Play can be used to engage children who have experienced CSA and their caregivers in the therapy process, to teach specific personal safety and coping skills, to create a fun therapeutic environment and to facilitate communication between the child and the therapist [16]. Historically, the efficacy of play therapy for CSA has been difficult to quantify, however, play therapy is beginning to develop an evidence base that is more than anecdotal, and is establishing play therapy as an effective empirically supported intervention for CSA [17, 18].

#### **3.3 Art therapy**

Trauma informed art therapy is effective for children who have experienced early relational trauma, such as intrafamilial sexual abuse, which may result in symptoms of PTSD [19]. Art therapy interventions can provide a voice and sense of self-agency to CSA survivors as they creatively and abstractly represent their traumatic experiences and use metaphors and visual symbols to describe their sexual abuse [20]. Through visual arts, youth who have been sexually abused can express overwhelming emotions without requiring words [21].

Healthy emotional expression as well as emotional regulation for children who have experienced CSA can be promoted through art therapy [21]. Children who have been sexually abused may present with dissociative tendencies, limiting their ability to create a verbal trauma narrative and art therapy can provide a medium of construction of the trauma narrative that is not dependent on verbal processing [22]. Art interventions, such as drawing, painting, sculpting, collaging, etc., employed in forming and processing of a trauma narrative can act as a catalyst for children who have experienced CSA to explore thoughts, feelings, trauma memories, and perceptions through visual, tactile, and other sensory means [23]. With child sexual abuse, it is especially important to explore the non-verbal memories that recall fragmented sensory and emotional experiences of the trauma [24]. Art therapy is a visual and sensory modality that assists youth who have been sexually abused with accessing traumatic material stored in implicit memory, which is body-based form of memory that is distinct from explicit, narrative and conscious memory [20]. Art therapy may provide a bridge between implicit and explicit memory that allows children who have experienced CSA to express feelings and memories that are not accessible by verbal means [23].

#### **3.4 Group therapy**

To treat CSA, there are numerous efficacious group interventions which aim to decrease symptoms of CSA while also providing future risk reduction skills [25]. Group therapy for CSA is a treatment modality that is frequently used and is often the treatment of choice for CSA. CSA group treatment has growing interest for a variety of reasons, such as an increase in demand for trauma focused mental health

#### *Intervention Strategies for Promoting Recovery and Healing from Child Sexual Abuse DOI: http://dx.doi.org/10.5772/intechopen.97106*

services and a need for a cost-effective approach [26]. Group modalities for CSA include TF-CBT groups, art therapy groups, support groups, psychoeducation groups, and process groups, among others. Children in CSA group therapy benefit from the support and understanding of peers who have had similar experiences. Group therapy provides an important sense of universality for CSA victims which can help combat feeling of isolation, social stigma, shame, guilt, and anger [27]. Universality is a key component of CSA group treatment and can assist with normalization of feelings of powerlessness, betrayal and helplessness, while simultaneously providing skills for resilience [27]. The relational consequences and mistrust that are often a result of CSA can be mitigated in group therapy for CSA as group members begin to connect through the opportunity to interact with supportive therapists and other CSA victims [28].

TF-CBT was initially provided as individual treatment although TF-CBT is frequently provided in a group format and group TF-CBT has also been identified as an efficacious treatment modality for CSA [29]. The group format of TF-CBT promotes cohesion by destigmatizing traumatic experiences. Children learn new skills together and can support one another to implement these skills [29]. When children are attending their group, caregivers are attending collateral group sessions to learn the TF-CBT components [10, 29]. Parenting and coping skills are taught to provide more consistency in the home and psychoeducation regarding trauma is provided [10, 29]. TF-CBT groups for CSA can decrease trauma symptoms such as anxiety, depression, avoidance, hypervigilance, and intrusive thoughts in youth [25]. Group therapy for CSA has shown to be effective for improving overall psychological distress, development of coping skills, and reducing sexual and other behavior problems [25]. Additionally, group TF-CBT has supported youth in developing stronger personal safety skills and decreasing emotional reactions in caregivers [25].

Art therapy groups for CSA are an expressive arts group treatment modality that incorporates creativity and can facilitate processing of traumatic experiences with other youth who have experienced CSA. Various types of abstract and representational art can be created in group and shared with group members in order to increase catharsis and connection/cohesion between group members. For example, group members may draw characters (animals, superheroes, objects) that represent themselves, their perpetrators and protective caregivers and then be asked to tell detailed stories to the group about these characters [20]. In this group art activity, a child may identify as an animal living in their safe place, until a predator presents and harms the animal (i.e., a fox attacking a rabbit, a bee stinging a kitten). Allowing the child to identify with the animal provides distance and separation from the event so as to prevent the children from being retraumatized or overwhelmed by trigger reminders [20]. An eight session art therapy group for latency age girls who had been sexually abused focused on four themes: establishing group cohesion and fostering trust, exploring feelings associated with the abuse, sexual behavior and the prevention of revictimization and termination of the group [30]. Group members utilized painting, drawing, clay sculpting, and dramatic role plays during this art therapy group. Outcome measures from this group art therapy intervention for girls who had been sexually abused evidenced a reduction in symptoms of anxiety and depression [30].

Support groups for CSA provide cohesion, connection with others with a shared experience, and psychoeducation about CSA. CSA support groups may focus on body boundaries, personal safety, CSA education, and coping skills and typically do not have a disclosure or trauma narrative as part of the group curriculum [31]. This may be due to the shorter length of treatment and/or group treatment provided outside of a clinical setting, such as at a school. Due to limited time and the need

for youth to not become emotionally triggered in a school setting, support groups typically do not have group members share details about their victimization.
