Effective Treatment for Children in Cases of Extrafamilial Sexual Abuse
Therese L. Wolf and Terence W. Campbell*
ABSTRACT: Many therapists believe that individual therapy is the
most appropriate therapeutic treatment fir children who have been
sexually abused. They assume that working with the child on a
one-on-one basis will reduce the effects of "trauma."
However, this belief is not empirically supported. This paper
outlines a family therapy technique for working with the non-incestuous
family whose child has been sexually abused Through this approach,
parents develop the confidence and ability to assist the child and
become the child's major support system.
We maintain that it is inappropriate to treat children for sexual
abuse per se. Sexual abuse is an event, not a clinical condition.
Undertaking treatment for children only because they have been sexually
abused, without specifying the condition that warrants treatment, is
tantamount to physicians claiming that they treat patients for
automobile accidents. In fact, many people involved in auto accidents
never require medical treatment; and when they do, treatment responds to
their clinical condition (e.g., fractures, concussions, internal
injuries, etc.), rather than the event responsible for the clinical
Similarly, Beutler and Hill (1992) observe that, for adult clients
contending with a history of childhood sexual abuse, treatment is most
effective when it responds directly to the clinical condition of the
client. That is, the research indicates effective treatment addresses
the anxiety, depressive, dissociative or other problems/conditions
manifested by the client. Beutler and Hill also challenge the assumption
that the population of adults sexually abused as children is clinically
unique and requires special expertise. We maintain that Beutler and
Hill's position applies equally to children who have been sexually abused.
Appropriate treatment for sexually abused children also raises
questions of whether treatment is actually necessary in a given case.
Research indicates that as many as half of sexually abused children are
asymptomatic despite their abuse (Caffaro-Rouget, Lang, & van
Santen, 1989). When the abuse involves a previously unknown perpetrator,
a low frequency of sexual contact, no use of force, and no experience of
penetration, the child is less likely to develop symptoms
(Kendall-Tackett, Williams, & Finkelhor, 1993). In these
circumstances, treatment can be short-term and problem-focused,
assisting parents to provide the psychological and social support their
child needs. Excessive treatment in such cases creates the risk of
iatrogenic outcomes. Treatment above and beyond what is necessary
suggests to children and their parents that the child's condition is
especially serious; and in turn, the child's psychological welfare can
suffer as a result of self-fulfilling prophecies.
Even when the child does exhibit a clinical condition warranting
treatment, the research contraindicates individual psychotherapy for
such children. Sexually abused children recover more completely as the
levels of enmeshment and expressed anger in their families decrease
(Kendall-Tackett et al., 1993).
Reducing parental frustration and self-doubt is a crucial goal when
treating sexually abused children. Parents understandably struggle with
considerable frustration and self-doubt as they attempt to aid their
child. Since frustrated, self-doubting parents suggest to their children
that their situation is a serious one, they can inadvertently prolong
their child's recovery. Children cannot recover age-appropriate, normal
behavior until they know their parents feel comfortable and
self-confident about their situation but the parents cannot feel comfortable and self-confident until they see
their child behaving normally. Therefore, treatment typically involves a
challenging impasse: The child cannot be "OK" until the
parents are "OK," but the parents cannot be "OK"
until the child is "OK" (Campbell, 1994a).
In addition to considerations of this impasse, the research related
to treatment effectiveness for children in general advises against
individual therapy for children who have been sexually abused. Removed
from the carefully defined and closely supervised treatment protocols of
academic-research settings, the accumulated evidence clearly
demonstrates that individual psychotherapy for children is no more
effective than no treatment (Weisz, Weiss, & Donenberg, 1992).
Gorin (1993), in assessing the effects of individual therapy for
children in a community mental health center, reports that parental
behavior change is one of the variables most predictive of treatment
effectiveness. Therefore, in view of the demonstrated significance of
parental response to child therapy, neglecting to systematically include
parents in treatment for their children is ill-advised.
Data underscoring the inadvisability of individual therapy for
children are especially applicable to play therapy and other expressive
modalities (Campbell, 1992a,1992b). As long ago as 1975, Davids observed
that the time had come to abandon the prevailing blind faith endorsing
the activities of play therapy rooms. Play therapy for sexually abused
children creates the risk of prolonging their recovery via mood
congruent memory effects (Matt, Vazquez, & Campbell, 1992; Singer
& Salovey, 1988). Play therapy characteristically encourages
dramatic expressions of affect that are presumably cathartic for the
child. But these supposedly cathartic expressions can be continual
reminders of the distress and trauma of the abuse, and consequently, the
child's recovery may be prolonged.
Effective treatment for sexually abused children requires
well-defined treatment goals specifying both ultimate and instrumental
outcomes related to therapy (Rosen & Proctor, 1981). Ultimate
outcomes in treatment correspond to the outcomes the therapist intends
to realize by the time therapy terminates. Instrumental outcomes refer
to the well-defined interventions therapists undertake to realize ultimate outcomes.
direct participation of parents in therapy for sexually abused children
facilitates the realization of both instrumental and ultimate outcomes
through social support.
Social support refers to the encouragement, assistance, and
reassurance available to individuals from their network of recurring
relationships with other people (Campbell, 1994b). High levels of
social support protect people from the adverse effects of stressful life
events and chronic life strains (Cohen & Hoberman, 1983). There is
overwhelming evidence underscoring the significance of social support in
maintaining effective psychological adjustment (Cohen & Syme, 1985;
Cohen & Wills, 1985; Sarason, Sarason, & Pierce, 1990).
Social support, however, is not a unitary phenomenon. In his review
of the relevant literature, Evans (1993) identified four different types
of social support: (a) esteem support, actions or statements that
provide people with evidence of their own worth; (b) informational
support, advice or guidance that is helpful in coping with problems; (c)
instrumental support, which consists of sharing, helping, and other
forms of prosocial behavior, and (d) companionship support, which
provides a sense of belonging through shared activities.
Investigation vs. Therapy
Since appropriate treatment in cases of extra-familial child sexual
abuse responds to the clinical condition of the child, treatments that
speculatively address why the condition has developed fail to resolve
problems. Instead, effective treatment addresses what courses of action
can be undertaken to ameliorate the child's clinical condition
(Campbell, 1993). The therapist works with the child's family to help
them manage problems resulting from the sexual abuse. Effective
treatment precludes therapists from undertaking investigative
responsibilities (Hoorwitz, 1992). An investigation attempts to
determine exactly what events transpired in the past related to the
child's abuse. In contrast, appropriate treatment addresses how to
increase the effectiveness with which parents respond to their child's
In view of the very different kinds of tasks facing investigators and
therapists, investigators should complete their work before therapists
undertake treatment (Ceci, Ross, & Toglia,1989). Once treatment has
begun, therapists are obligated to inform investigators that treatment
is designed to serve the welfare of the child, not the purposes of the
investigation. Though investigators can assist the treatment
informing the therapist of the legal status of a case there is very
little that therapists can do to aid the investigation.
Investigators can offer valuable information on the court process
that may affect the parents and child. The therapist can then assist the
family with frustrations resulting from the delays, adjournments, and
postponements that often hinder the legal system. Parents can be
educated as to the normality of this process. They are allowed to
express their frustrations so that their children do not see them as
angry, anxious, worried, or upset. Alternatives for coping with the long
waiting periods in the legal process can be discussed. Suggestions may
include the child being on call instead of waiting, encouraging the
parents to be in touch with their contact person (police, prosecutor,
victim witness advocate, etc.) to determine the status of the situation,
and bringing items to keep the child and family busy during these times.
Also, the therapist should obtain the results of any medical
examinations or tests that have been performed. Having this information
enables the therapist to anticipate and deal with any medical
procedures, illnesses, or injuries the family might be dealing with.
if no further medical attention is needed, the therapist could work with
the family's relief that their child has no physical illness or
Treatment for Clinical Conditions
A child who has been sexually abused may exhibit many different types
of clinical conditions (Kendall-Tackett et al., 1993). These can include
masturbation, nightmares, problems concentrating, nervousness, somatic
complaints, acting out the event, refusing to speak about the incident,
crying, not wanting to be left alone with certain people or people of a
certain sex, clinging, having trouble falling asleep, etc. (This listing is not meant to be complete or exclusive by any means.)
conditions can be grouped under various categories and identified as
sexualized behavior, depression and withdrawal, anxiety, and
dissociation. It must be emphasized, however, that these symptoms, in
and of themselves, do not mean that the child has been sexually abused
since such symptoms can have many different causes.
Effective treatment for sexually abused children necessitates the
active participation of the child's family. The therapist assists the
family in developing a treatment plan and setting appropriate goals to
solve the presenting problems (Haley, 1983). The approach emphasizes
developing well-defined strategies for working on specific problems.
"Interventions usually take the form of directives about something
that the family members are to do, both inside and outside of the
interview. These directives are designed to change the ways in which
people relate to each other and to the therapist" (Madanes, 1981,
The therapist and parents comprise the collaborative partnership to
develop the treatment plan for changing behavior and assisting the child
and to establish treatment goals (ultimate outcomes). The parents offer
their thoughts, ideas, and concerns as to what they believe will help
their child. The therapist asks what has already been tried since
obviously, these efforts have not worked or else the family would not be
in therapy (Fisch, Weakland, & Segal, 1988). The therapist then
makes observations and gives suggestions based on the parents concerns
in an effort to reframe the situation and move the family forward
(Minuchin & Fishman, 1981).
Once the parents and therapist agree, the therapist outlines the
goals of treatment (ultimate outcome) and then works with the parents to
develop treatment strategies (instrumental outcomes). The treatment
strategies are the step-by-step, day-to-day activities that will help
the child and parents address the problems that brought the family to
therapy. This process helps the parents feel more in control, increases
their confidence, and reduces their self-doubt. The parents must be an
integral part of therapy since they provide essential social support to the child.
therapist is merely available to assist the family.
Throughout, therapists bring their expertise, education, training,
and life experiences to the family. They remind the parents of the
normality of some of the child's activity/behavior based on the child's
developmental stage. They encourage and support the family as the
parents and children complete the assignments and change their
Treatment for Overtly Sexualized Behavior (performed by the child
The most distinctive problem behavior characterizing some sexually
abused children is overtly sexualized behavior. This can vary in its
focus. The child might masturbate or perhaps rub the genital area on a
person or on soft objects such as stuffed animals, towels, or bedding.
Or the child might engage in sex play with another child. This should
not be seen as further abuse, but rather as relieving the charged-up
sexual tension the child may have experienced as a result of the sexual
Madanes (1984) describes a technique of a nonparadoxical ordeal which
can be used with an overtly sexualized child. The goal of this technique
is to make the sexualized behavior less attractive. It also removes the
parents from the role of continually chastising the child about the
behavior. The technique is designed to set parameters for the behavior
and ultimately eliminate it.
The specific ordeal example presented here is based on suggestions
Jay Haley outlines in his book, Ordeal Therapy (1984). The parents bring
their young daughter to therapy and report she has been rubbing her
genital area constantly on different objects. They want the behavior to
stop. The therapist explains to the parents and child that, if the child
is going to perform the activity, she must perform it accurately and
appropriately. Therefore, the therapist works with the parents and
instructs how to establish a specific set of steps before the child is
allowed to begin the behavior.
First, the parents and child select a proper room and the proper
stuffed animal. They review the merits of each room in the house and
debate the pros and cons until an appropriate room is chosen. Next, they evaluate the
benefits and liabilities of every stuffed animal. The parents narrow
down the choices, but the child makes the final decision.
After the selection of the stuffed animal and room, the child chooses
where in the room the behavior is to take place. For example, if the
behavior is to occur in a bedroom, the child must decide whether it will
occur on the bed or elsewhere. If on the bed, another decision is made
whether to have the bed covers up or down. If the covers are to be down,
the parents practice the precise removal procedure with the child.
Next, the parent and child determine which clothes the child is to
wear and which are to be taken off. If clothing items are to be removed,
the parents and child practice (with other clothing items or pretend
clothes) the procedure to smooth, fold, and place them in a certain
Following this, the child chooses the exact position in which she
will sit or lay. Next, with her parents' help, she determines the
correct rubbing procedure. It is practiced for the full effect and
correctness of procedure.
The time frame of when to begin each activity and when to end is also
carefully specified. At home, the child must then engage in the behavior
only at the regularly scheduled times. Therefore, if the child is found
rubbing herself at any time, the parents must encourage her to wait
until the agreed-upon time.
This marks the end of the organization and establishment of the
ordeal. The parents are encouraged to be consistent in its
implementation by reminding the child of the appointed time, setting a
timer so the exact time is adhered to, and reminding the child of the
Once this ordeal routine is established, put in place, and
consistently adhered to and encouraged, it takes away the pleasure of
the activity because of all of the details involved. Additionally, if
the child is engaged in the behavior as an oppositional mechanism, this,
too, is removed, as the parents are encouraging the behavior. Soon, any
behavior which is organized in this way is quickly extinguished (Haley,
Treatment for Overtly Sexualized Behavior (performed with another
Another example is of a child engaging in sexualized behavior with
another child. Obviously, no parents want their child to become sexually
involved in this manner. Therefore, in therapy, the child is asked to
pretend to have the symptom and the parents are instructed to assist the
child with developing an alternate behavior (Madanes, 1981).
The therapist and parents explain the inappropriateness of this
behavior for the child at this time. (This must be done carefully so as
not to discourage or dissuade the child from having a normal sexual life
as the child matures.) Limits and boundaries must also be explained.
The parents explain this behavior in terms of the child having extra
energy which can be directed elsewhere. The child, therefore, is asked
to divert this energy to other activities which would be helpful to the
parents, child, or family. For example, there are many activities that
can be done with a parent. These can be household tasks or activities to
improve a sport or academic skill or to develop a hobby. This serves two
purposes it distracts the child and because it is done with the parent,
it keeps the child from being alone with other children. Additionally,
it contributes to social support. Therefore, the child gains from every
Treatment for withdrawal
Sexually abused children sometimes become withdrawn, which can be
seen by their lack of interest in many areas/friends/activities that
were formerly enjoyed. When this happens, parents become concerned and
worried. They have much self-doubt. They want to assist their child in
any way they can. Their first attempts are usually efforts to entice the
child with new activities or persuade their child to become involved in
the old familiar activities. By doing this, they try to return the child
to the way he or she was before the abuse.
A helpful strategy for drawing out the child is called
"Reversing the Family Hierarchy" (Madanes, 1984). In this
strategy, a parent develops a pretend problem. Children are naturally quite willing to help out the adults
in their lives (Madanes,1990). When called upon, children will do
anything to help their parent "get better" and readily agree
to the request. The purpose here is to have children focus on a
situation and become so involved in another's "misfortune"
that they forget their own.
For example, a young boy spends more time by himself and less time
with friends and family. He sits in front of the television, but is not
really watching it or he sits in his room for hours and reads or works
on puzzles. Formerly, he had played outside consistently, but now he is
not interested and rebuffs friends' offers to play.
The father is instructed to pretend to be more withdrawn than the
child. He is told to sit on the couch, in the dark and breathe deeply
and issue sighs of woe. The therapist, in a light way, explains to the
child that the parent is in need of assistance and asks for the child's
help. The therapist asks for input and directives on how to help the
parent. This child may suggest playing games, watching television
together, going to the store, or going for walks.
During the session, the family members practice the whole sequence of
events. The father sighs and breathes deeply. The child approaches the
father and frets over him and suggests an activity. The parent puts up a
slight amount of resistance so the child becomes further involved in
encouraging the father to participate. (However, the child should not
get to the point of being discouraged.) Soon, the father acquiesces and
joins in one of the activities the child had chosen.
The family is then given this assignment to perform at home at
certain days and times. By doing this with the child, the parents help
the child move forward and come out of his solitude.
Treatment for Depression
The above technique also works well with children who are depressed.
Children showing depression exhibit tearfulness and a sense of
hopelessness and helplessness. Their appetites may increase or decrease.
Their energy level decreases and they have difficulty focusing. They may
also be described as having low self-esteem (DSM-III-R, American
Psychiatric Association, 1987). Using the technique described above, once the hierarchy is
reversed, these children tend to focus on issues of planning and
implementing ways to distract their parents or loved one. They then have
limited time to focus on their own depressed feelings.
Treatment for Anxiety
Anxiety and sleep disturbances may also affect sexually abused
children. The symptoms include tension, concern, and uneasiness about
the possibility of impending danger. Anxious children might be described
as nervous, jittery or worried. Physically, they might tremble or shake,
have shortness of breath, feel dizzy, have nausea or pain in their
stomach, or experience a choking feeling (DSM-III-R, American
Psychiatric Association, 1987). Parents become very concerned about
these conditions, partly because it is affecting their child but also
because they may be having these problems themselves.
Structured relaxation techniques may help anxious children and their
parents. Such techniques help the child to concentrate on relaxing and
allow the parents to be the ones supporting and encouraging this
behavior. It puts the parents back in charge of the child's well being
and makes them the experts in their child's welfare. Because relaxation
is introduced as a formal technique, the parents' expectations of
helpfulness increase immensely and the child is assured that the parents
can help. Therefore, the parents are an integral part of the child's
Initially, the therapist meets alone with the parents to select a
happy memory or activity that the family has participated in. Then the
therapist describes the relaxation technique to the parents,
demonstrates it to them, and the parents practice the technique with the
help of the therapist.
At the next session, the therapist begins and one parent repeats the
instructions. The parent tells the child to sit or lay comfortably and
to close his eyes. He talks to the child about focusing on the sound of
the parent's voice and instructs the child about breathing in and out in
a regular manner and paying attention to the breathing. The parent can
say to the child:
Now, I want you to lay down and put your head in my lap. I want you
to take a deep breath and let it out slowly. That's good. I want you to continue to breathe in deeply and exhale
slowly; and as you breathe in deeply and exhale slowly, I'm going to
begin rubbing your eyebrows. First, you'll feel me rub your left eyebrow
and then I'll rub your right eyebrow. As I'm rubbing your eyebrows, your
eyelids will get heavier and heavier and heavier until your eyelids
simply close by themselves. And when your eyelids are closed, it's like
you're sitting in a theater watching a movie screen seeing a movie of us
in a very happy place. You can remember the last time we were at the
beach playing in the water, the waves rolling in, the wind was blowing
and you were having a wonderful time. At any time you want or need to
feel as good as you feel right now all you need to do is to breathe in
deeply, exhale slowly, let your eyelids close and think about all of us
at the beach.
The family is told to practice this regularly. After the child learns
the technique, he can be encouraged to respond to anxiety symptoms by
going to his room, lying down, listening to favorite music, and thinking
of the relaxing and happy image. This technique should also help a child
whose anxiety interferes with sleeping.
Treatment for Dissociative Reaction
A dissociative reaction in a child is most often seen as daydreaming
or impaired concentration in school. It is usually described as the
child having attention problems and can be reframed as wandering
attention episodes. A behavioral technique to remind the child to
refocus attention can help these children.
For example, a girl is often seen staring at the ceiling in the
classroom and not hearing the instruction during parts of the school
day. It interferes with her work and grades. The therapist is told what
the wandering episodes are like. In this case, the child says she always
finds herself looking up at the classroom ceiling. The therapist then
tells the child to "blank out" and let her attention wander to
the ceiling. She is told that when her attention wanders, it is to be
like an alarm (rinnnggg!!, rinnnggg!!) going off inside her head. She is
then told she will hear a warning, "I'm missing interesting things.
I want to pay attention to the interesting things that my teacher is
telling us." This can be practiced several times with the encouragement
of the parents.
Thus, the child learns to recognize when her attention has wandered
so that she can refocus her attention on what is happening in the
We have presented an alternative to the way many therapists treat
sexually abused children. Sexual abuse by itself does not necessitate
specialized treatment. As with other problems that bring children and
their parents to therapy) it is the clinical condition that should be
treated. The therapist must focus on these conditions and address what
needs to be done, rather than why the abuse occurred. The treatment
suggestions we have presented can ordinarily be accomplished in a brief
manner. These treatment suggestions include the child's parents since
the parents are the child's main source of social support. We believe
that this strategy offers maximal opportunity for the child to recover
from problems resulting from the sexual abuse and return to
age-appropriate normal behavior.
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|* Therese L.
Wolf is a Clinical social worker and Terence W. Campbell is a
clinical psychologist at 36250 Dequindre, Suite 320, Sterling
Heights, MI 48310. [Back]