The Cohen/Mannarino and the Deblinger et al. groups collaborated to conduct a multisite randomized, controlled trial for 229 sexually abused children (Cohen et al., 2004). Over 90% of these children had experienced multiple traumas, with a mean of 3.6 different types of traumatic events. Seventy percent had experienced the sudden unexpected death or terminal illness of a loved one; 58% had witnessed domestic violence; 26% were victims of physical abuse; 37% had witnessed or been involved in a serious accident; 17% were victims or witnesses of community violence; 14% had experienced a fire or natural disaster; and 25% had experienced other PTSD-level traumas such as school violence, medical traumas, terrorism or kidnapping.

Most of these children (59%) were living in single-parent families, and 24% of the participating parents had reported drug or alcohol problems. More than half of the participants (52%) were from low-income families. We believe that the children in this study were similar to sexually abused children typically seen in community settings.

This study demonstrated that TF-CBT was superior to child-centered supportive therapy (which included limited interpretations and prompts to discuss sexual abuse-related topics) in improving children's PTSD, depression, behavior problems, and shame and abuse-related attributions such as interpersonal trust. Parents receiving TF-CBT showed greater improvement in depression, emotional distress about their children's abuse, support of the child and effective parenting practices.

King et al. (2000) compared a wait-list control condition to child-only TF-CBT or child plus parent individual TF-CBT for 36 sexually abused children in Australia. They demonstrated that the TF-CBT groups improved significantly with regard to PTSD. It is important to note that therapists conducted the interviews that assessed PTSD symptoms, so these ratings were not blind to the treatment condition. Children in the child-only TF-CBT condition experienced the greatest improvement in anxiety and depressive symptoms after treatment, with the child plus parent group also experiencing significantly greater improvement in anxiety than the wait-list control group. At three-month follow-up, the child plus parent TF-CBT group had lower levels of fear than did the other two groups.

Randomized, controlled trials for sexually abused children that use models other than TF-CBT are rare. One study randomly assigned 71 sexually abused 6 to 14 year olds to 30 sessions of individual psychoanalytic therapy or 18 sessions of group psychoeducation (Trowell et al., 2002). Children receiving the individual psychoanalytic treatment experienced greater improvement in PTSD symptoms than did the group psychoeducation cohort, but the design of the study made it difficult to know whether this difference was due to treatment type, format or length.

Another study randomized 22 sexually abused children to psychodynamic therapy or behavioral reinforcement therapy and found that the reinforcement therapy was superior in improving sleep, enuresis, sexualized behaviors and general behavior problems (Downing et al., 1988). These studies suggest that well-designed randomized, controlled trials of psychoanalytic and behavioral therapies for sexually abused children should be conducted in the future.

In summary, the weight of current evidence supports the superiority of TF-CBT over treatments such as nondirective play therapy and supportive therapies, which are frequently provided to sexually abused children in community settings. We are currently conducting two studies funded by the National Institute of Mental Health to identify the critical components of TF-CBT, the optimal number of TF-CBT treatment sessions for children of different developmental levels, and whether adding sertraline (Zoloft) to TF-CBT improves outcomes in sexually abused children and adolescents. As part of the Substance Abuse and Mental Health Services Administration-funded National Child Traumatic Stress Network (NCTSN), we are also trying to identify optimal methods to successfully disseminate the use of TF-CBT in community settings across the United States. In the future, it will be critical to conduct research to evaluate the efficacy of TF-CBT and other treatments (including psychopharmacological interventions) for sexually abused children with multiple psychiatric or substance abuse comorbidities, and to further test whether TF-CBT and other treatments are effective for children with PTSD related to traumatic events other than sexual abuse.
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