Impact evaluation of a cognitive behavioral group therapy model in Brazilian sexually abused girls

Comparative effectiveness of psychological interventions for treating the psychological consequences of sexual abuse in children and adolescents: a network meta-analysis

BACKGROUND

Following sexual abuse, children and young people may develop a range of psychological problems, including anxiety, depression, post-traumatic stress disorder (PTSD), and a range of behaviour problems. Those working with children and young people experiencing these problems may use one or more of a range of psychological approaches.

OBJECTIVES

To assess the relative effectiveness of psychological interventions compared to other treatments or no treatment controls, to overcome psychological consequences of sexual abuse in children and young people up to 18 years of age. Secondary objectives To rank psychotherapies according to their effectiveness. To compare different 'doses' of the same intervention.

SEARCH METHODS

In November 2022 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and two trials registers. We reviewed the reference lists of included studies, alongside other work in the field, and communicated with the authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing psychological interventions for sexually abused children and young people up to 18 years old with other treatments or no treatments. Interventions included: cognitive behavioural therapy (CBT), psychodynamic therapy, family therapy, child centred therapy (CCT), and eye movement desensitisation and reprocessing (EMDR). We included both individual and group formats.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias for our primary outcomes (psychological distress/mental health, behaviour, social functioning, relationships with family and others) and secondary outcomes (substance misuse, delinquency, resilience, carer distress and efficacy). We considered the effects of the interventions on all outcomes at post-treatment, six months follow-up and 12 months follow-up. For each outcome and time point with sufficient data, we performed random-effects network and pairwise meta-analyses to determine an overall effect estimate for each possible pair of therapies. Where meta-analysis was not possible, we report the summaries from single studies. Due to the low number of studies in each network, we did not attempt to determine the probabilities of each treatment being the most effective relative to the others for each outcome at each time point. We rated the certainty of evidence with GRADE for each outcome.

MAIN RESULTS

We included 22 studies (1478 participants) in this review. Most of the participants were female (range: 52% to 100%), and were mainly white. Limited information was provided on socioeconomic status of participants. Seventeen studies were conducted in North America, with the remaining studies conducted in the UK (N = 2), Iran (N = 1), Australia (N = 1) and Democratic Republic of Congo (N = 1). CBT was explored in 14 studies and CCT in eight studies; psychodynamic therapy, family therapy and EMDR were each explored in two studies. Management as usual (MAU) was the comparator in three studies and a waiting list was the comparator in five studies. For all outcomes, comparisons were informed by low numbers of studies (one to three per comparison), sample sizes were small (median = 52, range 11 to 229) and networks were poorly connected. Our estimates were all imprecise and uncertain. Primary outcomes At post-treatment, network meta-analysis (NMA) was possible for measures of psychological distress and behaviour, but not for social functioning. Relative to MAU, there was very low certainty evidence that CCT involving parent and child reduced PTSD (standardised mean difference (SMD) -0.87, 95% confidence intervals (CI) -1.64 to -0.10), and CBT with only the child reduced PTSD symptoms (SMD -0.96, 95% CI -1.72 to -0.20). There was no clear evidence of an effect of any therapy relative to MAU for other primary outcomes or at any other time point. Secondary outcomes Compared to MAU, there was very low certainty evidence that, at post-treatment, CBT delivered to the child and the carer might reduce parents' emotional reactions (SMD -6.95, 95% CI -10.11 to -3.80), and that CCT might reduce parents' stress. However, there is high uncertainty in these effect estimates and both comparisons were informed only by one study. There was no evidence that the other therapies improved any other secondary outcome. We attributed very low levels of confidence for all NMA and pairwise estimates for the following reasons. Reporting limitations resulted in judgements of 'unclear' to 'high' risk of bias in relation to selection, detection, performance, attrition and reporting bias; the effect estimates we derived were imprecise, and small or close to no change; our networks were underpowered due to the low number of studies informing them; and whilst studies were broadly comparable with regard to settings, the use of a manual, the training of the therapists, the duration of treatment and number of sessions offered, there was considerable variability in the age of participants and the format in which the interventions were delivered (individual or group).

AUTHORS' CONCLUSIONS

There was weak evidence that both CCT (delivered to child and carer) and CBT (delivered to the child) might reduce PTSD symptoms at post-treatment. However, the effect estimates are uncertain and imprecise. For the remaining outcomes examined, none of the estimates suggested that any of the interventions reduced symptoms compared to management as usual. Weaknesses in the evidence base include the dearth of evidence from low- and middle-income countries. Further, not all interventions have been evaluated to the same extent, and there is little evidence regarding the effectiveness of interventions for male participants or those from different ethnicities. In 18 studies, the age ranges of participants ranged from 4 to 16 years old or 5 to 17 years old. This may have influenced the way in which the interventions were delivered, received, and consequently influenced outcomes. Many of the included studies evaluated interventions that were developed by members of the research team. In others, developers were involved in monitoring the delivery of the treatment. It remains the case that evaluations conducted by independent research teams are needed to reduce the potential for investigator bias. Studies addressing these gaps would help to establish the relative effectiveness of interventions currently used with this vulnerable population.

Pilot Randomized Control Trial: Efficacy of a Group-Based Psychosocial Program for Youth with PTSD in the Brazilian Favelas

The study aimed to evaluate Teaching Recovery Techniques (TRT) delivered to Brazilian youth who experienced drug violence in one Favela. Thirty children, 8 to 14 years, were randomly assigned to TRT (n = 14) or to a treatment as usual group (n = 16) involving boxing/martial arts. Youth received five 90-min sessions over successive weeks. Standardized measures assessed Posttraumatic Stress and Depression at 2 weeks pre and post-test. An exploratory assessment of posttraumatic growth was also utilized. An interview with group leaders explored perceptions of delivering TRT within the favela. Medium effect sizes were found for PTSD and Depression, and a small effect size for posttraumatic growth. Group leaders emphasized understanding the favela context for program adaptation. In conclusion, TRT was found to be effective for children with PTSD and Depression who experienced drug violence in a Brazilian favela. TRT is recommended for future delivery. Larger scale RCTs are needed in Brazilian favelas.

Psychological intervention with adult victims of sexual abuse: A comprehensive review

Child sexual abuse (CSA) is a phenomenon that is ubiquitous to all cultures and social classes. It has short- and long-term consequences, with specific treatment models that have been developed and adapted from psychological intervention models. A wide variety of studies have sought to evaluate the results of treatments with adult CSA survivors. This study presents an overview of research on the treatment of adult victims of CSA, by reviewing the existing literature on the types of treatment and the most studied psychotherapeutic avenues, and reports the findings related to the efficacy of these treatments. It is possible to conclude that psychological intervention exhibits benefits in the reduction of symptoms resulting from the experience of CSA and demonstrates the need to conduct further research on the effectiveness of intervention.

Relationships Between CSA Characteristics, Waiting Time, and Psychotherapy Treatment Response

Child sexual abuse (CSA) can cause negative outcomes on cognitive, emotional, physical, and social development of the victims. A significant amount of symptoms related to CSA can be minimized or even treated with professional interventions. Thereby, it is important to examine factors related to treatment response. This article aimed to identify the relationships between CSA characteristics (abuse form, age, relationship with the offender, context, and frequency), waiting time for psychotherapy, and treatment response. Zero-order correlation analysis and network analysis were performed. The analyses called the attention to two important aspects: victims' perception of guilt and waiting time for treatment. In conclusion, these results show that it is crucial to prioritize the development of guilt-related interventions on the treatment of CSA victims. Additionally, it also demonstrates that the immediate psychological care after the disclosure of the abuse can contribute for impact minimization of this experience on children and adolescents.

Evaluating the quality of meta-analytical reviews using the AMSTAR-2: A systematic review of meta-analytical reviews regarding child sexual abuse interventions

BACKGROUND

Effects of treatment for child sexual abuse (CSA) victims have important implications. Assessing Risk of Bias (RoB) is a vital step to inform interpretations of treatment effects for these victims. The AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) offers a comprehensive critical appraisal, allowing users to distinguish high quality reviews.

OBJECTIVE

The aim of this article is two-fold: 1) to provide an up-to-date systematic review of treatment program meta-analytical reviews on interventions for CSA victims; and 2) to evaluate the quality of meta-analytical reviews using the AMSTAR-2. This is the first systematic review to examine the quality of meta-analyses on the effectiveness of CSA interventions using the AMSTAR-2.

METHOD

Eight electronic databases were searched for articles published up to April 2019. Meta-analytical reviews that assessed the effectiveness of any treatment modality for sexually abused children and adolescents up to 18 years old were considered. Outcome measures included physical and mental symptoms, and disorders, measured through validated instruments. Of 2794 articles, nine meta-analyses met the eligibility criteria. There was a variety of interventions, including: trauma-focused cognitive-behavioral therapy CBT, psychodrama, play therapy, and eclectic interventions. The most common outcomes measured were post-traumatic stress disorder/trauma, externalizing, internalizing, and sexualized behaviors.

RESULTS

Although effect sizes were moderately significant, with treatment having a positive effect, all meta-analyses showed a high RoB.

CONCLUSIONS

To use the best available evidence in clinical decision-making for CSA victims, reviewers should conduct meta-analyses that employ RoB tools.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A Summary of Selective Experimental Research on Psychosocial Interventions for Sexually Abused Children

This study was conducted to explore current trends in psychosocial interventions for sexually abused children through a review of recent research. Our comprehensive review is limited to published (quasi) experimental studies in the English language over a period of 2000-2013. It provides a detailed analysis of the final 18 articles that met our inclusion criteria, from the 670 potentially relevant articles that were identified. Reviewers analyzed candidate articles to determine whether they met inclusion or exclusion criteria. The retrieved studies reported positive results with respect to improvements in the negative psychosocial sequelae of child sexual abuse following the use of a diverse set of treatment strategies. Of the various interventions, cognitive behavioral therapy was shown to be the most promising type of intervention for sexually abused children. In this review, we discuss some of the implications of psychosocial interventions for victims of child sexual abuse, citing both the methodological and ethical issues that should be considered.

Psicoterapia para Crianças e Adolescentes Vítimas de Violência Sexual no Sistema Público: Panorama e Alternativas de Atendimento

O objetivo deste ensaio é abordar a questão da garantia de acesso ao tratamento psicoterápico de crianças e adolescentes vítimas de violência sexual pelo sistema público, tendo em vista que o desenvolvimento de psicopatologias em curto e em longo prazo está associado à experiência de violência sexual. As principais leis e diretrizes sobre a organização dos serviços públicos de assistência social e de saúde para vítimas de violência sexual foram revisadas, bem como estudos sobre os encaminhamentos adotados nesses casos. Constatou-se que o serviço público de assistência deve oferecer atendimento psicossocial, enquanto o serviço público de saúde deve oferecer psicoterapia. No entanto, os estudos sobre encaminhamentos de casos de violência sexual contra crianças e adolescentes indicam baixos índices de encaminhamento para serviços que oferecem psicoterapia. Tal panorama é discutido a partir das diretrizes quanto ao público atendido pelo serviço público de saúde no que tange à saúde mental, bem como a partir da quantidade desses serviços em nosso país. Alternativas para a garantia de acesso ao tratamento psicoterápico de crianças e adolescentes vítimas de violência sexual pelo sistema público de saúde são discutidas.