The importance of culture in treating abused and neglected children: an empirical review

Modesty, religion, and community: Therapists' perspectives regarding the treatment of child sexual abuse in the ultra-orthodox community

BACKGROUND

Religion is a significant cultural component that impacts child sexual abuse (CSA) in various ways, including its definition, perception, and treatment. This study focuses on the Jewish ultra-Orthodox community in Israel, a strictly religious, segregated, and close-knit community with unique cultural practices and beliefs that impact children's safety and vulnerability to CSA.

OBJECTIVE

This qualitative study aimed to explore therapists' perceptions and ascribed meanings of CSA treatment within the ultra-Orthodox community.

PARTICIPANTS AND SETTING

Thirty in-depth interviews were conducted with therapists working with the ultra-Orthodox community in Israel.

METHODS

The interviews were analyzed using thematic qualitative analysis.

RESULTS

Three central axes pertinent to the treatment of CSA in the ultra-Orthodox community were discovered: 1) religious interventions, 2) modest approach, relating to the community's taboo attitude towards sexuality; and 3) the collectivistic nature of the community. The results include specific effect sizes and their statistical significance.

CONCLUSIONS

The discussion explores the findings in light of the literature on CSA among religious minority communities and connects them to the unique underlying perception of sexuality in the ultra-Orthodox community. Specific ramifications and recommendations for practice are then considered, alongside the limitations and directions for future study.

Racial Identification as a Protective Factor for At-Risk Parenting in Black Parents: A Longitudinal, Multi-Method Investigation

Although considerable literature focuses on risk factors predicting parents' likelihood to engage in maltreatment, relatively less work evaluates potentially protective parental resources, particularly culturally relevant qualities. The current investigation utilized a multi-method longitudinal study to examine parents' racial identification as a possible resource, hypothesizing that Black parents with stronger racial group identification would demonstrate lower at-risk parenting, operationalized as lower child abuse risk and less negative observed parenting. In a sample of 359 mothers and fathers (half self-identified Black, half non-Hispanic White), controlling for socioeconomic status, findings partially supported the hypothesis. Black parents' greater racial identification was associated with lower child abuse risk and less observed negative parenting, whereas the reverse was true for White parents. The potential limitations of current assessment approaches to gauge at-risk parenting in parents of color are discussed, as well as how racial identification could be considered in culturally informed prevention programming for at-risk parenting.

"It was Really Hard for Me to Tell": The Gap between the Child's Difficulty in Disclosing Sexual Abuse, and their Perception of the Disclosure Recipient's Response

Disclosure of child sexual abuse (CSA) is essential to its mitigation and the protection of children. Previous studies have greatly contributed to the understanding of disclosure rates both in childhood and adulthood, in addition to delayed disclosure and disclosure barriers. In acknowledging the relevancy of the ecological framework, researchers have illustrated how the various systems in the children's lives have a role in their decision to disclose the abuse. The current study was designed to delve into the disclosure stories shared by children during their forensic interviews. Fifty children, 30 girls and 20 boys, from diverse communities in the Jewish society in Israel (15 secular, 15 Orthodox and 20 ultra-Orthodox) were forensically interviewed for the first time following CSA. Thematic analysis was carried out on their narratives, focusing on two main themes. The first was the children's descriptions of their difficulties to disclose, which were embedded in their own perceptions and experiences, their fear of the disclosure recipient's response, and their dynamic with the perpetrator. The second theme provided a glance into the children's descriptions of the disclosure recipients' responses, which highlighted the children's central experience of loneliness in the context of the abuse. Theoretical and practical ramifications pertaining to these crucial gaps will be discussed. In addition, specific religious-cultural elements raised in relation to the disclosure will be highlighted. Limitations of the study as well as further recommendations and implications will be introduced.

Trapped in a Maze: Arab Teachers in Israel Facing Child Sexual Abuse Among Their Pupils

Cultural contexts are formative of and fundamental to how individuals understand, conceptualize, and act within a context of violence. Conceptually and methodologically, however, research from a culturally informed perspective on the experiences of teachers contending with the violence of child sexual abuse (CSA) in particular is broadly limited. As educators frequently confront cases of CSA in their everyday work, their ability to promote detection, disclosure intervention, and especially prevention gives them the potential to be agents of social change; however, while their responsibilities are critical, they are simultaneously members of their communities and cultures, and their interactions are bound by these dynamics. The purpose of the study is to analyze the experiences of Arab teachers in Israel who confront CSA in their everyday work. The findings are based on qualitative thematic analysis of semi-structured interviews conducted with 30 female Arab teachers working within the Arab school system in Israel. Results indicate that when facing CSA, the teachers experience an ongoing conflict between their cultural and professional codes, trapping them in a maze of intertwining and oppositional demands. On the one hand, they are constrained by the norm of protecting the honor and maintaining the status and reputation of those involved, including themselves; on the other hand, as empathetic professionals, they desire to aid their pupils. While the participants do not accept the status quo, they are effectively at a loss as to how to change it. In order find a way out of their entrapment in coping with CSA among their pupils, the only currently available path is to act as a lone hero; there is, however, the potential to foster the development of a secondary culture within the school to inaugurate cultural change in coping with CSA. Implications for future research, policy, and practice are discussed.

Childhood Physical Abuse and Antisocial Traits: Mediating Role of Posttraumatic Stress Symptom Clusters

Posttraumatic stress symptoms (PTSS) are associated with both childhood physical abuse (CPA) and antisocial (AS) traits, yet their potential as mediators of the CPA-AS traits link is understudied and the specific roles of individual symptom clusters in this relation is unknown. The current study aimed to examine the mediational role of PTSS in the relation between CPA and AS traits in a sample of low-income African American women with histories of intimate partner violence (IPV). It was hypothesized that avoidance would emerge as a significant mediator, whereas reexperiencing, numbing, and hyperarousal would not. Participants (N = 150) were recruited from a level-1 trauma public hospital and evaluated as part of a randomized controlled trial of a group therapy intervention for low-income, African American women suicide attempters with histories of IPV. The Childhood Trauma Questionnaire (CTQ), Posttraumatic Diagnostic Scale (PDS), and International Personality Disorder Examination-Screening Questionnaire (IPDE-SQ) were used to measure variables of interest. Using bootstrapping analyses, a parallel mediation model compared PTSS clusters as potential mediators of the CPA-AS traits relation, controlling for IPV. When reexperiencing, avoidance, numbing, and hyperarousal were entered simultaneously as potential mediators, only avoidance emerged as a significant mediator of the CPA-AS traits link. Avoidance symptoms may play a unique role in the link between early experiences of CPA and later AS traits among multiply traumatized African American women. Findings have implications for understanding AS traits in the context of early life trauma and suggest that targeting specific PTSS clusters (e.g., avoidance) may improve treatment outcomes for women in this population.

Disclosing the abuse: The effect of ethnoreligious identity on CSA disclosure in forensic interviews

Multiple studies have examined sexually abused children and their interactions with the legal system, as manifested in children's disclosures of sexual abuse during forensic interviews. Nevertheless, few have done so while referencing contextual variables, such as ethnoreligious identity. The current study was designed to examine how ethnoreligious identity affects children's disclosure in forensic interviews beyond the contribution of child characteristics and abuse characteristics. In addition, the moderating role of pre-interview disclosure was examined. An analysis of 1054 forensic interviews conducted in Israel indicated a relationship between a child's age, gender, and abuse characteristics (i.e., perpetrator identity and type of abuse) with the likelihood of disclosure during the forensic interview. The results indicated a relationship between ethnoreligious identity and forensic disclosure. Unexpectedly, Muslim Arab children were more likely to disclose than Jewish children. Predictably, pre-interview disclosure moderated the relationship between abuse characteristics and ethnoreligious identity (among Jews) and forensic disclosure. Conversely, it did not moderate the relationship between child characteristics and disclosure during the forensic interview. The findings demonstrate the importance of a context-informed examination of child abuse disclosure and its potential to advance the development of services adapted to children from diverse communities.

Cultural Betrayal as a Dimension of Traumatic Harm: Violence and PTSS among Ethnic Minority Emerging Adults

According to cultural betrayal trauma theory, within-group violence confers a cultural betrayal that contributes to outcomes, including symptoms of posttraumatic stress disorder (PTSS). Close relationship with the perpetrator, known as high betrayal, also impacts PTSS. The purpose of the current study is to examine cultural betrayal trauma, high betrayal trauma, and PTSS in a sample of diverse ethnic minority emerging adults. Participants (N = 296) completed the one-hour questionnaire online. Hierarchical linear regression analyses revealed that when controlling for gender, ethnicity, and interracial trauma, high betrayal trauma and cultural betrayal trauma were associated with PTSS. Clinical interventions can include assessments of the relationship with and in-group status of the perpetrator(s) in order to guide treatment planning with diverse survivors.

Child maltreatment and protective assets in the development of internalising and externalising problems: A study of youth offenders

INTRODUCTION

An emerging trend in child maltreatment research focuses on identifying protective assets that contribute to youth resilience. Extending the trend, this study examines not just whether but also how protective assets in various domains (e.g., the individual, family, and schools) are associated with internalising and externalising problems among youth offenders, which is a population that typically reports a high prevalence of child maltreatment experiences.

METHODS

This study used the baseline data of 790 youth offenders (85% male) aged between 12 and 19 years old from the EPYC project, a national longitudinal study in Singapore. Structural equation modelling was conducted to test the direct effects and interactive effects of protective assets and child maltreatment on internalising and externalising problems.

RESULTS

For direct effects, maltreated youth offenders reported higher levels of internalising and externalising problems than their non-maltreated counterparts. Higher levels of peer assets were directly related to lower levels of externalising, but not internalising problems. For interactive effects, overall protective assets, school/work assets and internal assets had significant buffering effects against physical/emotional abuse on externalising problems, whereas peer assets showed significant buffering effects against sexual abuse on internalising problems.

CONCLUSION

An overall level of protective assets, as well as assets from specific domains (peer, school/work, and internal assets) could provide protective effects on problematic behaviours among youth offenders. Interventions seeking to address youth internalising and externalising problems should focus on reducing child maltreatment incidence and enhancing protective assets within these domains.

Components associated with the effect of home visiting programs on child maltreatment: A meta-analytic review

BACKGROUND

Home visiting programs are widely endorsed for preventing child maltreatment. Yet, knowledge is lacking on what and how individual program components are related to the effectiveness of these programs.

OBJECTIVE

The aim of this meta-analysis was to increase this knowledge by summarizing findings on effects of home visiting programs on child maltreatment and by examining potential moderators of this effect, including a range of program components and delivery techniques.

METHODS

A literature search yielded 77 studies (N=48,761) examining the effectiveness of home visiting programs, producing 174 effect sizes. In total, 35 different program components and delivery techniques were coded.

RESULTS

A small but significant overall effect was found (d=0.135, 95 % CI (0.084, 0.187), p<0.001). Programs that focused on improving parental expectations of the child or parenthood in general (d = 0.308 for programs with this component versus d = 0.112 for programs without this component), programs targeting parental responsiveness or sensitivity to a child's needs (d = 0.238 versus d = 0.064), and programs using video-based feedback (d = 0.397 versus d = 0.124) yielded relatively larger effects. Providing practical and instrumental assistance was negatively associated with program effectiveness (d=0.044 versus d = 0.168). Further, program effects were larger when percentages of non-Caucasians/non-Whites in samples and follow-up durations increased.

CONCLUSIONS

In general, home visiting programs can prevent child maltreatment only to a small extent. However, implementing specific components and techniques can improve program effectiveness.

Specific effects of neglect and physical abuse on adolescent aggressive behaviors by gender: A multicenter study in rural China

BACKGROUND

Neglect and physical abuse may be typical risk factors for aggressive behavior in adolescents. However, findings on their specific effects and sex differences are still unclear. This study aimed to examine the specific effects of neglect and physical abuse on adolescent aggressive behaviors and to further explore the potential sex-specific effect.

METHODS

A multicenter school-based survey was conducted in rural China. A total of 15,957 students aged 11-20 years completed self-report questionnaires to record aggressive behaviors, neglect and physical abuse, and other related information. Participants were grouped into those who experienced none, one of, or both neglect and physical abuse for statistical analyses.

RESULTS

Of the participants, 37.0% experienced both neglect and physical abuse, 30.0% experienced neglect only, and 9.8% experienced physical abuse only. Higher risk for physical aggression (OR=1.24, 95% CI=1.06-1.45), and lower risk for verbal aggression (OR=0.83, 95% CI=0.72-0.94) and hostility (OR=0.81, 95% CI=0.69-0.94) were found in the physical abuse only group as compared to the neglect only group. No sex difference was found between neglect or physical abuse and general aggressive behaviors (P>0.05), except that females were more likely to exert physical aggression than males when exposed to neglect and physical abuse (P<0.05).

LIMITATIONS

Cross-sectional design, retrospective self-report data, and not including other maltreatment subtypes.

CONCLUSIONS

Neglect and physical abuse may each have distinct sensitivity for different subtypes of aggression. Targeted treatment for diverse aggressive symptoms is suggested, and strategies to prevent both neglect and physical abuse across gender would yield comprehensive benefits.

Latent classes of DSM-5 acute stress disorder symptoms in children after single-incident trauma: findings from an international data archive

Background: After a potentially traumatic event (PTE), children often show symptoms of acute stress disorder (ASD), which may evolve into posttraumatic stress (PTS) disorder. A growing body of literature has employed latent class analysis (LCA) to disentangle the complex structure underlying PTS symptomatology, distinguishing between homogeneous subgroups based on PTS presentations. So far, little is known about subgroups or classes of ASD reactions in trauma-exposed children. Objective: Our study aimed to identify latent classes of ASD symptoms in children exposed to a single-incident PTE and to identify predictors of class membership (gender, age, cultural background, parental education, trauma type, and trauma history). Method: A sample of 2287 children and adolescents (5-18 years) was derived from the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive, an international archive including studies from the USA, UK, Australia, and Switzerland. LCA was used to determine distinct subgroups based on ASD symptoms. Predictors of class membership were examined using a three-step approach. Results: Our LCA yielded a three-class solution: low (42%), intermediate (43%) and high (15%) ASD symptom severity that differed in terms of impairment and number of endorsed ASD symptoms. Compared to the low symptoms class, children in the intermediate or high severity class were more likely to be of female gender, be younger of age, have parents who had not completed secondary education, and be exposed to a road traffic accident or interpersonal violence (vs. an unintentional injury). Conclusions: These findings provide new information on children at risk for ASD after single-incident trauma, based on a unique set of international data. Classifying children based on latent symptom profiles helps to identify target groups for prevention and intervention after exposure to a PTE.

Childhood emotional abuse, self/other attachment, and hopelessness in African-American women

There is evidence that individuals emotionally abused as children endorse more hopelessness, a precursor of suicidal behavior in adulthood. However, there has been little focus on this association among African-Americans or on factors that may mediate the childhood emotional abuse (CEA) - adult hopelessness link. The present study examined whether CEA is linked to hopelessness in adulthood in African-American women suicide attempters and if adult self and other attachment models mediate this association. Participants included 116 African-American women recruited from a large, urban hospital. Results revealed that CEA had no direct effect on hopelessness in adulthood, but did have an indirect effect on hopelessness through attachment models. Bootstrapping analyses showed that higher levels of CEA were related to more negative self and other attachment models, which were then linked to higher levels of hopelessness. Implications for targeting attachment in suicide intervention programs are discussed.

Community Outreach Program for Child Victims of Traumatic Events

Behavioral and cognitive behavioral treatment interventions have been shown to be effective for the treatment of trauma-related problems in children. However, many children and families in need of treatment do not have adequate access to services and do not have access to effective, evidence-based treatment services. The present article describes a community-based program that provides in-home and in-school treatment services, based on behavioral and cognitive behavioral approaches to addressing trauma-related emotional and behavioral problems in children.

Assessment of the Harmful Psychiatric and Behavioral Effects of Different Forms of Child Maltreatment

IMPORTANCE

Several widely held beliefs about child abuse and neglect may be incorrect. It is most commonly assumed that some forms of abuse (eg, physical and sexual abuse) are more harmful than others (eg, emotional abuse and neglect); other assumptions are that each form of abuse has specific consequences and that the effects of abuse differ across sex and race.

OBJECTIVE

To determine whether widely held assumptions about child abuse and neglect are valid by testing the hypothesis that different types of child maltreatment (CM) actually have equivalent, broad, and universal effects.

DESIGN, SETTING, AND PARTICIPANTS

This observational study assessed 2292 racially and ethnically diverse boys (1254 [54.7%]) and girls (1038 [45.3%]) aged 5 to 13 years (mean [SD] age, 9.0 [2.0] years) who attended a research summer camp program for low-income, school-aged children from July 1, 1986, to August 15, 2012. Of these children, 1193 (52.1%) had a well-documented history of maltreatment. Analysis was conducted from September 25, 2013, to June 1, 2015.

MAIN OUTCOMES AND MEASURES

Various forms of internalizing and externalizing personality and psychopathologic traits were assessed using multiple informant ratings on the California Child Q-Set and Teacher Report Form as well as child self-reported depression and peer ratings of aggression and disruptive behavior.

RESULTS

Structural analysis showed that different forms of CM have equivalent psychiatric and behavioral effects, ranging from anxiety and depression to rule-breaking and aggression. We also found that nonsexual CM alters 2 broad vulnerability factors, internalizing (β = 0.185; SE = 0.028; P < .001) and externalizing (β = 0.283; SE = 0.023; P < .001), that underlie multiple forms of psychiatric and behavioral disturbance. We show that CM has comparable consequences for boys and girls of different races, and our results allowed us to describe a base rate and co-occurrence issue that makes it difficult to identify the unique effects of child sexual abuse.

CONCLUSIONS AND RELEVANCE

Our findings challenge widely held beliefs about how child abuse should be recognized and treated-a responsibility that often lies with the physician. Because different types of child abuse have equivalent, broad, and universal effects, effective treatments for maltreatment of any sort are likely to have comprehensive psychological benefits. Population-level prevention and intervention strategies should emphasize emotional abuse, which occurs with high frequency but is less punishable than other types of child maltreatment.

Trauma and Child Health: An Introduction to the Special Issue

Potentially traumatic events are common occurrences that can lead to significant psychological distress, and yet, there has been remarkably little attention to the associations between traumatic events and youth's physical health. The articles contained in this Special Issue of the Journal of Pediatric Psychology represent a significant step forward in the establishment of "Trauma and Child Health" as a major area of study within the field of pediatric psychology. In this introductory article, we briefly describe several contextual issues that may help to set the stage for the articles contained in this Special Issue. These contextual issues include the most common types of traumatic events that are studied, as well as the features of traumatic events that may affect physical and mental health outcomes, such as whether casualties or interpersonal violence is involved.

Trajectories of psychopathology and risky behaviors associated with childhood abuse and neglect in low-income urban African American girls

The current study examined patterns of psychopathology, drug and alcohol use, and sexual behavior associated with childhood abuse and neglect in a high-risk sample of low-income African American girls seeking mental health treatment. Participants (N=177) were African American girls recruited from mental health clinics serving low-income communities in Chicago, IL and followed over six waves of data collection (T1-T6) reflecting early (mean age 14) to late (mean age 17) adolescence. Child abuse and neglect history was determined from adolescent and caregiver reports. Latent curve modeling examined patterns of internalizing and externalizing psychopathology, drug and alcohol use, sexual experience, and risky sexual behavior reported by girls and associations with reported child abuse and neglect. Overall, these trajectories indicated a decrease in internalizing and externalizing symptoms, stability of drug and alcohol use, and an increase in sexual experience and risky sexual behaviors over time. Child abuse and neglect was associated with increased internalizing symptoms and sexual experience at baseline and with externalizing symptoms and risky sexual behavior both at baseline and the final point. Child abuse and neglect was not significantly associated with alcohol or drug use. This study adds to the literature on the long-term consequences of child abuse and neglect by demonstrating patterns of psychopathology and risky behavior that persist over time in a high-risk group of girls with self or parent reported histories of abuse and neglect. Interventions that address externalizing problems and health risk behaviors may be of particular importance for this population.

Cultural considerations and child maltreatment: in search of universal principles

Cultural diversity poses challenges within the health care setting, particularly regarding the question of how health professionals can resolve the tension between respecting cultural norms or child-rearing practices and the importance of determining what constitutes harm and child maltreatment. Cultural competency and respect for cultural diversity does not imply universal tolerance of all practices. The United Nations provides a standard of universal child rights, protecting them from harmful practices. Pediatric providers must respect cross-cultural differences while maintaining legal and ethical standards of safety and wellbeing for children, promoting evidence-based prevention of maltreatment, and advocating for child wellness across all cultures.

"Who can you tell?" Features of Arab culture that influence conceptualization and treatment of childhood sexual abuse

The literature on child sexual abuse reflects growing recognition of the manner in which culture impacts the conceptualization, experience, and treatment of such cases. Despite heightened visibility of Arab Americans within the United States, population due to recent media attention, little empirical research exists on the occurrence of child sexual abuse within this population. Arab culture is often characterized by an emphasis on collectivism and familial obligations, and such features may prove to either facilitate or impede assessment and treatment of child sexual abuse, depending on how they are manifested. In terms of reporting child sexual abuse, cultural values pertaining to shame and honor as well as the stigma attached to mental health problems may influence the response to abuse. As such, enhancing the cultural competence of the therapist is key to facilitating effective cultural practice. Empirical research is required to investigate and substantiate these concepts as they relate to child sexual abuse in Arab-American populations.

Childhood maltreatment among Hispanic women in the United States: an examination of subgroup differences and impact on psychiatric disorder

Prevalence rates of childhood maltreatment among Hispanic women in the United States are presented separately for nativity status and ethnic origin subgroups, and the associations between different types of maltreatment and the development of anxiety and depressive disorders are examined. Analyses used self-report data from 1,427 Hispanic women who participated in the National Latino and Asian American Survey. Foreign-born Hispanic women compared to U.S.-born Hispanic women reported significantly lower rates of sexual assault and witnessing interpersonal violence, and a significantly higher rate of being beaten. Ethnic subgroups reported similar rates of maltreatment, with the exception of rape. Bivariate analyses were remarkably consistent in that regardless of nativity status or ethnic subgroup, each type of maltreatment experience increased the risk of psychiatric disorder. In multivariate models controlling for all types of victimization and proxies of acculturation, having been beaten and witnessing interpersonal violence remained significant predictors of both disorders, but sexual abuse increased risk of anxiety only. A significant interaction effect of family cultural conflict and witnessing violence on anxiety provided very limited support for the hypothesis that acculturation moderates the influence of maltreatment on mental health outcomes. Implications for culturally relevant prevention and intervention approaches are presented.

Cultural issues in child maltreatment

AIMS

Waves of immigration from the latter half of the 20th century have changed the cultural and ethnic mix of major regions of the world. Dynamic multicultural societies now are a reality across the Western world. The relationship and influence of these diverse cultures to the understanding and identification of child abuse and neglect is challenging and complex. Health professionals working with children from culturally and linguistically diverse groups often find themselves with the challenge of exploring and resolving the tension between definitions of harm in child protection practice and various cultural and child-rearing practices. In this paper, we set out ways of thinking about the influence of culture when approaching and dealing with the suspicion of child maltreatment.

METHODS

We will explore how culture shapes the experiences of childhood, child-rearing practices, and identify common barriers in working with children and families from culturally diverse backgrounds when presenting with child maltreatment. We will use case examples from Europe and Australia to illustrate the real life challenges of working in the area of child maltreatment across cultures. We will review the scientific literature exploring the nexus between culture and child maltreatment, identifying the gaps in the literature and highlight areas for future research.

RESULTS

We suggest a model for dealing with cultural issues in child maltreatment that is culturally competent and respectful.

CONCLUSIONS

The model for cultural competency in child health and child protective services incorporates four domains for advocacy and action - individual, professional, organisational and systemic.

Childhood psychological abuse and adult aggression: the mediating role of self-capacities

The current study examines the utility of self-trauma theory for explaining the long-term impact of childhood psychological abuse on aggression. Specifically, the self-capacities of interpersonal relatedness, identity, and affect regulation are tested as mediators of the impact of psychological abuse on various types of aggression in adulthood. Hierarchical regression analyses are used to examine data collected from 268 university students who completed the Personality Assessment Inventory, Comprehensive Child Maltreatment Scale, and the Inventory of Altered Self-Capacities. Results show that self-capacities were predicted by maltreatment, particularly psychological abuse. Altered self-capacities fully mediate the impact of child maltreatment on various forms of aggression. Problems with interpersonal relationships play the most significant role in mediating the relationship between child maltreatment and aggression. Results suggest more frequent maltreating experiences predict more dysfunctional self-capacities, which increases the probability of displaying various forms of aggression.

Cognitive-behavioral treatment for posttraumatic stress disorder in children and adolescents

Several cognitive-behavioral therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). These treatments include common elements (eg, psychoeducation, gradual exposure, relaxation). This review (1) delineates common elements in CBT approaches for treating child and adolescent PTSD; (2) provides a detailed review of three CBT approaches with substantial evidence of effectiveness; and (3) describes promising practices in the area of CBT approaches to treating child and adolescent PTSD. Cultural and implementation considerations are also included.

Child sexual abuse, links to later sexual exploitation/high-risk sexual behavior, and prevention/treatment programs

This paper reviews the literature on the nature and incidence of child sexual abuse, explores the link between child sexual abuse and later sexual exploitation, and reviews the literature on prevention strategies and effective interventions in child sexual abuse services. Our understanding of the international epidemiology of child sexual abuse is considerably greater than it was just 10 years ago, and studies from around the world are examined. Childhood sexual abuse can involve a wide number of psychological sequelae, including low self-esteem, anxiety, and depression. Numerous studies have noted that child sexual abuse victims are vulnerable to later sexual revictimization, as well as the link between child sexual abuse and later engagement in high-risk sexual behaviour. Survivors of child sexual abuse are more likely to have multiple sex partners, become pregnant as teenagers, and experience sexual assault as adults. Various models which attempt to account for this inter-relationship are presented; most invoke mediating variables such as low self-esteem, drug/alcohol use, PTSD and distorted sexual development. Prevention strategies for child sexual abuse are examined including media campaigns, school-based prevention programmes, and therapy with abusers. The results of a number of meta-analyses are examined. However, researchers have identified significant methodological limitations in the extant research literature that impede the making of recommendations for implementing existing therapeutic programmes unreservedly.

Implementing trauma-focused CBT with fidelity and flexibility: a family case study

Effective approaches for the treatment of childhood posttraumatic stress disorder and traumatic grief are needed given the prevalence of trauma and its impact on children's lives. To effectively treat posttraumatic stress disorder in children, evidence-based practices should be implemented with flexibility and responsiveness to culture, developmental level, and the specific needs of the family. This case study illustrates flexibility with fidelity in the use of a manualized treatment, describing the implementation of Trauma Focused-Cognitive Behavior Therapy with three traumatized family members-a caregiver and two children. Particular attention is paid to the use of creative strategies to tailor interventions to the individual clients while maintaining fidelity to the principles and components of this evidence-based treatment.

Associations of child maltreatment and intimate partner violence with psychological adjustment among low SES, African American children

OBJECTIVE

This study assessed the unique and interactive effects of child maltreatment and mothers' physical intimate partner violence (IPV) status on low-SES African American children's psychological functioning.

METHODS

Mothers were recruited from a large, inner-city hospital, and those who met eligibility criteria were asked to complete a lengthy face-to-face interview while their child was assessed separately but concurrently. The sample included 152 mother-child dyads. The children's mean age was 10 years, and 45% were male. Multivariate linear regression analyses tested the main and interactive effects of child maltreatment and mothers' exposure to physical IPV on children's psychological functioning (internalizing and externalizing symptoms, traumatic stress symptoms), while controlling for covariates.

RESULTS

Children who experienced child maltreatment and children whose mothers experienced physical IPV had higher levels of psychological distress than their respective counterparts. Post hoc analysis of significant interaction effects indicated that child maltreatment was associated with internalizing and externalizing problems and traumatic stress only when mothers reported higher levels of physical IPV. This finding did not hold true for youth whose mothers did not acknowledge elevated rates of physical IPV.

CONCLUSIONS

African American youth from low-SES backgrounds who are maltreated and whose mothers experience physical IPV are at particularly high risk for psychological distress. Targeted prevention and intervention programs are needed for these poly-victimized youth.

Families who begin versus decline therapy for children who are sexually abused

OBJECTIVE

To identify child characteristics, factors related to the therapy referral, and caregivers' psychological and social variables that predict sexually abused children's beginning therapy following a therapy referral.

METHOD

Investigators abstracted data from case records of 101 families whose children were referred to a Children's Advocacy Center for therapy because of sexual abuse. Face-to-face interviews were conducted with a subsample of 45 caregivers 2-3 months after the referral to therapy. Case record and interview variables were entered into bivariate and multiple variable logistic regression analyses to identify predictors of entry into therapy.

RESULTS

Only 54% of children had started therapy by 2 months post referral. The odds of entry into therapy were 2.10 times greater for non-Black versus Black children and, contrary to what would be expected, 13.90 times greater for children whose mother figures were accused of neglectful supervision. Among those interviewed (n=45), caregivers who initiated child therapy more often saw therapy as giving emotional help and reported that they themselves felt comfortable making disclosures to a therapist. They also differed with respect to the activities they liked to do with their children.

CONCLUSIONS

Many children who experience sexual abuse and are referred to therapy never begin it. Black children are overrepresented among these. In-depth interviews may reveal more subtle differences between families initiating and declining therapy than case records.

PRACTICE IMPLICATIONS

High rates of non-initiation of psychotherapy for sexually abused children indicate the need to identify how these rates could be reduced. To this end, the present study suggests the usefulness of focusing attention on engagement of Black families and on proactive involvement with caregivers identified as potentially unsupportive of their children.

An analysis of the impact of diverse forms of childhood psychological maltreatment on emotional adjustment in early adulthood

Recent research has documented the long-term mental health consequences of childhood psychological maltreatment; however, this research is limited in that it typically fails to recognize the qualitative differences of the various behaviors labeled as psychological maltreatment. This study examines the predictive ability of caregiver terrorizing, degradation, ignoring, and isolating during childhood on the self-reported occurrence of anxiety, depression, somatic complaints, and features of borderline personality disorder (BPD) in a sample of 256 university students between the ages of 18 and 22. Witnessing violence and childhood physical abuse are included in the analyses. Simultaneous regression analyses reveal that different forms of maltreatment emerge as predictors of the variables of emotional adjustment. Terrorizing predicted anxiety and somatic concerns, ignoring predicted scores of depression and features of BPD, and degradation predicted BPD features only. Findings suggest psychological maltreatment is a multifaceted construct requiring further research to investigate the long-term impact of various subtypes.

Post-traumatic Stress in Children and Adolescents Exposed to Family Violence: I. Overview and Issues

Exposure to child physical abuse and parents' domestic violence can subject youth to pervasive traumatic stress and lead to Post-traumatic Stress Disorder (PTSD). The often repeating and ongoing nature of family violence exposure may result in youth exhibiting problems in multiple domains of functioning and meeting criteria for multiple disorders in addition to PTSD. These characteristics as well as unique factors related to children's developmental level and symptom presentation complicate a PTSD diagnosis. This paper describes evolving conceptualizations in the burgeoning field of trauma related to family violence exposure, and reviews considerations that inform assessment and treatment planning for this population.

Ethnicity in child maltreatment research: a replication of Behl et al.'s content analysis

This study examines the use of ethnicity in 489 empirical research articles published in three major child maltreatment specialty journals from 1999 to 2002. Of the American samples, 12.5% focus on ethnicity, 76.2% report the ethnic composition of participants, and 33.8% use ethnicity of participants in analyses. Ethnicity has a significant effect in 52.3% of articles in which it was used in analyses, suggesting its importance as a variable in a wide range of studies. African Americans and Native Americans are underrepresented in research samples. These findings indicate more attention to ethnicity in American research than Behl, Crouch, May, Valente, and Conyngham's 2001 study might suggest but also highlight the need for continued expansion in focusing on, reporting, and using ethnicity in research.

Predictors of Resilience in Maltreated and Nonmaltreated Latino Children

To date, few studies have sought to investigate the effects of child maltreatment and processes influencing maladaptation and resilience in Latino children. In the current investigation, multiple aspects of functioning, personal resources, and relationship features were examined in school-age maltreated and nonmaltreated Latino children. Maltreated Latino children were found to have fewer areas of resilient functioning. Ego-resiliency and ego-control, as personal resources, and the ability to form a positive relationship with an adult figure outside of the immediate family predicted resilience. However, certain aspects of interpersonal functioning were differentially related to resilience for maltreated and nonmaltreated Latino children. These findings have implications for understanding how resilience can be promoted in maltreated and nonmaltreated Latino children.

Adolescent sexual assault: an update of the literature

PURPOSE OF REVIEW

In this review, we examine the most recent literature on adolescent sexual assault, and summarize new findings regarding prevalence, risk factors, sequelae, cultural factors, genital injury, legal issues and practice implications.

RECENT FINDINGS

Child and adolescent sexual-assault victims are at risk for a range of negative outcomes, including comorbid post-traumatic stress disorder and major depressive episode, comorbid post-traumatic stress disorder and substance abuse, eating disorders, delinquency, and revictimization. Cultural factors and severity levels of trauma may serve as risk factors to such outcomes in adolescent sexual-assault victims. Compared with adults, adolescent sexual-assault victims have a greater frequency of rape-related anogenital injuries, but data on healing of injuries in this population are lacking. Factors related to a child sexual-assault victim's demeanor and intelligence can influence the perceived credibility of the child as a witness to the abuse.

SUMMARY

Recent studies investigating prevalence, risk factors, and sequelae of child and adolescent sexual assault highlight the need for educational programs and primary prevention interventions to educate pre-pubescent children and adolescents about sexuality, including sexual assault. In addition, further research is warranted in the area of statutory rape reporting to determine its effects on adolescent health-service-seeking behaviors and outcomes. Although most adolescent sexual assault victims do not seek acute post-rape medical care, forensic nurse examiners are often the first clinicians to encounter the adolescent sexual assault victim. Nursing protocols that standardize evidence collection as well as psychological support are important in the comprehensive care of these traumatized teens.

Treating child abuse-related posttraumatic stress and comorbid substance abuse in adolescents

OBJECTIVE

Child abuse is a risk factor for developing Posttraumatic Stress Disorder (PTSD) and subsequent Substance Use Disorder (SUD). The purpose of this review is to summarize current knowledge about effective treatments for adolescent abuse-related PTSD, SUD, and the co-occurrence of these conditions.

METHOD

The literature on empirical treatment studies for these conditions in adolescence was reviewed, summarized, and synthesized.

RESULTS

Randomized controlled studies of abuse-related PTSD and SUD in adolescents have supported the efficacy of cognitive behaviorally-based individual and family treatment components. Components overlap considerably in empirically supported treatments for each disorder. An integrated treatment approach is described for use in adolescents with abuse-related PTSD and SUD, with recommendations for optimizing services for this population and for future research.

CONCLUSIONS

The available evidence on effective treatments suggests that integrated PTSD- and SUD-focused cognitive-behavioral and family treatment for adolescents with comorbid abuse-related PTSD and SUD may optimize outcomes for this population.

Psychosocial and pharmacological interventions for child crime victims

Children may develop a variety of difficulties following victimization, including posttraumatic stress disorder (PTSD), other anxiety symptoms, depressive disorders, externalizing symptoms, or substance use disorders. Some children appear to be resilient in the face of victimization and do not report significant difficulties. A growing number of treatment studies for child abuse victims has supported the efficacy of trauma-focused cognitive-behavioral therapy (CBT); however, more research is needed to determine the critical components and optimal dosage of CBT, and to evaluate the efficacy of this approach for other groups of child crime victims. Psychopharmacological treatments are widely used for childhood PTSD, but little research has evaluated such treatments. Treatment guidelines and future directions are discussed.

Culture and child maltreatment: cultural competence and beyond

OBJECTIVE

The objective of this article is to comment on current issues in the relationship between culture and child maltreatment.

METHOD

A review of the literature on culture and child maltreatment is the basis of the article.

RESULTS AND CONCLUSION

While attention has been directed to the relationship between culture and maltreatment for more than 20 years, there is a need for further development in this area. Efforts need to be made to "unpack" culture, to promote understanding culture in context, and to enhance research on child maltreatment and culture.