Vol. 20, No. 2
April 2015

Providing a Trauma-Informed Response to Child Sexual Abuse

We know children who experience sexual abuse can be further traumatized by CPS assessments and law enforcement investigations. We also know that without appropriate treatment, survivors of child sexual abuse are at increased life-long risk for a broad array of physical and mental health problems, as well as future victimization (Hilaski, et al., 2008; O'Brien & Scher, 2013; Sachs-Erisson, et al., 2009; all cited in Flick, et al., 2014).

What can child welfare workers and agency leaders do to ensure their involvement minimizes trauma and promotes healing?

1. Practice self-care. We can't take care of others unless we care for ourselves. Workers and agencies must find ways to integrate self-care into their normal routines. Hearing horrific details of child sexual abuse, feeling the pressure of added legal scrutiny, managing uncertainty and ambiguity, and experiencing intense reactions towards the alleged offender and other family members--all this can cause workers to dread and distance themselves emotionally from these cases (van Dernoot Lipsky, 2009). Yet child sexual abuse victims need an authentic connection with an engaged and caring worker who will advocate for and support them. Professionals themselves need support and protection from the damaging effects of secondary traumatic stress. For more on this, visit http://bit.ly/1COZSUn.

2. Reduce the trauma of the investigative process. The following steps reduce the negative impact on a child while the interdisciplinary process unfolds (Aprile, et al., 2009; Saywitz & Comparo, 2014; Staller & Faller, 2010; all cited in Flick, et al., 2014):

Reduce the number of interviewers. Have the same person interview the child when more information is needed, rather than requiring the child to tell their story over and over to different people. This rapport building may also increase the child's feeling of safety, making disclosure in a later interview possible even if the child does not initially disclose.
Reduce the number of interviews. Use video recording, one-way mirrors, and other methods to minimize the number of times the child needs to be questioned. Children's Advocacy Centers (CACs) use many of these approaches, as well as skilled interviewers who can make the experience less stressful and more empowering for the victim. Ask parents, school teachers, and counselors not to interview or interrogate the child.
Select the interview location carefully. Use a place that is private, comfortable, and familiar to the child.
On the rare occasion that a very young child refuses to be seen without a caregiver present, allow a support person to be with the child. Tell this person they can come into the room initially, but must sit behind the child, must not respond to anything the child says or does, and must not be involved in the interview. If the child looks to them for an answer, they are to say, "I can't help you answer. It's okay to tell Miss Carol." Once the child is comfortable, the adult should find an excuse to leave. "Have the adult give the child instructions: Tell the truth because we want to understand what you remember."
Get the child's agreement for the medical exam. Children who have been sexually violated need as much control as possible over their bodies. If the child resists the exam, don't force the child to cooperate. Giving an age-appropriate explanation of what to expect during the exam, the reasons for the exam, and rescheduling it can help the child feel psychologically safe enough to cooperate. If it is a medical emergency and the exam must be done immediately, the doctor could make the child feel safer through the use of sedation.
Explain everything--at the child's developmental level--and offer choices. Children may be able to give their agreement to many things that happen in an investigative assessment, such as where and when to meet, where they might like to sit, or what supports or people would be helpful. If the child and family are safe and mental health issues are stable, older youth may be part of discussions about whether to arrest an alleged offender. Offering choices helps you join with the child and increases their sense of control over what happens to them.
Do not use polygraphs or voice analyzers with children or teens. Such methods give the message that they are not believed, and their efficacy has not been established for children.
Have the law enforcement officer testify at the probable cause hearing, not the child.

3. Let children talk. Sometimes workers feel anything related to the abuse is a forbidden topic if there is an on-going investigation, says Jeanne Preisler, Coordinator of Project Broadcast, North Carolina's federally-funded initiative to build a trauma-informed child welfare system. "You're not conducting an interview and you don't want to probe, but the child may mention things or want to tell you how they're feeling. They may spontaneously disclose things that they haven't said to others." Children may also express feelings of guilt and responsibility, not only for the abuse but also for the upheaval that followed their disclosure. Families that have experienced sexual abuse often have cultures of secrecy and shame, and children are frequently given the message that they are to blame for what has happened (Sgroi, 1982).

As a child welfare professional, you may provide a safe place for the child to express their true feelings, and you can send the child the message that she is not to blame for what has happened. It is possible to listen empathically and reduce children's sense of shame without compromising the investigation.

4. Attend to psychological and physical safety. In child sexual abuse cases our attention is understandably focused on physical safety: making sure the alleged abuser has no unsupervised contact or access to the child. Yet it's important to remember that to heal, children have to feel safe.

Various factors can contribute to children continuing to worry even after being removed from an abusive situation, including "valid fears about their own safety or the safety of loved ones, difficulty trusting adults to protect them, hyperawareness of potential threats, and problems controlling their reactions to perceived threats" (NCTSN, 2013). Further complicating the situation, children may face "people, situations, places, or things that remind them of traumatic events," causing them to "experience intense and disturbing feelings tied to the original trauma. These ‘trauma reminders' can lead to behaviors that seem out of place, but were appropriate--and perhaps even helpful--at the time of the original traumatic event" (NCTSN, 2013).

Talk with children about people, places, and situations that make them feel worried, and those that make them feel safe. Some children more easily share their ideas about a "safe home" by creating a drawing in which they draw or list inside the house things that make them feel safe, and draw or list worrisome things outside the house.

Since children may not even be aware their reactions are related to trauma, you can also educate caregivers to look for patterns of difficult or confusing behavior that may be related to trauma reminders. Caregivers need education to help them interpret children's problematic behaviors as trauma reactions, rather than labeling the child as "bad" or "manipulative."

5. Advocate for and support effective treatment. The good news for children who experience sexual abuse is that there are effective, evidence-based treatments available. One effective model becoming increasingly available in our state is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). To find therapists certified in TF-CBT, visit the NC Child Treatment Program's provider map: www.childtreatmentprogram.org/NCCounties/Index.rails

What about when TF-CBT is not available, or not appropriate for a particular child? DSS agencies are important voices to advocate for increasing the availability and funding for TF-CBT and other trauma-informed treatments. Your Managed Care Organization (MCO), System of Care agencies, and current providers are all important partners in bringing effective, high quality treatment to your community.

Once children access treatment, as a child welfare professional you are a consultant for the therapist, just as they are a consultant for you in understanding what is happening for the child and how best to help. Social workers can:

Ensure the therapist has the information needed for a comprehensive assessment and treatment plan;
Promote the use of a trauma- and evidence-informed approach; and
Monitor whether the child is making measurable progress over time.

See the box below for questions to ask therapists, and the following interview on the next page for tips on collaboratively supporting children's treatment and healing.

Trauma-Focused Questions for Mental Health Providers

1. Do you provide trauma-specific or trauma-informed therapy? If yes, how do you determine if the child needs a trauma-specific therapy?
Providers should describe an assessment process that involves obtaining a detailed social history, including all forms of trauma, as well as the use of a standardized, trauma-specific measure.

2. How familiar are you with the evidence-based treatment models designed and tested for treatment of child trauma-related symptoms?
Providers should mention one of the specific interventions listed on this site: http://www.NCTSN.org.

3. Describe a typical course of therapy for traumatized children and their families. Approaches described should incorporate some or all of the following:

Building a strong therapeutic relationship. Trauma treatment requires the skillful development of a clinical relationship with the child and caregivers.
Psycho-education about normal responses to trauma. Most trauma-informed therapy includes a component that helps the child and caregivers understand normal reactions to trauma.
Parent support, conjoint therapy, or parent training. Caregivers are typically powerful mediators of the child's treatment and recovery. Involving caregivers is a vital element of trauma treatment.
Emotional expression and regulation skills. Helping the child to identify and express powerful emotions related to the trauma and to regulate or control their emotions and behavior is an important element of trauma-informed therapy.
Anxiety management and relaxation. It is often necessary to teach the child (and sometimes the caregiver) skills and tools for mastering the overwhelming emotions associated with trauma and its reminders.
Cognitive processing or reframing. Many children form destructive misunderstandings in the aftermath of the trauma. Therapy often helps correct these misattributions.
Construction of a coherent trauma narrative. Trauma treatment often includes building the child's capacity to talk about what happened in ways that do not produce overwhelming emotions and that make sense of the experience. This sometimes involves gradual exposure to traumatic reminders while using newly acquired anxiety management skills.
Personal safety training and other empowerment activities. Trauma treatment often teaches children strategies that give them a sense of control over events and risks.
Resiliency and closure. Treatment often ends on a positive, empowering note, giving the child a sense of satisfaction and closure as well as increased competency and hope for the future.

Adapted from National Child Traumatic Stress Network, 2013

References for this and other articles in this issue