• A number of psychological therapies are used to help children and young people overcome the consequences of sexual abuse.
• There is largely uncertain evidence to suggest that any particular interventions is better than management as usual in helping children and young people recover from sexual abuse.
• We need more and better studies of interventions to establish whether one is better than another in addressing the various consequences of sexual abuse.
What do we mean by psychological interventions?
Psychological interventions are those that try to bring about change in people. They are often referred to as 'talking therapies' but they also include therapies in which communication between therapist and patient is based on activity, such as play, or art.
There is a range of psychological interventions that are used to help children and young people who have been sexually abused to overcome the sorts of difficulties that can develop as a result of the abuse; for example, post-traumatic stress disorder (PTSD), anxiety, depression, and a range of behaviour problems.
Why is this important for children and young people who have been sexually abused?
Previous systematic reviews suggest that psychological therapies can improve outcomes for children, but we do not know whether some therapies are more effective than others.
What did we want to find out?
We wanted to find out which interventions were best for treating the range of problems that can occur following sexual abuse. We wanted to find out if we could rank them in order of how well they work. For example, we wanted to find out which intervention was the best at helping children who have PTSD, or children who are depressed. Which was second best? And so on.
What did we do?
We searched for studies that examined the effectiveness of a range of psychological therapies, including cognitive-behavioural therapy (CBT), eye movement desensitisation and reprocessing (known as EMDR), child-centred therapy (CCT), psychodynamic therapy, and family therapy. We included studies that compared:
• one therapy to another therapy;
• different 'doses' of therapy; for example, eight weeks of a therapy to 16 weeks of the same therapy;
• one version of a therapy with another version; for example, one that involved parents as well as the child with the same therapy that did not;
• one therapy to management as usual; and
• one therapy to no therapy (mainly those on a waiting list).
We used methods that allowed us to compare the effectiveness of each therapy against others, for particular outcomes. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as the number of studies and how large or small they were.
What did we find?
We found 22 studies (1478 participants) and most of them were from North America. Fourteen of these examined the effectiveness of CBT and eight examined the effectiveness of CCT. Psychodynamic therapy, family therapy and EMDR were each examined in two studies. Management as usual was the comparator in three studies and a waiting list was the comparator in five studies.
On the available evidence it is not clear whether one intervention is more effective than others in helping children and young people who have been sexually abused. There is some evidence, though it is largely uncertain and imprecise, that CBT may be better than management as usual when it comes to reducing the symptoms of PTSD at the end of treatment. No evidence pointed to the effectiveness of other therapies for PTSD, and no therapy appeared to do better than management as usual for the other outcomes we examined.
The evidence base for the effectiveness of other psychotherapeutic interventions for sexually abused children and adolescents is limited, particularly in relation to psychodynamic therapy, family therapy and EMDR.
What are the limitations of the evidence?
Our confidence in the results is not strong. The treatment effects we identified were small or close to 'no change' and not very precise. Whilst the studies were broadly comparable in some respects (settings; the use of a manual to deliver the intervention; the 'amount' of therapy), there was considerable variability in others, such as the age of participants and the format in which the interventions were delivered (individual or group).
The results of further research could differ from the results of this review.
How up to date is this evidence?
The evidence is up to date to 1 November 2022.
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.
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.
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.
To rank psychotherapies according to their effectiveness.
To compare different ‘doses’ of the same intervention.
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.
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.
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.
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.
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.
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).