1 Child Abuse & Neglect 29 (2005) Treating sexually abused children: 1 year follow-up of a randomized controlled trial Judith A. Cohen, Anthony P. Mannarino, Kraig Knudsen Drexel University College of Medicine, Allegheny General Hospital, Department of Psychiatry, Four Allegheny Center, 8th Floor, Pittsburgh, PA 15212, USA Received 1 May 2003; received in revised form 24 November 2003; accepted 27 December 2004 Abstract Objective: To measure the durability of improvement in response to two alternative treatments for sexually abused children. Method: Eighty-two sexually abused children ages 8 15 years old and their primary caretakers were randomly assigned to trauma-focused cognitive-behavioral therapy (TF-CBT) or non-directive supportive therapy (NST) delivered over 12 sessions; this study examines symptomatology during 12 months posttreatment. Data analysis: Intent-to-treat and treatment completer repeated measures analyses were conducted. Results: Intent-to-treat indicated significant group time effects in favor of TF-CBT on measures of depression, anxiety, and sexual problems. Among treatment completers, the TF-CBT group evidenced significantly greater improvement in anxiety, depression, sexual problems and dissociation at the 6-month follow-up and in PTSD and dissociation at the 12-month follow-up. Conclusion: This study provides additional support for the durability of TF-CBT effectiveness Elsevier Ltd. All rights reserved. Keywords: Child sexual abuse; Posttraumatic stress disorder; Trauma-focused cognitive-behavioral therapy; Treatment outcome This study was funded by the Office of Child Abuse and Neglect (formerly NCCAN), Administration for Children, Youth and Families, Department of Health and Human Services, Grant No. 90-CA Corresponding author /$ see front matter 2005 Elsevier Ltd. All rights reserved. doi: /j.chiabu
2 136 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) Introduction Child sexual abuse is associated with psychiatric difficulties which can potentially be long lasting and cause significant functional impairment. Sexually abused children and adolescents have been found to have increased rates of depression, anxiety, posttraumatic stress disorder (PTSD), externalizing symptoms, and substance use disorders (Saywitz, Mannarino, Berliner, & Cohen, 2000). Although it has been suggested that these deleterious outcomes are attributable to family factors which heighten risk for both sexual abuse and psychiatric dysfunction, recent epidemiologic and twin studies have demonstrated that sexual abuse per se accounts for increased rates of depression, suicide attempts, PTSD, substance use disorders and sexual victimization in adulthood (Kendler et al., 2000; Nelson et al., 2002). Thus, it is critical to identify treatments which optimally reduce these difficulties in children who have been sexually abused, and which produce lasting symptomatic remission. In the past decade, knowledge about efficacious treatments for sexually abused children has grown substantially, due to the publication of several empirically rigorous treatment outcome studies for this population. These studies have incorporated gold standard elements of evidence-based treatment trials, such as random assignment to well defined, manualized treatments, and the comparison of index treatments to alternative treatments or wait list controls. Deblinger, Lippman, and Steer (1996, 1999) followed 100 sexually abused children who were randomly assigned to receive trauma-focused cognitive-behavioral therapy ( TF-CBT ) provided to the child only, the non-offending parent only, or to the child and parent, and compared these three groups to children who received standard community care. This study documented that the children who received TF-CBT (either child only or child + parent treatment conditions) experienced significantly greater improvement in PTSD symptoms, whereas children whose parents received TF-CBT (in the parent only or parent + child treatment conditions) experienced significantly greater improvements in child-reported depression and parent-reported behavioral problems, and that these differences were maintained at a 1-year follow-up. Cohen and Mannarino (1996, 1998) randomly assigned 69 sexually abused preschool children to TF- CBT or non-directive supportive therapy (NST); children receiving TF-CBT experienced significantly greater improvements in PTSD symptoms including sexualized behaviors, and in internalizing and total behavior problems. These differences were maintained over the course of a 1-year follow-up. Cohen and Mannarino (1998) conducted a parallel study for sexually abused children ages 8 15 years, and found significant group time differences among 49 treatment completers, with children who received TF-CBT experiencing significantly greater improvement in depression and social competence compared to children who received NST. King et al. (2000) randomly assigned to 17-year-old sexually abused child to one of three conditions: CBT provided individually, CBT family therapy, or a wait list control condition. This study indicated that the two CBT conditions were both superior to the wait list condition and that at a 3-month follow-up, the children whose families were included in treatment experienced significantly greater improvement in anxiety than those who received only individual CBT. Another randomized controlled trial compared 30 sessions of individual psychoanalytic treatment to18 sessions of group psychoeducation and found that children in the individual psychoanalytic condition experienced significantly greater improvement in PTSD symptoms. However, the design of this study did not make it possible to determine whether these differences were because of the treatment orientation (psychoanalytic vs. psychoeducation), the mode of treatment (individual vs. group), or the length of treatment (30 weeks vs. 18 sessions). Cohen, Deblinger, Mannarino, and Steer (2004) conducted a multisite study in which 229 sexually abused children were randomly assigned to TF-CBT or supportive Child Centered Therapy (CCT). At
3 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) posttreatment, the TF-CBT group demonstrated significantly greater improvement in PTSD, depression, behavior problems, abuse-related attributions, and shame. Parents receiving TF-CBT also showed greater improvement with regard to their own depression, abuse-specific distress, support of the child and effective parenting practices. In developing, testing, and disseminating evidence-based treatments for traumatized children, it is important to address not only the efficacy of treatment (how well it works to achieve specified results), but also the efficiency of treatment (how quickly it achieves these results) and the duration of treatment effects (how long treatment effects are maintained after treatment is completed). These issues may be particularly relevant for sexually abused children because of the documented deleterious long-term effects of child sexual abuse (Kendler et al., 2000; Nelson et al., 2002) and the potentially negative psychobiological impact of this type of child maltreatment. Sexually abused children have been found to have abnormalities in stress hormones related to dysregulation of the hypothalamic pituitary adrenal axis (DeBellis, Baum, et al., 1999; Kaufman et al., 1997), increased adrenergic tone as evidenced by elevated resting and reactive heart rate and blood pressure (Perry, 1994), and alterations in immunological functioning (DeBellis, Burke, Trickett, & Putnam, 1996). Perhaps most concerning is the finding that sexually abused children had smaller intracranial volume and lower scores on intelligence tests than carefully matched controls, with earlier age of onset and longer duration of abuse predicting smaller brain size and lower intellectual functioning (DeBellis, Keshavan, et al., 1999). Although it is not clear that psychosocial treatment can reverse these changes, one case report indicates that successfully treating children s abuserelated psychological symptoms may reverse the associated psychobiological abnormalities (DeBellis, Keshevan, & Karenski, 2001). Thus, it may be critically important to identify treatments that not only reduce psychological symptoms, but also lead to the most prompt and long-lasting symptom remission. For this reason, it is essential to examine treatment response to relatively brief interventions, and to assess outcome not only immediately at the conclusion of therapy, but for a period of time after therapy has ended. By definition more efficient treatments result in faster symptomatic improvement (thus shortening the time that children must suffer from these psychiatric symptoms); the DeBellis, Keshavan, et al. (1999) findings suggest that more efficient treatments are also associated with less psychobiological adversity. Treatments with longer duration of effects (i.e., that maintain superior symptom remission over time) not only provide ongoing relief from psychological symptoms, but may also have the most promise for potentially halting or even reversing the adverse psychobiological effects of child sexual abuse. Such treatments may optimally protect children from the deleterious adult outcomes associated with child sexual abuse discussed above (Nelson et al., 2002). Thus, while minimizing psychological suffering more quickly is in itself an important goal, maintaining this effectiveness over time may be of even greater value in preventing the long-term negative sequelae of child sexual abuse. The current study evaluates the duration of treatment effects of two alternative brief (12 week) treatments for sexually abused children over the course of the year following the end of treatment. TF-CBT was selected as the index treatment because TF-CBT interventions were superior to play therapy in improving these symptoms in sexually abused younger children (Cohen & Mannarino, 1996, 1997), have been effective in treating PTSD in adult sexual assault victims (Foa, Rothbaum, Riggs, & Murdock, 1991), and have a sound theoretical basis for alleviating PTSD, depressive and anxiety and associated symptoms (Cohen, Mannarino, Berliner, & Deblinger, 2000). We selected the comparison treatment, NST, because it typifies the empowering, supportive and non-directive techniques provided to children and adults in many rape crisis and community mental health settings, and because it contains therapeutic elements which
4 138 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) theoretically might reverse some of the traumagenic dynamics (Finkelhor, 1987) associated with child sexual abuse (i.e., powerlessness, stigmatization, traumatic sexualization and betrayal). Although this type of treatment is often provided over a longer period of time (New & Berliner, 2001), the importance of evaluating treatment efficiency led to the decision to limit treatment duration to 12 weeks. It was hypothesized that, although both treatments were theoretically sound and frequently used for treating this population, TF-CBT would be more effective for reducing psychological difficulties, particularly depressive and anxiety symptoms, and that these differential treatment effects would be sustained over the course of a 1-year follow-up. This was based on TF-CBT but not NST containing treatment components specifically targeting conditioned fear responses and cognitive errors which contribute to symptom development and maintenance in these particular disorders (Cohen et al., 2000), as well as a treatment component aimed at helping children optimally integrate the abuse experience into their view of themselves, others and their world. An initial analysis of pre to posttreatment results for 49 treatment completers (30 CBT, 19 NST) in this study indicated that TF-CBT was superior to NST in improving depressive and social competence problems (Cohen & Mannarino, 1998). A subsequently published review of cognitive-behavioral therapies for children and adolescents suggested the importance of following children after completion of treatment, using intent-to-treat analyses to determine the durability of treatment effects (Brent, Gaynor, & Weersing, 2002). The present paper examines the outcomes of these children during the course of 1 year following treatment completion. Methods Subjects Subjects were 82 children and adolescents aged 8 15 years old who were referred to an urban outpatient child psychiatric program specializing in the treatment of traumatic stress in children. This clinic is part of the Department of Psychiatry in an academically affiliated, not-for-profit general hospital. It receives referrals from child protective services (CPS), pediatric clinics and offices, police, forensic investigative agencies, victim advocacy programs, community mental health agencies, rape crisis centers, the courts, and from patient- or family-initiated referrals. It accepts all types of insurance, and approximately half of its patients receive Medicaid or are uninsured. Although located in an urban area, the clinic is geographically within a few miles of suburban and 15 miles of rural areas. Thus, the clinic serves a population believed to be representative of treatment-seeking sexually abused children in many communities. Although agencies, which routinely refer clients to our program were informed of the study, no recruitment ads were utilized to obtain referrals. Children referred to the clinic were screened for appropriateness for inclusion, and those who met criteria were invited to participate. Parents or caregivers were paid $25 for their time and expenses (travel, parking, babysitting, etc.) involved in completing initial and follow-up evaluations. Treatment was provided free of charge. Inclusionary criteria included the following: contact sexual abuse within the past 6 months which had been validated by CPS or an independent forensic evaluation prior to entry into the study, significant symptomatology related to the sexual abuse experience (as documented by a score in the clinical range on any of the self-report instruments or the presence of sexually inappropriate behavior as reported by the parent), and availability of a non-offending parent or primary caregiver who was able to participate in treatment. Exclusionary criteria included active psychotic symptoms or substance abuse, or mental retardation or pervasive developmental delay in the child, or active psychosis in the parent or
5 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) primary caretaker participating in the treatment. Power analysis indicated that inclusion of 40 subjects in each treatment condition would provide adequate power to detect medium or greater effect sizes. Sample composition included 56 females and 26 males. Mean ages were 11.4 years (TF-CBT) and 10.8 years (NST). Self-reported racial identity of participants was as follows: 49 (60%) Caucasian, 30 (37%) African American, 2 (2%) Biracial, and 1 (1%) Hispanic. Most intrusive type of abuse experienced was intercourse for 38 (46%) children, oral-genital contact for 3 (4%) children, fondling for 28 (34%) children, and other or unknown for 13 (16%) children. Twenty-five (31%) children experienced a single sexual abusive act, 11 (14%) experienced 2 5 abusive episodes, 9 (11%) experienced 6 10 episodes, 22 (27%) experienced more than 10 abusive episodes, and 15 (17%) were unable to report the number of abusive episodes. Perpetrators of the abuse were father or stepfather for 12 (14%) children, mother s paramour for 5 (6%), grandmother for 2 (3%), mother for 1 (1%), brother for 12 (15%), cousin for 8 (9%), uncle for 2 (3%), older person for 13 (16%), non-familial adult for 13 (16%), and other for 14 (17%). There were no significant differences between the TF-CBT and NST groups on any of these demographic variables. Measures The following measures were utilized to evaluate symptomatology. The Children s Depression Inventory (CDI) (Kovacs, 1985), a 27-item self-report instrument widely used to evaluate depressive symptoms in children and young adolescents; the Trauma Symptom Checklist for Children (TSC-C) (Briere, 1995), a 54-item self-report instrument which measures trauma-related symptoms with distinct scales based on factor analysis for anxiety, depression, PTSD, sexual problems, dissociation and anger; the State-Trait Anxiety Inventory for Children (STAIC) (Spielberger, 1973), a two-factor self-report instrument which measures both state anxiety and trait anxiety in children; the Child Sexual Behavior Inventory (CSBI) (Friedrich et al., 1992), a 42-item parent report scale which measures both normative and inappropriate sexual behaviors; and the Child Behavior Checklist (CBCL) (Achenbach & Edelbrock, 1983), a parent report instrument which measures a variety of child emotional and behavioral difficulties and includes four broad band factors (Social Competence, Behavior Problems Total, Internalizing, and Externalizing), and nine narrow band scales. Only the broad band factors were included in the present analysis. All of these instruments have documented strong psychometric properties, and have been used in past studies of sexually abused children (Cohen & Mannarino, 1998). Design and procedures Upon referral, initial phone screening was conducted, and for children who appeared to qualify for inclusion in the study, an initial evaluation was conducted at the clinic where treatment was to be provided. The Allegheny General Hospital Institutional Review Board approval was obtained prior to the start of the study and informed parental consent/child assent procedures were utilized. Children were randomly assigned to treatment using a random number series generated by computer. The evaluator conducting the initial and follow-up assessments was blind to treatment condition or assignment. As noted, there was a differential drop out rate, with 30/41 children assigned to TF-CBT completing treatment and 19/41 children assigned to NST completing treatment. Following completion of treatment or drop out, attempts were made to obtain follow-up assessments on all participants at posttreatment (Time 2), and at 6- (Time 3) and 12 (Time 4)-month follow-ups. A total of 46 children (27 CBT, 19 NST) completed the T3 assessment, and 39 children (23 CBT, 16 NST) completed the T4 assessment.
6 140 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) Treatments Both treatments were manualized; adherence monitoring was conducted through intensive supervision and rating of randomly selected audiotapes of treatment sessions. Treatment manuals are available upon request from the first author. All children and their caretakers received 12 sessions of treatment. Each session consisted of 45 minutes for the child and 45 minutes for the caretaker. TF-CBT. The trauma-focused CBT intervention has been described in detail elsewhere (Cohen et al., 2000). Major components for the child included feeling identification, stress inoculation techniques, direct discussion of various aspects of the sexual abuse experience through gradual exposure exercises, cognitive processing of the abuse and integrating this experience into the child s self-and world-views, education about healthy sexuality, and safety skill building. Components of parental treatment generally paralleled those for the child, with the addition of parenting management skills building. NST. The NST intervention was a non-directive child/parent-centered treatment model provided individually to the child and parent. This model focused on the establishment of a trusting therapeutic relationship which was self-affirming, empowering and validating for the parent and child. In the NST model therapists encouraged children and parents to direct the content and structure of each treatment session. Therapists provided active listening, reflection, accurate empathy, encouragement to talk about feelings, and belief in the child s and parent s ability to develop positive coping strategies for abuse-related difficulties. A variety of expressive arts materials (puppets, human figures, drawing and writing materials) were available for the child or parent to use if they so desired. Therapists did not provide direct advice regarding the management of behavioral problems, but instead encouraged the parent and child to generate their own strategies in this regard. Data analysis In order to examine comparative treatment effects of the two alternative treatments over the course of the 1-year follow-up, an intent-to-treat repeated measures analyses (using the SPSS general linear model) was conducted for the 82 children who entered the study. The Bonferroni correction was used to minimize the risk of overestimating effect sizes due to the large number of analyses conducted. A conservative Last Observation Carried Forward (LOCF) method (in which the score at the most recent available data point was used at subsequent incomplete data points) was used to account for missing data. To examine improvement in the 49 treatment completers at the 6- and 12-month follow-ups, simple main effects analyses were conducted to determine change from pretreatment to 6-month (T3) and 12-month (T4) follow-ups, respectively. Effect sizes at the 12-month follow-up were also calculated. Results Intent-to-treat analyses As shown in Table 1, significant intent-to-treat group time differences were found on the CDI, the State and Trait scales of the STAIC, and the anxiety, depression and sexual problems factors of the
7 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) Table 1 Pretreatment to 1-year follow-up group by time interactions on outcome measures Measure Pretreatment mean Posttreatment mean 6-month follow-up 12-month follow-up Group F Time F Group vs. time F CSBI TF-CBT (N = 41) (10.70) 8.59 (9.52) 8.32 (8.52) 6.93 (7.87) *** NST (N = 41) (8.91) (8.77) 9.20 (7.72) 9.28 (7.92) CDI TF-CBT (8.84) 7.61 (7.04) 9.20 (7.88) 8.85 (7.37) *** 3.86 **.17 NST (7.46) (7.97) (8.22) (7.51) STAIC-STATE TF-CBT (9.69) (8.16) (7.51) (6.32) *** 2.57 *.21 NST (9.87) (8.96) (9.02) (8.87) STAIC-TRAIT TF-CBT (8.66) (7.44) (6.39) (7.87) *** 3.07 *.12 NST (9.22) (8.98) (9.23) (8.83) TSCC-PTSD TF-CBT (5.17) 8.78 (4.88) 7.66 (3.94) 7.17 (4.17) *** NST (5.84) 9.92 (5.28) 9.60 (5.79) 9.58 (5.81) TSCC-ANX TF-CBT 8.07 (4.67) 5.90 (3.82) 5.34 (3.15) 5.76 (3.92) *** 2.87 *.11 NST 7.65 (4.68) 6.88 (3.75) 7.02 (3.81) 6.23 (4.06) TSCC-DEP TF-CBT 7.44 (4.66) 5.56 (4.35) 5.10 (3.45) 5.90 (4.49) ** 3.11 *.09 NST 6.40 (4.49) 6.30 (3.95) 6.15 (3.87) 5.50 (3.79) TSCC-SEX TF-CBT 5.29 (4.02) 4.10 (3.39) 3.68 (2.84) 4.17 (3.66) *.10 NST 5.28 (3.78) 4.85 (3.81) 5.67 (4.64) 4.55 (3.75) TSCC-DIS TF-CBT 9.02 (5.29) 7.80 (5.72) 6.88 (4.49) 6.68 (4.97) * NST 8.43 (4.32) 8.20 (4.74) 8.73 (5.03) 7.78 (4.53) TSCC-ANG TF-CBT 8.51 (5.07) 6.49 (4.87) 6.80 (4.17) 6.85 (4.92) * NST 8.85 (5.86) 8.40 (5.48) 8.68 (6.70) 7.70 (5.43) CBCL-SOCIAL TF-CBT (13.11) (12.01) (11.42) (10.76) *** NST (13.45) (11.55) (11.12) (11.42) CBCL-INTERNAL TF-CBT (15.40) (13.38) (14.11) (13.67) *** NST (17.38) (16.54) (16.22) (16.28) CBCL-EXTERNAL TF-CBT (14.74) (13.83) (14.63) (15.96) NST (16.41) (16.91) (16.01) (16.39) CBCL-TOTAL (15.54) (14.35) (15.22) (15.87) ** TF-CBT (17.08) (16.74) (15.96) (16.40) Effect size (d) 12-month Note. CSBI: Child Sexual Behavior Inventory; CDI: Child Depression Inventory; STAIC: State-Trait Anxiety Inventory for Children; TSCC: Trauma Symptom Checklist for Children; CBCL: Child Behavior Checklist. p <.05. p <.01. p <.001. p =.06. p =.07.
8 142 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) TSCC, with the TF-CBT group experiencing significantly greater improvement over time than the NST group on all of these measures. Group time differences also approached significance (p =.07) on the TSCC dissociation factor. It should also be noted that most instruments demonstrated significant time effects, suggesting that children significantly improved over time in both treatment groups. At the 12- month follow-up, medium effect sizes (.30) were found for sexual behaviors (CSBI), PTSD, and social competence (CBCL) (Cohen, 1988). Treatment completer analysis Among the 49 treatment completers analysis of change from pretreatment to 6-month follow-up demonstrated significantly greater improvement in the TF-CBT group on the state (F = 5.92, p <.01) and trait (F = 5.43, p =.02) scales of the STAIC, and the anxiety (F = 5.73, p <.01), depression (F = 5.49, p =.02), sexual problems (F = 4.64, p =.03) and dissociation (F = 7.42, p <.01) factors of the TSCC. From pretreatment (T1) to 12-month (T4) follow-up, the TF-CBT group demonstrated significantly greater improvement on the PTSD (F = 3.70, p <.05) and dissociation (F = 4.09, p <.05) factors of the TSCC. At both the 6-month and 12-month follow-ups, the TF-CBT group had greater improvement on the CSBI, which approached but did not reach statistical significance (p =.06). Discussion The results of this study indicate that TF-CBT was superior to a prototypical supportive, empowerment therapy (NST) in producing durable improvement in depressive, anxiety, and sexual concern symptoms over the course of a year following treatment. Additionally, treatment completers receiving TF-CBT demonstrated significantly greater improvement than those receiving NST in PTSD and dissociative symptoms at the 1-year follow-up. These findings are consistent with previous studies (Cohen & Mannarino, 1997; Deblinger et al., 1999) which similarly demonstrated the maintenance of TF-CBT effects during posttreatment follow-ups. The present study adds to the growing evidence indicating the efficacy and durability of TF-CBT interventions for sexually abused children and adolescents. One of the limitations of this study is that the measure used for PTSD was less than optimal. The TSCC does not inquire about PTSD symptoms in specific relation to the identified traumatic experience (in this case, sexual abuse). Such inquiry increases the sensitivity with which PTSD symptoms are identified, and it is likely that use of a PTSD-specific instrument would have had higher sensitivity in detecting such symptoms (American Academy of Child and Adolescent Psychiatry, 1998). Use of such an instrument would most likely have increased the significance of the differences noted between the two treatment groups with regard to PTSD, which in the present analyses were only significant among treatment completers at the 12-month follow-up. Thus, one possible explanation for the fact that significant differences in PTSD only appeared at the 12-month follow-up is insufficient sensitivity of the instrument used to measure PTSD. An alternative explanation which is supported by the data is that while both treatment groups experienced improvement in PTSD immediately after treatment, the TF-CBT group continued to substantially improve with regard to PTSD during the follow-up year (mean T1 to T2 improvement = 1.85; mean T2 to T4 improvement = 1.61) while the NST group did not experience this degree of ongoing improvement (mean T1 to T2 improvement =.91; T2 to T4 improvement =.32). This suggests that the positive impact of TF-CBT on PTSD symptoms continues beyond the duration of
9 J.A. Cohen et al. / Child Abuse & Neglect 29 (2005) treatment to a greater extent than that of NST. Another limitation of this study is the relatively high dropout rate, particularly in the NST group. This differential drop-out rate was in part due to a larger number of children in the NST group (N = 7) than in the CBT group (N =2,χ 2 = 3.44, df =1,p <.06) needing to be removed from the study due to ongoing sexual behaviors with other children (Cohen & Mannarino, 1998). However, even aside from the removed subjects, drop-out was higher in the NST group (N = 15) than in the TF-CBT group (N = 9). Although intent-to-treat analyses were used to address the differential dropout rate, a larger cohort of treatment completers would have enhanced the generalizability of the present findings. Given the significant findings of this study despite limited power, it is likely that increasing the number of treatment completers would have also increased the statistical significance of these results. On the other hand, the higher drop-out rate among NST subjects indicates that field objections to the use of CBT on the grounds that it is experienced as less individualized and supportive may be unwarranted. As reported earlier, child and parent satisfaction did not differ between the two treatment groups (Cohen & Mannarino, 1998). Despite these limitations, the present findings add to the growing number of studies supporting the durability of TF-CBT effects for treating a variety of psychological difficulties following child sexual abuse. Acknowledgment The authors thank the study therapists, project coordinators, the children and families who participated in this project, and Ann Marie Kotlik for assistance in manuscript preparation. References Achenbach, T. M., & Edelbrock, C. S. (1983). Manual for the child behavior checklist and revised child behavior profile. Burlington, VT: Department of Psychiatry, University of VT. American Academy of Child and Adolescent Psychiatry. (1998). Practice parameters for the assessment and treatment of posttraumatic stress disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37(10, Suppl.), Brent, D. A., Gaynor, S. T., & Weersing, V. R. (2002). Cognitive-behavioral approaches to the treatment of depression and anxiety. In M. Rutter & E. Taylor (Eds.), Child and adolescent psychiatry: Modern approaches (4th ed., pp ). London: Blackwell Scientific Publications. Briere, J. N. (1995). Professional manual for the Trauma Symptom Checklist for Children (TSCC). Odessa, FL: Psychological Assessment Resources. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates Publishers. Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for sexually abused children with PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, Cohen, J. A., & Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, Cohen, J. A., & Mannarino, A. P. (1997). A treatment study of sexually abused preschool children: Outcome during a one year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36, Cohen, J. A., & Mannarino, A. P. (1998). Interventions for sexually abused children: Initial treatment findings. Child Maltreatment, 3, Cohen, J. A., Mannarino, A. P., Berliner, L., & Deblinger, E. (2000). Trauma-focused cognitive-behavioral therapy: An empirical update. Journal of Interpersonal Violence, 15,