Campbell Systematic Reviews 2012:14 First published: April, 2006 Last updated: March, 2012 Search executed: December, 2011 Cognitive-Behavioural Interventions for Children Who Have Been Sexually Abused: A Systematic Review Geraldine Macdonald, Julian PT Higgins, Paul Ramchandani, Jeffrey C. Valentine, Latricia P. Bronger, Paul Klein, Roland O’Daniel, Mark Pickering, Ben Rademaker, George Richardson, Matthew Taylor Colophon Title Cognitive-behavioural interventions for children who have been sexually abused: A Systematic Review Institution The Campbell Collaboration Authors Macdonald, Geraldine Higgins, Julian PT Ramchandani, Paul Valentine, Jeffrey C. Bronger, Latricia P. Klein, Paul O’Daniel, Roland Pickering, Mark Rademaker, Ben Richardson, George Taylor, Matthew DOI 10.4073/csr.2012.14 No. of pages 110 Last updated March, 2012 Citation Macdonald G, Higgins JPT, Ramchandani P, Valentine JC, Bronger LP, Klein P, O’Daniel R, Pickering M, Rademaker B, Richardson G, Taylor M. Cognitive-behavioural interventions for children who have been sexually abused: A Systematic Review. Campbell Systematic Reviews 2012:14 DOI: 10.4073/csr.2012.14 ISSN 1891-1803 Co-registration This review is co-registered within both the Cochrane and Campbell Collaborations. A version of this review can also be found in the Cochrane Library. Contributions Geraldine Macdonald, Paul Ramchandani and Julian Higgins each contributed to all aspects of the review. For the original review, GM and PR selected studies for inclusion in the review and extracted data from the included studies. JH, GM and PR entered data in Review Manager. GM and JH took primary responsibility for assessing the risk of bias in the studies, for describing them and analysing the data. GM and PR took responsibility for drafting the discussion and identifying issues for research and practice. For the update, Jeff Valentine contributed to all aspects of the review. Latricia Bronger, Paul Klein, Roland O'Daniel, Mark Pickering, Ben Rademaker, George Richardson, Matthew Taylor and Jennifer Wolf selected studies for inclusion in the review and extracted data from the new follow-up. GM, JV, JH and PR all contributed to the drafting of this version of the review. Editors for Editors: William Turner, Julia Littell this review Managing editors: Jane Dennis, Laura MacDonald Support/funding Northern Ireland Research & Development, UK Nordic Campbell Center, Denmark Potential conflicts Julian PT Higgins - received a payment from the Nordic Campbell Centre for of interest his work on the first version of this review in 2006. All other authors - none known Corresponding Geraldine Macdonald author Director, Institute of Child Care Research School of Sociology, Social Policy and Social Work, Queen's University Belfast 6 College Park Belfast Northern Ireland BT7 1LP UK Email: [email protected] Campbell Systematic Reviews Editors-in-Chief Mark W. Lipsey, Vanderbilt University, USA Arild Bjørndal, The Centre for Child and Adolescent Mental Health, Eastern and Southern Norway & University of Oslo, Norway Editors Crime and Justice David B. Wilson, George Mason University, USA Education Sandra Wilson, Vanderbilt University, USA Social Welfare William Turner, University of Bristol, UK Geraldine Macdonald, Queen’s University, UK & Cochrane Developmental, Psychosocial and Learning Problems Group International Birte Snilstveit, 3ie, UK Development Hugh Waddington, 3ie, UK Managing Editor Karianne Thune Hammerstrøm, The Campbell Collaboration Editorial Board Crime and Justice David B. Wilson, George Mason University, USA Martin Killias, University of Zurich, Switzerland Education Paul Connolly, Queen's University, UK Gary W. Ritter, University of Arkansas, USA Social Welfare Aron Shlonsky, University of Toronto, Canada Jane Barlow, University of Warwick, UK International Peter Tugwell, University of Ottawa, Canada Development Howard White, 3ie, India Methods Therese Pigott, Loyola University, USA Ian Shemilt, University of Cambridge, UK The Campbell Collaboration (C2) was founded on the principle that systematic reviews on the effects of interventions will inform and help improve policy and services. C2 offers editorial and methodological support to review authors throughout the process of producing a systematic review. A number of C2's editors, librarians, methodologists and external peer- reviewers contribute. The Campbell Collaboration P.O. Box 7004 St. Olavs plass 0130 Oslo, Norway www.campbellcollaboration.org Table of contents TABLE OF CONTENTS 4 ABSTRACT 6 Background 6 Objectives 6 Search methods 6 Selection criteria 7 Data collection and analysis 7 Results 7 Authors' conclusions 8 PLAIN LANGUAGE SUMMARY 9 1 BACKGROUND 10 1.1 Description of the condition 10 1.2 Description of the intervention 13 1.3 How the intervention might work 14 1.4 Why it is important to do this review 15 2 OBJECTIVES 16 3 METHODS 17 3.1 Criteria for considering studies for this review 17 3.2 Search methods for identification of studies 18 3.3 Data collection and analysis 19 4 RESULTS 23 4.1 Description of studies 23 4.2 Risk of bias in included studies 28 4.3 Effects of interventions 28 5 DISCUSSION 38 5.1 Summary of main results 38 5.2 Overall completeness and applicability of evidence 39 5.3 Quality of the evidence 40 5.4 Potential biases in the review process 40 5.5 Agreements and disagreements with other studies or reviews 40 4 The Campbell Collaboration | www.campbellcollaboration.org 6 AUTHORS’ CONCLUSIONS 41 6.1 Implications for practice 41 6.2 Implications for research 41 7 ACKNOWLEDGEMENTS 43 8 DIFFERENCES BETWEEN PROTOCOL AND REVIEW 44 9 CHARACTERISTICS OF STUDIES 45 9.1 Characteristics of included studies 45 9.2 Characteristics of excluded studies 65 9.3 Characteristics of studies awaiting classification 65 10 ADDITIONAL TABLES 66 10.1 Outcome measures used by studies in the review 66 10.2 Additional methods for future updates 69 10.3 Participants 70 11 REFERENCES TO STUDIES 78 11.1 Included studies 78 11.2 Excluded studies 80 11.3 Studies awaiting classification 80 12 OTHER REFERENCES 81 12.1 Additional references 81 12.2 Other published versions of this review 90 13 DATA AND ANALYSES 91 13.1 CBT vs no CBT 91 14 FIGURES 94 14.1 Study flow diagram 94 14.2 Risk of Bias Graph 95 14.3 Risk of bias summary 96 15 APPENDICES 97 15.1 Search strategies for original review 97 15.2 Search strategies for updated review 100 5 The Campbell Collaboration | www.campbellcollaboration.org Abstract BACKGROUND Despite differences in how it is defined, there is a general consensus amongst clinicians and researchers that the sexual abuse of children and adolescents ('child sexual abuse') is a substantial social problem worldwide. The effects of sexual abuse manifest in a wide range of symptoms, including fear, anxiety, post-traumatic stress disorder and various externalising and internalising behaviour problems, such as inappropriate sexual behaviours. Child sexual abuse is associated with increased risk of psychological problems in adulthood. Cognitive-behavioural approaches are used to help children and their non-offending or 'safe' parent to manage the sequelae of childhood sexual abuse. This review updates the first Cochrane review of cognitive- behavioural approaches interventions for children who have been sexually abused, which was first published in 2006. OBJECTIVES To assess the efficacy of cognitive-behavioural approaches (CBT) in addressing the immediate and longer-term sequelae of sexual abuse on children and young people up to 18 years of age. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011 Issue 4); MEDLINE (1950 to November Week 3 2011); EMBASE (1980 to Week 47 2011); CINAHL (1937 to 2 December 2011); PsycINFO (1887 to November Week 5 2011); LILACS (1982 to 2 December 2011) and OpenGrey, previously OpenSIGLE (1980 to 2 December 2011). For this update we also searched ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP). 6 The Campbell Collaboration | www.campbellcollaboration.org SELECTION CRITERIA We included randomised or quasi-randomised controlled trials of CBT used with children and adolescents up to age 18 years who had experienced being sexually abused, compared with treatment as usual, with or without placebo control. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the eligibility of titles and abstracts identified in the search. Two review authors independently extracted data from included studies and entered these into Review Manager 5 software. We synthesised and presented data in both written and graphical form (forest plots). RESULTS We included 10 trials, involving 847 participants. All studies examined CBT programmes provided to children or children and a non-offending parent. Control groups included wait list controls (n = 1) or treatment as usual (n = 9). Treatment as usual was, for the most part, supportive, unstructured psychotherapy. Generally the reporting of studies was poor. Only four studies were judged 'low risk of bias' with regards to sequence generation and only one study was judged 'low risk of bias' in relation to allocation concealment. All studies were judged 'high risk of bias' in relation to the blinding of outcome assessors or personnel; most studies did not report on these, or other issues of bias. Most studies reported results for study completers rather than for those recruited. Depression, post-traumatic stress disorder (PTSD), anxiety and child behaviour problems were the primary outcomes. Data suggest that CBT may have a positive impact on the sequelae of child sexual abuse, but most results were not statistically significant. Strongest evidence for positive effects of CBT appears to be in reducing PTSD and anxiety symptoms, but even in these areas effects tend to be 'moderate' at best. Meta-analysis of data from five studies suggested an average decrease of 1.9 points on the Child Depression Inventory immediately after intervention (95% confidence interval (CI) decrease of 4.0 to increase of 0.4; I2 = 53%; P value for heterogeneity = 0.08), representing a small to moderate effect size. Data from six studies yielded an average decrease of 0.44 standard deviations on a variety of child post-traumatic stress disorder scales (95% CI 0.16 to 0.73; I2 = 46%; P value for heterogeneity = 0.10). Combined data from five studies yielded an average decrease of 0.23 standard deviations on various child anxiety scales (95% CI 0.3 to 0.4; I2 = 0%; P value for heterogeneity = 0.84). No study reported adverse effects. 7 The Campbell Collaboration | www.campbellcollaboration.org AUTHORS' CONCLUSIONS The conclusions of this updated review remain the same as those when it was first published. The review confirms the potential of CBT to address the adverse consequences of child sexual abuse, but highlights the limitations of the evidence base and the need for more carefully conducted and better reported trials. 8 The Campbell Collaboration | www.campbellcollaboration.org Plain language summary The sexual abuse of children is a substantial social problem that affects large numbers of children and young people worldwide. For many children, though not all, it can result in a range of psychological and behavioural problems, some of which can continue into adulthood. Knowing what is most likely to benefit children already traumatised by these events is important. This review aimed to find out if cognitive- behavioural approaches (CBT) help reduce the negative impact of sexual abuse on children. Ten studies, in which a total of 847 children participated, met the inclusion criteria for the review. The reporting of studies was poor, and there appear to be significant weaknesses in study quality. The evidence suggests that CBT may have a positive impact on the effects of child sexual abuse, including depression, post- traumatic stress and anxiety, but the results were generally modest. Implications for practice and further research are noted. 9 The Campbell Collaboration | www.campbellcollaboration.org