Child sexual abuse and family relations: The effect of sharing the trauma narrative with parents

Many studies have investigated the influences of parental emotional reactions
on children*s adjustment following child sexual abuse (CSA), but few have
examined the relational effects of discovery of CSA and parental emotional
reactions on its discovery. Specifically, systematic empirical research on the
effects of CSA on the parent-child relationship, the interparental
relationship, and parenting skills is lacking. Because these relational effects
play a crucial role in children*s adjustment to CSA, the purpose of this
investigation is to examine the relational effects of discovering CSA on
adjustment and treatment outcome among families of CSA survivors. In addition,
it is unclear if sharing the trauma narrative with parents is beneficial. We
will only include families in which the parents were not the molesters. We
expect that in families where CSA has been discovered as compared to families
where no CSA took place, the parent-child relationship and the interparental
relationship are impaired, and that these relational effects play a crucial
role in children*s adjustment to CSA. We hypothesize that sharing the trauma
narrative will improve the parent-child relationship and thereby reduce child
symptomatology. The results of this study will contribute to the growing
literature that aims to identify the ingredients of the optimal treatment for
children who experienced CSA.

Study 1: Examine how interparental and parent-child relationships in families
who have experienced CSA differ from interparental and parent-child
relationships in families who have not experienced CSA, and how these
relational effects are related to children*s adjustment to CSA. Study 2:
Examine the effect of sharing the trauma narrative during therapy with parents
on treatment outcome, child adjustment, the parent-child relationship and
parenting skills as compared to sharing the trauma narrative with the
therapist.

Study 1 will use a non-experimental design. Study 2 will use a multicenter
randomized controlled trial with measurements before, during and after
treatment with a follow-up of 6 months.

The Horizon intervention for child sexual abuse is a group therapy based on
TF-CBT principles. The intervention includes TF-CBT components as described by
Cohen, Mannarino and Deblinger (2006), such as psychoeducation, exposure,
parenting skills, relaxation and stress management, affective expression and
modulation, cognitive coping and processing, trauma narrative, conjoint-parent
child sessions and enhancing future safety and development. The differences
with TF-CBT are that the Horizon is given in groups instead of individual
sessions and the Horizon is abuse focused to address specific symptoms and
difficulties associated with CSA.
The main goal of the Horizon is to guide children in processing the traumatic
event(s). Children learn to feel and trust their emotions and to trust in
others. Horizon components are designed to prevent or reduce negative emotional
and behavioral responses to CSA, such as PTSD symptoms, depression, anxiety,
and other difficulties related to the traumatic event(s). The Horizon
intervention consists of 14 weekly parallel sessions of 90 minutes for parents
(nonoffending) and children. Every session focuses on a specific theme, such as
emotions, anger management and nightmares.

Study 1 will focus on observing the family relations in families who
experienced child sexual abuse. These families are referred to different Child
and Adolescent Trauma Centers and will receive treatment. Participants of this
study will fill in questionnaires and participate in two observational tasks
(FIT and AEED) once. This will take approximately a total of 1,5 hours for both
parents and children. The observational tasks will take 30 minutes. Children
will fill in questionnaires for only 35 minutes. Earlier research showed no
negative effects of the observational tasks and children reported enjoying the
FIT and the AEED (Oppenheim et al., 2009; Willemen, Schuengel & Koot, 2011).
The questions in the standard clinical diagnostic evaluation may bring up
memories of the traumatic event(s) in parents, however parents in a pilot study
reported that the supplemental questions within the current study design were
relatively easy. Children will be reminded by the questions of the traumatic
event(s) in the standard clinical diagnostic evaluation, but not by the
supplemental questionnaires. Both parents and children reported in a pilot
study that the supplemental questions were easy and light as compared to the
standard clinical diagnostic evaluation. Completing the questionnaires will be
professionally guided by researchers and trained students. When completing the
questionnaires is stressful for parent or child, they have the option to
(temporarily) stop. The risks for participating in this study are therefore
considered negligible.
Families who also participate in study 2 will have four additional moments of
measurement. Three of those measurements will take about an hour and the other
measurement will take 20 minutes for the parents and 35 minutes for the
children. Weekly measures will take 10 minutes for parent and child. The
assessment with questionnaires and observation will take place on a separate
day before the treatment starts and after the last treatment session to prevent
it from affecting the therapy and to minimally burden parents and children. The
families will be randomly assigned to sharing the trauma narrative with
therapist condition or sharing the trauma narrative with parent(s) condition.
For the last 10 years, sharing the trauma narrative with parents was not
included in the Horizon intervention. This Horizon intervention is a Trauma
Focused -Cognitive Behavioral Therapy (TF-CBT) (see p. 20 of the research
protocol) based intervention and TF-CBT is effective in reducing emotional and
behavioural problems and PTSD symptoms (Silverman et al., 2008). Previous
research has not provided evidence that adding the sharing TN with parents
component to the therapy is more effective then not including this component.
Based on theoretical considerations, we expect that sharing with parent(s) is
more beneficial by improving the parent-child relationship, but our study has
yet to confirm this hypothesis. The risks for participating in this study are
therefore considered negligible.
The observational tasks and part of the questionnaires of this study are
approved by the METC for the research project of Prof. Dr. F. Lamers-Winkelman
(protocol ID 80-82435-98-8010/3). These studies have not been done before and
cannot be carried out with adults. The study is therefore group-related.