Engagement and completion of therapy following a disclosure of child sexual abuse to authorities
Trauma from child sexual abuse has harmful and long-term effects, especially when left untreated.1 However, children disclosing abuse often have considerable barriers to engaging with therapy, and many children may not receive therapy to address their trauma until their symptoms become more severe later in life. The disclosure of child sexual abuse to authorities is an opportunity for services to address the effects of abuse.
Across Australian jurisdictions, the extent to which supportive or therapeutic services are connected to police and child protection investigations varies considerably.2 Understanding the evidence on the barriers that may exist at a local level will help services to consider what strategies may improve the accessibility of therapy for children following a disclosure. An evidence review was conducted to better understand typical rates of therapy attendance and completion across a variety of contexts. It also sought to identify which factors consistently influence engagement and completion rates across five characteristic types: abuse, child, perpetrator, family and response.
Studies included in the review reported on rates of engagement or completion of therapy for children/young people who had disclosed sexual abuse, and/or how different characteristics influenced engagement with or completion of therapy. The review included 49 individual studies (predominately from the USA), which highlights a need for Australian data.
What were the main findings?
Rates of therapy use following a disclosure of child sexual abuse
For engagement with therapy, the review found that:
- of the children who did not receive a referral after a forensic interview, 30% began therapy
- of the children who did receive a referral after a forensic interview, 61% began therapy
- for children/families who initiated contact with therapy providers, 81% began therapy.
For completion of therapy, the review found that:
- in studies where children had to meet a threshold of symptoms to be included, 73% completed therapy
- in studies where children didn’t need to meet a threshold of symptoms to be included, 59% completed therapy.
Factors influencing therapy use following a disclosure of child sexual abuse
For engagement with therapy, the review found that engagement was more likely when:
- abuse was more severe
- parents had more positive attitudes to therapy.
For completion of therapy, the review found that completion was more likely when:
- abuse was more severe
- children had more initial symptomatology
- caregivers attended therapy with the children.
The studies included many conflicting results, which we observed may reflect two different trends:
- Families experiencing greater complexity were less likely to engage in or complete therapy because of the ongoing difficulties in their lives and a lack of resources (social and economic).
- Families experiencing less complexity were less likely to engage or complete therapy out of concerns of stigmatising children.
What are the implications of the findings?
The findings indicate that many children don’t receive therapy following disclosure of child sexual abuse. While not every child would complete therapy, informal referral processes can limit the access of these services to children and families with more complex circumstances. A review of these factors found few consistent findings, which highlights the importance of understanding barriers at a local service level.
Referral practices that don’t reflect the realities of the families using these services potentially reduce the take-up of therapy, which in turn increases untreated sexual harm in the community, with all its associated costs.3 Targeted interventions to address barriers and improve motivation to engage would increase the likelihood of children completing therapy, which may also have a positive effect on treatments through improved caregiver participation in therapy.4,5 Addressing caregiver hesitancy about mental health services and building motivation at the intake and assessment phase of services may also help to improve engagement and completion.
Potential solutions should meet the needs and circumstances of the children and families disclosing abuse to authorities. Some possible responses that may help to address barriers include:
- involving workers whose specific role is to support and engage caregivers with services (i.e. child and family advocate) as part of the police/child protection response to abuse
- more formalised connections between therapy providers and police/child protection investigations, including a dedicated group of providers for referrals
- motivational interviewing and other interventions to address negative parental attitudes about mental health services and previous experiences of mental health care
- networks of specialist child sexual abuse therapy providers, with a centralised waitlist and an emphasis on choice of providers
- an assessment of readiness to engage as part of the intake process for child sexual abuse therapy, and planning of supports to address disengagement risks.
1. O'Leary, P., Coohey, C., & Easton, S. D. (2010). The effect of severe child sexual abuse and disclosure on mental health during adulthood. Journal of Child Sexual Abuse, 19(3), 275–289. doi: 10.1080/10538711003781251
2. Herbert, J., & Bromfield, L. (2018). National comparison of cross-agency practice in investigating and responding to severe child abuse. Melbourne: Australian Institute of Family Studies. Retrieved from aifs.gov.au/cfca/publications/national-comparison-cross-agency-practice-investigating-and-responding
3. Kezelman, C., Hossack, N., Stavropoulos, P., & Burley, P. (2015). The cost of unresolved childhood trauma and abuse in adults in Australia. Sydney: Adults Surviving Child Abuse and Pegasus Economics. Retrieved from www.blueknot.org.au/Portals/2/Economic%20Report/The%20cost%20of%20unresolved%20trauma_budget%20report%20fnl.pdf
4. Dorsey, S., Pullmann, M. D., Berliner, L., Koschmann, E., McKay, M., & Deblinger, E. (2014). Engaging foster parents in treatment: A randomized trial of supplementing trauma-focused cognitive behavioral therapy with evidence-based engagement strategies. Child Abuse & Neglect, 38(9), 1508–1520. doi:10.1016/j.chiabu.2014.03.020
5. Mannarino, A. P., & Cohen, J. A. (2021). Evidence-based treatment for victims of child sexual abuse and exploitation. In E. Caffo (Ed.), Online Child Sexual Exploitation (pp. 95–106). Cham, Switzerland: Springer. doi:10.1007/978-3-030-66654-5_8