Disclosure of sexual abuse, and personal and familial factors as predictors of post-traumatic stress disorder symptoms in school-aged girls

Abstract

OBJECTIVE

The aim of the present study was to analyze predictive factors of post-traumatic stress disorder (PTSD) symptoms in school-aged girls.

METHODS

A group (n=67) of seven- to 12 year-old girls consulting a paediatric hospital following disclosure of sexual abuse were compared with a group (n=67) of nonabused girls. The girls answered questionnaires related to PTSD, coping, sense of hope, self-esteem, sibling relationships and perceived social support. Mothers answered questionnaires related to family relationships, family violence, perceived support given and psychological distress.

RESULTS

The mean ± SD age of the girls was 9±1.5 years. In the sexual abuse group, single-parent families were more frequent (53.7% versus 32.3%; P<0.01), mothers were less educated (10.8% versus 13.1%; P<0.0001) and socioeconomic level was lower (36.8% versus 47.9%; P<0.0001). A history of sexual abuse in childhood was reported by 50% of mothers of sexually abused children and 37% of mothers of the comparison group children. A higher prevalence of PTSD clinical scores was found for the girls reporting sexual abuse (46.3% versus 18.5%; P<0.001). Regression analyses controlling for parental education level and family structure revealed that group membership (sexual abuse group versus comparison group) was predictive of the level of PTSD symptoms. In addition, the mother’s level of support, the child’s perception of parental support and the child’s reliance on avoidance coping predicted PTSD symptoms. Sense of hope and the child witnessing interparental physical violence were marginally associated with the level of PTSD symptoms.

CONCLUSIONS

PTSD was common in the present study’s sample of sexually abused girls. Because predictive factors relate to both child-related variables and familial context, interventions for this population should target not only the child, but also the family.

Child sexual abuse (CSA) and its consequences are an increasingly important issue for child health professionals. Prevalence estimates suggest that between 12% and 35% of women and between 4% and 9% of men report having experienced sexual abuse before 18 years of age (1). The sequelae of CSA indicates that children not only express short-term adaptation problems (2), but are also at risk of adolescence and adulthood revictimization, drug and alcohol abuse and a host of other symptoms (1,3). It is, therefore, imperative to clearly document the short-term sequelae of CSA and implement adequate interventions to minimize potential associated long-term correlates (4).

Considering the magnitude of this phenomenon, a number of researchers have investigated the short-term impact of sexual abuse in children, focusing increasingly on mother-reported symptoms as well as child-reported symptoms, in an effort to gather cues to help design possible interventions.

ADJUSTMENT DIFFICULTIES OF SEXUALLY ABUSED CHILDREN

Although no sexual abuse-specific syndrome has been described, aggressive behaviour, social isolation, somatization, anxiety, depression, nightmares, inappropriate sexualized behaviours and symptoms of post-traumatic stress disorder (PTSD) are the most frequent sequelae reported (2,5–7). It appears that the frequency of PTSD is quite high in sexually abused children, and that approximately 40% of sexually abused children develop PTSD symptoms (2,8–11). Furthermore, McLeer et al (8) suggest that stability of PTSD symptoms over time, its resistance to treatment and its effects on behavioural, social and emotional development put sexually abused children at risk for long-term dysfunction in various domains.

Theoretical models have been developed to explain the variety of consequences in sexually abused children. Spaccarelli (12) has outlined a transactional model in which sexual abuse is a stressor that carries a risk for maladjustment that increases as a function of abuse components, and abuse- and disclosure-related events. Psychological outcomes are also mediated by cognitive appraisals and coping strategies. Intrapersonal factors (age, sex and personality) and environmental factors, including support resources, may moderate relationships between sexual abuse stressors and child responses. An ecological view of psychological trauma was proposed by Harvey (13). Vulnerability to victimization and varied outcomes are determined by interactions of three sets of mutually influential factors: personal variables (age, developmental stage, personality, cognitions, coping capabilities, and relationship between victim and offender), event factors (frequency, severity, duration of the events, violence involved and significance of circumstantial details) and environmental factors (ecological context, support system, community attitudes and values, and care and advocacy resources).

The analysis of multidimensional factors may allow to explain why some children do not exhibit significant adjustment difficulties at first intake (2,5,14). Protective factors can be classified into personal, familial and extrafamilial correlates. In terms of personal factors, the types of coping strategies used by children may be related to outcomes. In a study by Johnson and Kenkel (15) that included a sample of 40 adolescent girls who were victims of incest, it was reported that the use of magic thought and strategies aimed at avoiding the stressor (‘avoidant coping’) was associated with a higher level of distress. Among familial factors, family cohesion and positive support from the mother improved the sexually abused child’s adjustment (16,17). Among extrafamilial factors, peer support has been rarely studied and the results have been inconclusive (11).

OBJECTIVE

The general objective of the present study was to evaluate the presence of PTSD symptoms in school-aged girls, while accounting for individual, contextual and familial factors. The analysis of protective factors included personal factors (coping, self-esteem and child’s sense of hope), familial factors (family cohesion, positive maternal support and quality of sibling relationships) and extrafamilial factors (perceived peer support and level of activities outside of home). The presence of risk factors relating to concomitant violence (mother victim of partner violence and child witnessing partner violence) that may have solicited coping mechanisms of school-aged girls were also considered.

The study attempted to overcome some of the methodological issues of previous studies. Because few studies of PTSD in CSA have included comparison groups, a comparison group of girls was recruited in an attempt to better delineate the outcomes of the girls in the CSA group. A specific effort was made to recruit children within three months of sexual abuse disclosure, under the criterion that they were not involved in a therapeutic program at the time of their first visit to the child protection clinic of Sainte-Justine UHC, a teaching tertiary care hospital in Montreal, Quebec. To preserve a developmental homogeneity, the sample was restricted to girls between seven and 12 years of age.

METHODS

Sample

A total of 67 girls between seven and 12 years of age were recruited from the child protection clinic. Approximately 350 prepubertal children are seen every year for alleged maltreatment (CSA, physical abuse and neglect) by this multidisciplinary team. Children are referred by child protection services, their physician, by a community clinic or by the emergency department. The child’s history is generally obtained through the clinic social worker (or the child protection services), and the clinic coordinating nurse; the medical examination is performed by one of five part-time paediatricians. A comparison group (n=67) was recruited among school-aged girls in the Montreal area, matching participants by age and quality of public neighbourhood school.

Procedure

For the CSA group, the nonabusive parent (generally the mother) was approached by a research assistant during his or her visit to the child protection clinic. The procedure was explained and written informed consent was obtained. A questionnaire (18) was used to describe sociodemographic characteristics and life events. Mothers completed questionnaires about the family environment, concomitant violence, their perceived support given to the child and psychological distress. With the help of the research assistant, the child completed questionnaires about PTSD, coping strategies, sense of hope, self-esteem, sibling relationships and perceived support. Details regarding the abuse were obtained from medical records using the history of victimization form (19,20). For the comparison group, families were approached through the school by a letter explaining that a study about child development and reactions to stressful events was being performed. Parents from the comparison group were also asked in the first interview about the presence of sexual abuse experiences by answering whether a list of events (CSA, hospitalization, separation, residential move, adoption and illness) had occurred in the child’s past. Comparison children who had experienced CSA were excluded from the study. The study was approved by the ethics review board of Sainte-Justine UHC.

Information from patients’ charts:

Three abuse-related variables were used to describe the girls in the CSA group: severity of abuse (21) describing very severe sexual abuse (oral, vaginal or anal penetration, or attempted penetration), severe sexual abuse (unclothed touching or digital penetration) and less severe sexual abuse (touching while clothed or exhibitionism); duration of abuse as a single episode, more than one episode but lasting less than three months or chronic abuse (more than three episodes over a prolonged period of more than six months); and identity of the perpetrator (from the immediate family, extended family, a known extrafamilial aggressor or a stranger).

Information from mothers:

The Family Relationship Index (22) was used to evaluate the degree of family conflict and family cohesion. A brief version of the Conflict Tactics Scale (23) evaluated physical violence occurring with the mother’s present or last partner. Following the method of Moore and Pepler (24), the mother specified how often the child had witnessed parental conflicts. The Indice de Détresse Psychologique Enquête Santé Québec (IDPESQ) (25) furnished a global measurement of the level of the mother’s psychological distress; four dimensions were measured – anxiety, depression, irritability (negative feelings toward others, or becoming baffled or annoyed easily) and cognitive problems (concentration, memory and decision-making problems). A questionnaire evaluated the mother’s perception of support given to the child following disclosure. Another questionnaire gathered information on how often the child engages in activities outside of school – physical activities (team sports and swimming lessons), cultural activities (painting and music), and community programs and activities (library visits and neighbourhood social gatherings).

Information from children:

The Children’s Impact of Traumatic Events Scale – Revised (26,27) evaluated PTSD symptoms, covering typical re-experiencing symptoms (eg, nightmares), avoidant behaviours (eg, trying to forget the event) and hyperarousal problems (eg, feeling agitated or nervous). The Self-Report Coping Scale (28,29) identified types of strategies used while facing a problem based on the theory of Roth and Cohen (29) about approach (strategies aimed at confronting the stressor) versus avoidance strategies (aimed at distancing oneself and avoiding the stressor). Children’s sense of hope was evaluated with the Children’s Attributional Style Questionnaire – Revised (30) and a score of global self-perception was obtained with the Self-Perception Profile for Children (31). Finally, the Sibling Relationship Inventory (32) was used to evaluate the positive components of sibling support (degree of warmth and intimacy), while the Perceived Social Support Scale (33,34) gathered information concerning peer support and parental support received.

Statistical analysis:

Sociodemographic variables were compared between the CSA group and the comparison group using the χ² test for categorical variables, and the Student’s t test for continuous variables. A composite score of parental education was derived by averaging maternal and paternal education levels. Analyses of covariance with parental education level and family structure (single-parent family versus intact family) as covariates were performed to explore differences between the CSA group and the comparison group. Finally, multiple regression analyses were conducted to identify factors contributing to the prediction of PTSD symptoms. For each regression, two control variables, parental level of education and family structure (single family versus intact family), as well as group membership (CSA group versus comparison group) were entered in the first step.

RESULTS

Sociodemographic variables of the CSA group and the comparison group girls

As shown in Table 1, there were no significant differences between sexually abused girls and the comparison group for age (9.03±1.35 years versus 9.29±1.58 years) and the proportion of working mothers (63.6% versus 70.8%). However, a larger proportion of sexually abused girls came from single-parent families (53.7% versus 32.3%; χ²=7.52; P<0.01). Mothers and fathers of the comparison group had a higher level of education (13.08±3.85 years versus 10.87±2.68 years [t=3.8; P<0.001] and 13.25±4.01 years versus 11.34±2.40 years [t=3.09; P<0.01]). Socioeconomic level was higher for mothers of the comparison group (49.68±16.27 versus 36.17±11.49 [t=4.64; P<0.001]).

TABLE 1.

Summary of sociodemographic variables for both the child sexual abuse (CSA) and the comparison groups (n=67 in each group)

	CSA group	Comparison group
	Mean ± SD or %	Mean ± SD or %	Significance tests
Age of the child	9.03±1.35	9.29±1.58	t(130)=1.03*
Family structure
Intact	25.4%	46.2%	–
Single mother	53.7%	32.3%	–
Recomposed	20.9%	21.5%	χ2(2)=7.52†
Mother’s level of education, years	10.87±2.68	13.08±3.85	t(114)=3.82‡
Father’s level of education, years	11.34±2.40	13.25±4.01	t(98)=3.09‡
Working status
Social beneficiary	24.2%	26.2%	–
Student	7.6%	3.1%	–
Unemployment insurance	4.5%	0.0%	–
Working mothers	63.6%	70.8%	χ2(3)=7.52*
SES level	36.17±11.49	49.68±16.27	t(91)=4.64‡
Maternal history of sexual abuse	50.0%	36.9%	χ2(1)=2.06*

^*Nonsignificant;

^†P<0.05;

^‡P<0.01. SES Socioeconomic status

Characteristics of the abuse and other familial victimization events for the CSA group

One-quarter of the girls were sexually abused on a single episode, while almost one-half had experienced chronic sexual abuse lasting more than six months (Table 2). Close to two-thirds of the abusive acts were considered to be severe, with attempted or actual penetration. The perpetrator came from the immediate family in 50% of the cases, and from the extended family in one-fifth of cases. Among extrafamilial cases, only a minority were unknown to the child. Almost all perpetrators were male (98.5%), two-thirds of them were between 20 and 59 years of age, and one-fourth were younger than 19 years of age. One-fourth of mothers reported physical violence from their spouse, either minor (23.9%) or severe (11.9%), that was witnessed by their daughter in 16.4% (minor violence) and 1.5% of cases (severe violence). Approximately 50% of the mothers had been sexually abused during their childhood.

TABLE 2.

Abuse-related characteristics of the child sexual abuse participants (n=67)

	%
Severity level of abuse
Less severe	1.6
Severe	32.8
Very severe	65.6
Perpetrator’s relationship to patient
Immediate family	49.2
Extended family	19.4
Known extrafamilial	25.4
Stranger	6.0
Age of the perpetrator (years)
<15	7.7
15–19	18.5
20–59	67.6
≥60	6.2
Duration of abuse
Single episode	25.0
Multiple episodes over <3 months	28.1
Multiple episodes over >3 months	46.9
Partner violence
Physical violence
Minor	23.9
Severe	11.9
Child witness of physical violence
Minor	16.4
Severe	1.5

Less severe abuse – touching over clothes and exhibitionism; severe abuse–touching under clothes and digital penetration; very severe abuse – oral contacts, anal or vaginal penetration or attempted penetration; chronic abuse–more than three episodes over a prolonged period (three to six months)

Differences between the CSA and the comparison group

Adjusted means and results of significance tests are presented in Table 3. No significant difference was identified between groups regarding family cohesion and family conflict as reported by mothers. Mothers of CSA girls were found to achieve higher psychological distress total scores relative to mothers of comparison group girls, as well as significantly higher scores on the anxiety and depression subscales. There were no differences of reported partner physical violence experienced by both groups of mothers. Although this difference is not statistically significant, 50% of sexually abused mothers and 36.9% of comparison group mothers reported they had been sexually abused during childhood.

TABLE 3.

Adjusted means and percentage for child-related variables and family characteristics

	CSA group (n=67)	Comparison group (n=67)	Significance tests
Variables	Mean or %	Mean or %	Value	P
Family functioning	18.70	19.07	F(1,125)=0.25	NS
Cohesion	7.17	7.25	F(1,125)=0.04	NS
Conflict	5.67	5.84	F(1,125)=0.14	NS
Maternal history of sexual abuse	50.0%	36.9%	χ 2(1)=2.06	NS
Partner minor physical violence	23.9%	16.9%	χ2(1)=0.98	NS
Child witness of minor physical violence	16.4%	12.3%	χ2(1)=0.45	NS
Partner severe physical violence	11.9%	4.6%	χ2(1)=2.32	NS
Child witness of severe physical violence	1.5%	1.5%	χ2(1)=0.00	NS
Mother’s psychological distress	28.51	21.40	F(1,123)=6.60	<0.05
Anxiety	10.00	7.06	F(1,123)=6.68	<0.05
Depression	11.49	7.94	F(1,123)=9.56	<0.01
Irritability	3.38	3.53	F(1,123)=0.11	NS
Cognitive problems	3.63	2.86	F(1,123)=2.73	NS
Child’s approach coping	3.59	3.64	F(1,128)=0.13	NS
Child’s avoidance coping	2.35	2.24	F(1,129)=0.81	NS
Child’s self-esteem	18.14	19.33	F(1,128)=3.11	NS
Child’s sense of hope	2.76	3.14	F(1,122)=4.23	<0.05
PTSD	22.86	16.64	F(1,126)=18.13	<0.001
Clinical score for child’s PTSD*	46.3%	18.5%	χ2(1)=11.62	<0.001

^*P<0.01.

CSA Child sexual abuse;

NS Nonsignificant

PTSD Post-traumatic stress disorder

Girls in the CSA group did not differ significantly from girls in the comparison group in their reported use of bothapproach and avoidance coping strategies or on their self-esteem scores. Girls in the CSA group, however, obtained a lower score of hope and a higher score of PTSD symptoms relative to girls in the comparison group. A higher percentage of sexually abused girls met the criteria for PTSD compared with the comparison group (46.3% versus 18.5% [χ²=11.62; P<0.001]).

Predictors of PTSD symptoms

The first stepwise regression was performed with group membership (CSA group versus comparison group) and concomitant violence (witnessing domestic violence) as predictors of PTSD symptoms. The regression equation reached significance level and revealed that while controlling for group membership, being witnesses of physical domestic violence was a marginally significant predictor. A second stepwise regression was performed with personal protective factors – child’s coping strategies, self-esteem and sense of hope. Two variables contributed to the prediction of PTSD symptoms – child’s avoidance coping and sense of hope, suggesting that the children relying on avoidance coping to deal with stressors and displaying a lower sense of hope obtained higher PTSD scores. The third stepwise regression performed on family factors (perceived support, family functioning, mother’s mental health and support from siblings) reached significance, and two variables contributed to the prediction of PTSD symptoms – the child’s perception of parental support and the mother’s perceived level of support given. Thus, children perceiving high parental support and mother’s perception of support given acted as protective factors against PTSD symptoms. The stepwise regression conducted on extrafamilial factors (support from peers and child’s involvement in social activities outside the home) did not identify a specific variable contributing to the prediction of PTSD symptoms after controlling for group membership.

Finally, all variables found to be significant were entered into a final regression model to ascertain whether they would maintain a unique contribution once other variables were accounted for. The regression achieved a significant level and explained 31% of the variance. Table 4 illustrates the percentage of explained variance at each step for each group of variables, and provides summary statistics for the final step of the regression analysis. Results indicated that after controlling for group membership, maternal perception of support given, children’s perception of parental support received and children’s avoidance coping predicted PTSD symptoms. In addition, children with a lower sense of hope and witnessing partner physical violence displayed higher PTSD scores, albeit these two predictors achieved a marginal level of significance (P=0.06).

TABLE 4.

Predictors of post-traumatic stress disorder: Results of multiple regression analyses

	β	P	Significance tests
Abuse-related variables
Group membership (CSA versus comparison)	0.38	<0.001
Witness of physical violence	0.16	0.06
			F(3,128)=6.74; P<0.001; adjusted R2=0.12
Personal factors
Group membership (CSA versus comparison)	0.33	<0.001
Child’s avoidance coping	0.29	<0.001
Child’s sense of hope	–0.16	<0.05
			F(5,126)=8.37; P<0.001; adjusted R2=0.22
Familial factors
Group membership (CSA versus comparison)	0.28	<0.01
Mother’s perception of support given	–0.23	<0.01
Child’s perception of support received	–0.23	<0.01
			F(5,126)=6.88; P<0.001; adjusted R2=0.21
Extrafamilial factors
Group membership (CSA versus comparison)	0.38	<0.001
			F(3,128)=6.74; P<0.001; adjusted R2=0.12
Final equation
Group membership (CSA versus comparison)	0.26	<0.01
Witness of physical violence	0.14	0.06
Mother’s perception of support given	–0.16	<0.05
Child’s perception of support received	–0.16	<0.05
Child’s avoidance coping	0.23	<0.01
Child’s sense of hope	–0.15	0.06
			F(8,123)=6.77; P<0.001; adjusted R2=0.31

CSA Child sexual abuse

DISCUSSION

The present study reveals a prevalence rate of 46.3% of PTSD symptoms in a sample of seven- to 12-year-old girls referred for evaluation of sexual abuse. These findings are in accordance with recent literature reporting a frequency of PTSD in sexually abused children varying between 40% (8) and 50% (10). The meta-analysis of Paolucci et al (2) suggests a minimum of a 20% increase in PTSD outcome over the baseline in individuals having experienced CSA.

In our comparison group of girls who had not been sexually abused, the prevalence rate of PTSD was 18.5%. A number of empirical reports suggest that a significant number of children and adolescents in the general population report a traumatic experience. For instance, Giaconia et al (35) estimated that approximately 43% of their community adolescent sample, followed from kindergarten to 15 years of age, experienced a trauma such as rape, assault or sudden injury. McCloskey and Walker (36) showed that 24.6% of 205 children (n=337) reporting a stressful event met the symptom criteria for PTSD, and that exposure to family violence was the second strongest risk factor for the development of PTSD. Approximately 19% of children who witnessed the abuse of their mother had the symptom criteria for PTSD. It is striking that in our own comparison group, mothers had experienced similar levels of partner physical violence as mothers of CSA girls. Under these circumstances, one can easily imagine that girls of the comparison group, although not victims of sexual abuse, experienced their share of traumatic experiences and PTSD symptoms.

The prevalence of CSA among mothers was approximately 50% in the CSA group and 37% in the comparison group. This percentage is higher than figures reported by other adult Canadian studies. Badgley et al (37) reported that 10% of women in their national sample had been abused before 14 years of age. In the Ontario Health Supplement study (38), a history of sexual abuse during childhood was reported by 13% of women. However, other surveys (4,39,40) of CSA of general population samples of women have reported prevalence rates ranging from 21% to 34%. These estimates approach the prevalence rates of CSA observed in mothers of our comparison group. The prevalence of 50% of CSA in mothers of the sexually abused group is similar to reported estimates in the literature that vary between 50% and 65% (41). Moreover, McCloskey and Bailey (42) reported a 3.6 times increased risk of sexual abuse in children of mothers sexually abused during childhood.

Our data suggest that a number of factors are related to PTSD symptoms in school-aged girls, namely sexual abuse. The coping strategies used by the child emerged from regression analyses as an important factor for the outcome of PTSD over and above group membership. In our study, children’s coping strategies were analyzed according to Roth and Cohen’s (29) approach and avoidance conceptualization. Approach strategies allow for cognitive and emotional apprehension of an event; they facilitate the gathering of the information required for appropriate action, or for taking advantage of changes that might make a situation more controllable; they also provide ventilation for affect. On the other hand, avoidance strategies may protect the individual from becoming emotionally overwhelmed and dysfunctional. However, they may also interfere with the gathering of information which could lead to productive action. Moreover, this may lead to emotional numbness, intrusion of threatening material, disruptive avoidance behaviours and lack of awareness of relationship of symptoms to trauma. Although avoidance may be a valuable form of coping for a limited time, in cases of sexual abuse, avoidant coping has been shown to be detrimental in the long-term. In their study of seven- to 12-year-old abused children, Chaffin et al (43) postulated that avoidant coping may buffer initial stress responses, and preclude the cognitive processing necessary for the long-term resolution of the trauma. However, avoidant coping was associated with greater negative attitudes and anxieties about sexuality. Tremblay et al (11) reported that children who used more avoidant coping were perceived by their mother as exhibiting more behavioural difficulties.

In the present study, avoidance coping was a strong predictor of PTSD. This finding may be explained by the fact that behavioural and psychological consequences that usually proceed from avoidance strategies appear to share some common features with core PTSD symptoms (re-experiencing, avoidance and hyperarousal). Intrusions of threatening material that are often described in avoidant coping could be responsible for the re-experimentation with nightmares, flashbacks and intrusive thoughts of PTSD. Disruptive avoidant behaviours and affective numbing constitute another diagnostic criteria of PTSD, and are frequently present in avoidant coping situations. Finally, the increase in externalized and internalized behaviours frequently described in association with avoidant coping could also be interpreted as symptoms of hyperarousal.

In our sample, perceived parental support was an important protective factor, be it documented through the child’s perception or the mother’s perception. Generally, maternal support has been evaluated through clinical assessment by health professionals (44,45), parental reports (46), children’s reports (11,14,47), or both parent and child reports (16). In our study, we chose to measure support perception by both mother and child to obtain a better definition of this correlate. Parental support would indeed help the child express fears and anxious feelings by offering a protection against intrusive thoughts and re-experiencing. In the presence of a comforting and responsive parent, the child would be less reliant on avoidant behaviour and emotional numbness, and would manifest fewer episodes of hyper-arousal. Peer support did not contribute to the prediction of PTSD symptoms. These findings are similar to the study of Tremblay et al (11), in which no significant relationship between perceived support from peers and adjustment variables in sexually abused girls were found. Girls of our sample had not reached adolescence, an age when peer support may become a more salient protective factor.

Our results should be interpreted with the limitations inherent to the cross-sectional nature of the study with measures that were administered only once. A longitudinal design would allow for a better interpretation of the role of predictive factors, and would investigate how these factors interplay with PTSD symptoms on a long-term perspective. Moreover, our sample was limited to girls between seven and 12 years of age, and results should not be generalized to boys or to preschool or adolescent girls, who are at different levels of development and social competence, and for whom different predictive factors could be involved.

Nonetheless, our study outlines the role of the child’s coping strategies and the role of parental support as protective factors against PTSD. These results provide additional support for interventions addressing the needs of both the child and the nonoffending parent. Recent studies (48,49) on trauma-focused cognitive-behavioural therapy provided to the child and the nonoffending parent have shown promising results over short-term intervals, that appear to be sustained during the first and second years after treatment (50–52).

CONCLUSION

The present data confirm the importance of PTSD in sexually abused girls in the seven- to 12-year-old age groups. They also point out predictive factors related to personal and familial variables. Acknowledging the role of the child’s coping strategies and parental reactions in the psychological distress or adjustment of school-aged girls will not only help therapists focus their interventions with the child, but also with the family confronted with the disclosure of the abuse.