Psychological and psychosocial interventions for children aged 7 years or younger who have been exposed to sexual violence – A Systematic Review including Ethical Aspects

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SBU Policy support

identifies and presents available scientific evidence to support policy and decision making, including the development of national guidelines, at other government agencies. In consultation with professional experts, SBU staff generates supporting documentation to address the various questions that have been posed.

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Published: Report no: 380 Registration no: SBU 2024/474 ISBN: 978-91-987555-9-6 https://www.sbu.se/380e

Conclusions

There are too few well-conducted studies to be able to draw any conclusions about the effects of psychological or psychosocial interventions for children 7 years of age or younger, who have been exposed to sexual violence or have witnessed someone else being abused to sexual violence.

Being subjected to sexual violence means violations of the person's integrity, self-determination, and dignity. This can have a negative impact on future quality of life and damage the person's opportunities to live a safe, rich, and independent life. Young children may have difficulties understanding that they have been exposed to an assault as well as difficulties reporting the assault. This means that ethical values, such as health and well-being, autonomy, and integrity, as well as professional and research ethical aspects are important to consider when caring for or conducting research regarding treatment aimed for young children exposed to sexual violence.

Background

Children may lack understanding, words and concepts for sexuality and sexual violence, which means that they may react with confusion or diffuse discomfort to sexual abuse. If the child is not protected from further abuse, the reaction can deepen and become more complex and severe over time. The reactions of adults and those around them when sexual violence is revealed or suspected are often decisive for the child. Sexual violence against children can take different forms and involves stress that can be both physical and psychological. However, not all children exposed to sexual violence show symptoms.

It is difficult to know how common sexual violence against children seven years or younger is. The prevalence in different countries differs depending on the legislation and how sexual violence is defined and measured.

Professionals that meet children who are 7 years or younger where the children have been exposed to sexual violence, or alternatively have witnessed sexual violence when someone close to them has been exposed, request knowledge about this target group, for example regarding effective treatment efforts. Research on the consequences of sexual violence for children 7 years of age or younger is however limited.

Aim

The aim of this systematic review is to evaluate the body of evidence for psychosocial or psychological interventions for children aged 7 or younger who have been exposed to sexual violence or have witnessed when someone close to them has been exposed to sexual violence.

Method

This systematic review has been conducted in accordance with the PRISMA statement. The protocol is registered in Prospero https://www.crd.york.ac.uk/prospero/CRD42024519031. 
For a study to be included in this systematic review, the following inclusion criteria needs to be fulfilled.

Inclusion criteria:

Population
Children 7 years of age or younger, where at least 50 % have been exposed to sexual violence or have witnessed when someone close to them has been exposed to sexual violence. The results must be reported separately for the group of children aged 7 years or younger.

Intervention
Psychological or psychosocial interventions, regardless of form and length, relevant to a Swedish health care context.

Control
Another treatment than the intervention that is relevant to a Swedish context. Treatment as usual, no treatment, medication, waiting list or an active control treatment.

Outcome
The outcome must be linked to the child and include mental illness, quality of life, relationship/attachment to caregiver, behavioural problems, or cessation of violence.

Study design
Randomized or non-randomized controlled trials (RCTs) or systematic reviews.

Language: English, Swedish, Danish, and Norwegian.

Search date: Final literature search was conducted in May 2023.

Databases searched:

  • CINAHL (EBSCO)
  • Cochrane Library (Wiley)
  • Criminal Justice Abstracts (EBSCO)
  • EMBASE (Embase.com)
  • Ovid MEDLINE(R) ALL
  • APA Psycinfo (EBSCO)
  • PTSDpubs (ProQuest)
  • Scopus (Elsevier)
  • Social Services Abstracts (ProQuest)
  • Sociological Abstracts (ProQuest)
  • SocINDEX (EBSCO)

Supplementary searches for ongoing and published systematic reviews and HTA reports were made in the following databases:

  • The Campbell Collaboration
  • Epistemonikos
  • International HTA Database
  • PROSPERO

Client/patient involvement: No.

Results

Two relevant and well-conducted studies that were assessed to have a moderate risk of bias are included in this review. They studied effects of cognitive behavioural therapy. (CBT), aimed at influencing feelings and behaviours to reduce symptoms.

In the study by Cohen et al (1993), the effect of CBT for sexually exposed preschoolers was compared with nondirective support therapy. The supportive therapy is designed so that sexual violence is not specifically addressed. Both the child and a guardian (non-perpetrator) are included in the treatment. The results indicate strong preliminary evidence for the effectiveness of the specific CBT-treatment for sexually exposed preschoolers and their parents. Comparisons between pre- and post-test showed that the CBT-group showed significant symptom improvements in most of the outcome measures, while those who had received nondirective supportive therapy did not show any significant change in symptoms.

Deblinger et al (2001) compared the effect of CBT, by investigating symptoms in a group that was given CBT and comparing the results to a group that received support treatment. The results suggest that the children and their non-perpetrator mothers may benefit from participating in group therapy, regardless of whether they receive CBT or support group treatment. However, the effect size regarding the change between pre- and post-treatment was generally greater for the group that had received CBT.

As the scientific basis only consists of two studies that are different in terms of studied intervention and analysis of results, no synthesis or certainty of evidence was performed in this systematic review.

Ethics

Not caring for or treating a child exposed to sexual violence means a high risk of negative consequences for the child, which makes risk assessment, detection, care and support important for the child's future health and quality of life. Although this report shows that there is a lack of scientific knowledge for interventions, there are risks in not providing support and treatment. In the absence of scientific support, it is important that one rests as much as possible on proven experience as well as documenting the basis for the decisions made, whether to give a treatment or not.

Interventions may need to be adapted to younger children, and then of course the intervention will not be completely comparable to the same intervention given to older children. In addition, measures suitable for younger children need to be used and evaluated.

To the extent that younger children have autonomy, it is limited as they may have difficulties with understanding, reasoning, and making decisions. A child in the age range 0-7 years may have difficulties understanding that what they have been subjected to constitutes abuse. Furthermore, even if they can identify abuse, they may have difficulties reporting abuse due to fear or other barriers. Despite the limitations that younger children may have in consenting to care, there are several initiatives to develop a consent process.

The aspects of justice and equality that are relevant in the context of this report primarily concern the accessibility of care. Girls have a higher risk of being exposed to sexual violence and perpetrators are usually men. Younger children cannot seek care themselves, and parents or other guardians are essential for younger children's access to care. Studies show that parents to children who have been exposed to sexual violence can be obstacles to children receiving treatment.

There are strong ethical and scientific reasons for giving young children the opportunity to participate in research studies as active research subjects. Children have a right to be heard and to have an influence on things that concern them. Research also shows that there can be differences between answers that children give and answers that adults give for children, which means that you do not get the answers you are looking for. When it comes to young children, one should therefore not, with reference to the children's young age and lack of maturity, routinely be satisfied with letting adults answer for the children.

Discussion

The lack of research studies regarding young children may be because there are few children who receive support and help from the health services. Unreported figures can be assumed to be high as younger children may find it difficult to express what they have been exposed to or may not even have understood what they have been exposed to.

Many children are exposed to several different types of abuse (polyvictimisation), and this applies to a particularly large extent to sexually exposed children. In practice, it is not reasonable to provide several interventions that are specifically adapted to different types of abuse, in parallel or one after the other. Instead, a feasible path for both research and practice seem to be to develop, implement and evaluate interventions for children 7 years of age or younger with reliability for different types of a trauma and exposure.

When planning an intervention, certain factors need to be met: the child must be protected, everyone who will participate in the treatment needs to be motivated to receive help, and there must be resources, routines and working models for both protection, information, and motivation. The child's need for protection must therefore first be met and there must be routines for risk assessments and safety work. The choice of intervention needs to be made based on the conditions and needs of the child or the family. For example, the child's age, the severity of symptoms, what the child has been exposed to, and how this has affected the child's mental health and social relationships. A specific method is seldom sufficient when multiple problems occur. Access to continuous advice and support and various types of help is important.

Conflicts of Interest

In accordance with SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

Project Group

Experts

  • Gisela Priebe, Karlstad University, Karlstad, Sweden
  • Ulrik Kihlbom, Karolinska institutet, Stockholm, Sweden

SBU

  • Gunilla Fahlström, project manager

 

External reviewers

  • Kjerstin Almqvist, Karlstad University, Karlstad, Sweden

Flow chart

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