Children’s Coping and Perceptions of Coping Efficacy After Sexual Abuse: Links to Trauma Symptoms

Abstract

Despite an emphasis on coping following childhood sexual abuse (CSA) to reduce trauma-related symptoms, very few studies have researched the associations between sexually abused children’s coping and trauma-related difficulties, and perceived coping efficacy has been largely overlooked. The current study investigated whether children’s use and perceived efficacy of avoidant, internalized, angry, and active/social coping strategies were associated with caregiver- and child-reported posttraumatic stress symptoms (PTSS), and caregiver-reported internalizing and externalizing symptoms among 202 sexually abused children (8-12 years; M = 10.47 years, SD = 1.70 years). Children reported using approximately eight types of coping strategies (M = 8.29, SD =2.50). Regression models indicated that internalized and angry coping were associated with child-reported PTSS. In contrast to expectations, none of the types of coping strategies were linked with caregiver’s reports of PTSS or internalizing and externalizing symptoms. Interestingly, perceived efficacy of coping was largely unrelated to symptoms, with only perceived efficacy of avoidant coping inversely related to child-reported PTSS. Perceived efficacy was not tied to caregiver’s reports of children’s symptoms. Coping strategies may be associated with children’s, but not caregiver’s, reports of children’s trauma-related difficulties. Furthermore, perceived efficacy of coping strategies may also be largely unrelated to children’s symptoms, or children may have limited insight regarding the efficacy of their coping strategies. To further inform trauma-focused interventions that support effective long-term coping, future research should investigate which coping strategies children perceive to be efficacious, as well as potential reasons why.

Keywords

child sexual abuse children’s coping posttraumatic stress symptoms

Childhood sexual abuse (CSA) is an unfortunately common traumatic event—an estimated 13% to 26.6% of children report experiencing CSA (Finkelhor, Shattuck, Turner, & Hamby, 2014; Stoltenborgh, Bakermans-Kranenburg, Alink, & van Ijzendoorn, 2015). Although some children are remarkably resilient in the aftermath of CSA, others exhibit trauma-related difficulties, including posttraumatic stress symptoms (PTSS) and internalizing and externalizing symptoms (Chen et al., 2010; Hillberg, Hamilton-Giachritsis, & Dixon, 2011; Putnam, 2003). Work has, therefore, been devoted to identifying risk factors for more adverse symptom trajectories, and the current literature indicates that there are strong links between coping strategies and trauma-related symptoms in adults (Relyea & Ullman, 2015; Ullman & Relyea, 2016; Ullman, Townsend, Filipas, & Starzynski, 2007). However, there is relatively little research regarding the ties between sexually abused children’s utilization of coping strategies and trauma-related symptoms. To help promote resilience following CSA, it is critical to understand how coping may correspond with symptoms in the more immediate aftermath of the CSA. The bulk of the prior literature regarding childhood trauma and coping has utilized children exposed to noninterpersonal traumatic events (e.g., Khamis, 2008; Marsac et al., 2016; Marsac, Donlon, Winston, & Kassam-Adams, 2011; Stallard, Velleman, Langsford, & Baldwin, 2001; Vigna, Hernandez, Kelley, & Gresham, 2010). Although this research is informative, it is paramount to specifically investigate CSA, given the higher rates of trauma-related difficulties following interpersonal traumatic events (Ullman et al., 2007). Furthermore, children may utilize a variety of forms of coping following abuse, some of which may not be valued clinically but may be perceived to be effective by the child. Therefore, it is important to also understand the relations between children’s perceptions of efficacy and symptoms, which remain understudied. The aims of the study were to advance the emerging literature regarding childhood trauma and coping by investigating the ties between both the utilization and perceived efficacy of children’s coping strategies and trauma-related symptoms among sexually abused children.

Coping in Response to Trauma

To buffer against the adverse reactions from stressors or threatening situations, individuals may engage in a range of thoughts and behaviors, a process known as coping (Folkman & Lazarus, 1980; Lazarus & Folkman, 1984). In the context of traumatic events such as CSA, coping strategies such as distraction, self-blame and other cognitive distortions, self-harm behaviors, or seeking support from family and friends may be used to attempt to lessen trauma-related distress (Lazarus & Folkman, 1984, 1987). Several theoretical models for coping have been applied to CSA (e.g., Burgess & Holmstrom, 1976; Finkelhor & Browne, 1985; Spaccarelli, 1994; Walsh, Fortier, & DiLillo, 2010) that emphasize the importance of coping as a predictor of response to CSA. Although the specific terms often vary across studies, coping strategies are frequently conceptualized into overarching adaptive and maladaptive categories. For example, coping strategies considered to be ineffective or unhelpful in the context of trauma-related symptoms, including distraction and blaming oneself, may be termed maladaptive, negative, passive, or avoidant coping strategies. Those referred to as adaptive, active, positive, or approach coping strategies (e.g., seeking social support and problem solving), however, are thought to buffer against symptoms (Bal, Crombez, De Bourdeaudhuij, & Van Oost, 2009; Walsh et al., 2010).

Coping and Distress Among Trauma-Exposed Adults

The majority of the prior research regarding trauma and coping has utilized adult survivors of CSA and other traumas and has indicated that coping may play an important role in predicting responses to traumatic events (Ullman, Peter-Hagene, & Relyea, 2014; Ullman & Relyea, 2016; Ullman et al., 2007; Walsh et al., 2010). The adult literature has relatively consistently observed that maladaptive coping is a strong predictor of various trauma-related difficulties including general distress, depression, reduced self-esteem, and PTSS (Badour, Blonigen, Boden, Feldner, & Bonn-Miller, 2012; Merrill, Thomsen, Sinclair, Gold, & Milner, 2001; Ullman et al., 2014; Ullman & Relyea, 2016; Ullman et al., 2007; Walsh et al., 2010). Furthermore, these relations have persisted after controlling for abuse severity (Brand & Alexander, 2003; Coffey, Leitenberg, Henning, Turner, & Bennett, 1996; Leitenberg, Greenwald, & Cado, 1992). Cantón-Cortés and Cantón (2010) similarly reported an association between a diagnosis of posttraumatic stress disorder (PTSD) and utilization of avoidant coping strategies among adult CSA survivors. Nonetheless, in one review of the literature, Walsh and colleagues (2010) concluded that the use of maladaptive coping was more frequently related to increased level of difficulties than reports that adaptive strategies were observed to buffer against symptoms. Indeed, utilization of adaptive coping strategies has not been consistently related to levels of distress (Cantón-Cortés & Cantón, 2010; Wright, Fopma-Loy, & Fischer, 2005), and when relationships are observed, they are often weak (Filipas & Ullman, 2001; Merrill et al., 2001; Murthi & Espelage, 2005). Cantón-Cortés and Cantón speculated that for these adaptive coping strategies to be effective, one must have additional resources, such as positive social support, material resources (i.e., income), and stability that would create a sense of control over one’s environment. Therefore, it is critical to research various forms of coping in relation to symptoms as the relationships between types of coping and trauma-related distress are unlikely to be uniform.

Although research with adult samples provides important insight into the enduring effects of coping in relation to symptoms, studies using adult samples may not directly inform the child trauma and coping literature for several reasons. Most critically, the findings from adult samples who experienced sexual abuse as children are almost certainly influenced by numerous unaccounted for historical confounds (e.g., revictimization, secondary stressors, chronic mental health difficulties) that may obscure the relationships between coping and symptoms. Furthermore, the coping strategies utilized by adults may present differently than with children who have undergone CSA more recently, particularly as they have been utilizing the coping strategies for a much shorter period of time. Children are also at a different developmental epoch than adults and have different abilities and awareness in implementing arguably more complex adaptive coping strategies, such as cognitive restructuring and problem solving. Consequently, research using pediatric samples is needed to better understand the relationships between coping strategies and children’s trauma-related symptoms following CSA.

Coping and Symptoms in Children

Although the amount of research with trauma-exposed children is strikingly smaller, much of the findings from this literature have echoed studies with trauma-exposed adults. Specifically, maladaptive coping has been associated with increased externalizing and internalizing symptoms, behavior difficulties, PTSS, and generalized distress in several studies (Bal et al., 2009; Khamis, 2008; LaGreca, Silverman, Vernberg, & Prinstein, 1996; Marsac et al., 2016; Marsac et al., 2011; Stallard et al., 2001; Tremblay, Hébert, & Piché, 1999). Similar to the adult literature, adaptive strategies have not generally been related to symptoms including overall distress, PTSS, and internalizing and externalizing symptoms (Marsac et al., 2011; Spaccarelli, 1994; Tremblay et al., 1999). Nonetheless, some studies have reported inconsistent findings regarding type of coping strategies and symptoms. For instance, in one of the very few studies with sexually abused children, Chaffin, Wherry, and Dykman (1997) found that whereas internalized and angry coping corresponded with higher levels of symptoms, avoidant coping was associated with fewer behavior difficulties, in contrast with much of the prior literature. Interestingly, active/social strategies were unrelated to children’s difficulties (Chaffin et al., 1997). The differing findings of maladaptive coping strategies in this study indicate the importance of further differentiating between types of coping rather than examining broad maladaptive/adaptive categories. On the whole, it appears that coping in the aftermath of trauma, particularly maladaptive strategies, may have significant implications for children’s symptom development.

Notably, much of the prior literature has focused on medical traumas and natural disasters (e.g., Khamis, 2008; LaGreca et al., 1996; Marsac et al., 2016; Marsac et al., 2011; Stallard et al., 2001; Vigna et al., 2010). In fact, research utilizing samples of children who have experienced interpersonal traumas is limited to only a few studies (i.e., Bal et al., 2009; Chaffin et al., 1997; Tremblay et al., 1999). This is problematic as CSA survivors may utilize more maladaptive coping strategies compared with other traumas (Littleton, Horsley, John, & Nelson, 2007; Ullman et al., 2014), and there may be a stronger relationship between maladaptive coping and trauma-related symptoms in those who have experienced CSA as opposed to noninterpersonal traumas (Ullman et al., 2007). Additional research examining utilization of coping strategies and symptoms in sexually abused children is, therefore, warranted.

Furthermore, very few studies have addressed children’s perceived efficacy of their coping strategies. It is important to investigate not only how coping strategies may relate to children’s post-CSA functioning but also the perceived efficacy of these strategies from the child’s perspective. Children often report using a myriad of coping strategies (Lack & Sullivan, 2008; Marsac et al., 2011), and those that are considered maladaptive are still commonly endorsed and are often rated as being effective by the child (Chaffin et al., 1997; Lack & Sullivan, 2008; Stallard et al., 2001). It may be valuable to acknowledge that some maladaptive coping strategies, such as avoidance, may provide benefit for some, but not all, trauma-related difficulties when used for a short period of time and in moderation, becoming ineffective and increasingly harmful after more habitual, long-term reliance. For example, Bal and colleagues (2009) found avoidant coping to be related to children’s externalizing, but not internalizing, symptoms after CSA. However, only one study to date has examined trauma-exposed children’s perceived efficacy of their coping strategies in relation to clinical outcomes (Stallard et al., 2001). Interestingly, Stallard and colleagues (2001) found no differences in perceived efficacy of coping strategies utilized between children with and without a diagnosis of PTSD after experiencing a motor vehicle accident (MVA), although children with PTSD used more strategies overall. This finding may suggest a disconnect between children’s perceived efficacy of their coping strategies and their level of trauma-related distress. Alternatively, as symptoms were examined categorically (i.e., PTSD diagnosis present or not), this may have restricted the variance in symptoms needed to detect associations. As only one study has examined the relationships between perceived efficacy and symptoms among trauma-exposed children, and this study focused on a noninterpersonal trauma, there is a critical gap in the research literature regarding sexually abused children’s perceptions of coping strategies in relation to levels of trauma-related symptoms. Research is needed to delineate the relationships between perceptions of coping attempts and symptoms for sexually abused children.

Current Study

The majority of the existing research has largely utilized adult survivors of childhood trauma, and within the childhood trauma literature, very few studies have examined coping strategies and symptoms following interpersonal traumas, such as CSA. Instead, the prior child literature has focused predominately on MVAs and medical traumas (e.g., Khamis, 2008; Marsac et al., 2016; Marsac et al., 2011; Stallard et al., 2001). Moreover, as indicated by prior research (i.e., Chaffin et al., 1997), it is important to differentiate between forms of coping when understanding children’s clinical outcomes. The first aim of the present study was to contribute to the child trauma and coping literature by investigating the associations between specific forms of coping strategies and symptoms among sexually abused children. The Kidcope (Spirito, Stark, & Williams, 1988) is a commonly used measure of 10 distinct forms of coping strategies, which are grouped into active and passive strategies. However, the lone study of sexually abused children and coping using the Kidcope observed that a four-factor solution best represented the data: avoidant, internalized, angry, and active/positive coping (Chaffin et al., 1997), and other studies have utilized different subscales for the Kidcope (e.g., Khamis, 2008; Marsac et al., 2016; Marsac et al., 2011). As this study was also focused on sexually abused children, the four-factor coping model was utilized in the present study. Furthermore, prior research indicates that there may be differing associations between the utilization of angry coping, avoidant coping, and internalized coping and PTSS (e.g., Chaffin et al., 1997; LaGreca et al., 1996); thus, the use of four different forms of coping strategies will provide more complete information regarding children’s coping and symptoms than simply investigating active and passive strategies. It was expected that greater utilization of avoidant, internalized, and angry coping would be positively related to caregiver- and child-reported PTSS and caregiver-reported internalizing and externalizing symptoms. Although avoidant coping was previously found to be related to lower levels of behavior problems among sexually abused children in one study (Chaffin et al., 1997), avoidant coping was anticipated to correspond with higher levels of symptoms to be consistent with the bulk of the prior literature, which has observed that avoidant coping is related to higher levels of symptoms (Bal et al., 2009; Cantón-Cortés & Cantón, 2010; Tremblay et al., 1999; Marsac et al., 2016; Stallard et al., 2001). Greater use of active/social coping was hypothesized to be associated with lower levels of PTSS and internalizing and externalizing symptoms. Due to the preliminary nature of the prior literature, specific hypotheses were not made regarding the strength of the associations between forms of coping strategies.

Furthermore, no research has examined sexually abused children’s perceived efficacy of their coping strategies in relation to their trauma-related symptoms. Understanding children’s perspectives may yield important insights regarding how coping strategies are perceived by children, which may inform trauma-focused interventions. The second aim of the current study was to examine the associations between perceived efficacy of types of coping strategies and PTSS and internalizing and externalizing symptoms. It was hypothesized that greater perceived efficacy of avoidant, internalized, angry, and active/social coping strategies would be tied to lower levels of PTSS and internalizing and externalizing symptoms.

Method

Participants

Two hundred two children aged 8 to 12 years (M = 10.47 years, SD = 1.70 years) and their nonoffending mothers who were seeking treatment from a child advocacy center (CAC) participated in the study. The sample was largely female (69.8% female, 30.2% male) and approximately half of the children identified as White (52%; 42.6% Black, 4% biracial/multiracial, and 1.5% Asian). Due to small cell sizes, racial and ethnic status were collapsed into two groups, nonminority status (52%) and minority status (48%). Household income was rated categorically in groupings of US$10,000 (e.g., less than US$10,000, US$10,000-US$20,000). In the current sample, the mean household income was 2.03 (SD = 1.24), which corresponds to US$20,000 to US$40,000. Mother’s marital status was as follows: 27.3% never married, 32.7% married, 32% divorced, and 8% separated. Approximately half of the sample had involvement with Child Protective Services (CPS; 50.9%). The child’s mother was his or her legal guardian in 77.7% of the cases, and for the remainder of the cases, the child was in CPS legal custody at the time of intake but his or her mother accompanied the child to treatment. All the children in the sample had experienced sexual abuse. Caregivers reported the perpetrator’s relationship to the child categorically: 22% in-home primary caretaker; 22% acquaintance, babysitter, and neighbor; 20% in home nonparent adult; 16.7% in-home sibling; 6.7% noncustodial parent; 6.7% stranger; 5.9% teacher, minister, daycare worker, other adult relative.

Measures

Demographic information

At intake, children’s mothers reported on demographic information including children’s age, gender, and race, and family information such as parental marital status, family income, and involvement with CPS.

Kidcope

The Kidcope (Spirito et al., 1988) is a 15-item child-reported measure for children aged 7 to 12 years that assesses children’s use of 15 different coping strategies that are rated dichotomously (i.e., used yes or no). Although in the original instrument, the coping strategies were collapsed into two categories, active and passive, a subsequent factor analysis of the Kidcope found that coping strategies among sexually abused children better fit into a four-factor model (Chaffin et al., 1997). These factors were labeled avoidant coping (five items), internalized coping (four items), angry coping (two items), and active/social coping (three items). One of the items from the original Kidcope (i.e., “I wished I could make things different”) did not significantly load onto any of the factors and was not included. This four-factor model was utilized in the present study. For the current study, children were asked whether they used a particular strategy in relation to the sexual abuse. If the child used the specific strategy, he or she was then asked to indicate on a 3-point Likert-type scale how helpful each strategy was perceived to be (0 = not at all, 2 = a lot). Strategies rated a 1 or 2 are considered to be perceived as at least a little effective. Average perception of efficacy scores were calculated for each type of coping strategy using the items for which the child rated. If a child did not use each type of coping strategies within the subscale, the mean was calculated using the items the child reported using.

Child Behavior Checklist (CBCL)

The CBCL is a 113-item parent-reported questionnaire that assesses behaviors of children aged 6 to 18 years old (Achenbach & Rescorla, 2001). The CBCL is comprised of eight subscales including Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior, and produces three overall scores—Internalizing, Externalizing, and Total Problems. Content, construct, and criterion-related validity has been established, and Cronbach’s alpha ranges from .78 to 1.0 (Achenbach & Rescorla, 2001). Only the Internalizing and Externalizing total scores were utilized in the present study, Cronbach’s α = .95 for the total subscale. There were 188 completed CBCLs in the current study.

Trauma Symptom Checklist for Young Children (TSCYC)

The TSCYC is a 90-item parent-reported questionnaire that assesses PTSS on a 4-point Likert-type scale for children aged 3 to 12 years old (Briere, 2005). The TSCYC includes eight clinical scales—Anxiety, Depression, Anger/Aggression, Posttraumatic Stress-Intrusion, Posttraumatic Stress-Avoidance, Posttraumatic Stress-Arousal, Dissociation, and Sexual Concerns, as well as a total summary score. The TSCYC demonstrates acceptable internal consistency for the clinical scales (α = .81-.93; Gilbert, 2004), as well as acceptable construct and criterion validity. This study included 156 completed TSCYCs and used only the PTSS–Total subscale score. Cronbach’s alpha for the present study PTSS subscale was .96.

Trauma Symptom Checklist for Children (TSCC)

The TSCC is a 54-item child-reported questionnaire that assesses PTSS in children aged 8 to 16 years old who have been exposed to a traumatic event (Briere, 1996). The TSCC yields six clinical subscales for Anxiety, Depression, Anger, PTSS, Dissociation, and Sexual Concerns, as well as two validity scales of Underresponse and Hyperresponse. The TSCC clinical scales demonstrate good internal consistency (α = .77-.89) and adequate convergent, discriminant, and predictive validity in both normative and clinical samples (Briere, 1996). The study included 175 completed TSCCs and utilized only the PTSS subscale, Cronbach’s α = .94.

Procedure

Participants were a treatment-seeking sample of trauma-exposed children and their non-offending mothers. Children and their mothers completed a battery of self-report measures as part of the intake procedures at the CAC. Inclusion criteria for the study were child aged 8 to 12 years, to be able to include the child’s self-reported trauma symptoms on the TSCC, as well as a completed intake evaluation that included the Kidcope and at least one of the clinical symptom measures (i.e., CBCL, TSCYC, and/or TSCC). The CSA did not need to be substantiated by CPS to be included in the study. There were no exclusion criteria, and no incentives were provided. The study was approved by the University of Missouri- St. Louis.

Data analytic plan

Frequencies and means were used to identify the rates of coping strategies children used and the perceived efficacy of each of these strategies. Potential covariates were assessed (i.e., child’s age, gender, minority status, household income). Four linear regression models, one for each of the dependent variables, were planned to examine how each of the four Kidcope subscales may correspond with caregiver-reported PTSS, internalizing, and externalizing difficulties, as well as child-reported PTSS. Bivariate correlations were also computed to test the hypothesis that perceived efficacy of coping strategies would be inversely related to children’s symptoms. As children only rated a particular coping strategy as being effective if they reported using the strategy, the ns for these perceived efficacy subscales differ.

Results

Preliminary and Descriptive Analyses

Across the subscales, the average number of coping strategies a child endorsed was 8.29 (SD = 2.50; see Table 1). Most (91.6%) of the sample endorsed using at least one active/positive coping strategy, nearly all the participants (98.5%) utilized at least one avoidant strategy, and most (87.6%) of the children endorsed at least one internalized strategy. Utilization of angry coping strategies was less common, with approximately half (54.2%) of the sample reporting using at least one of the two angry coping strategies. Some of the coping strategies were correlated with one another. For instance, use of avoidant coping was related to active/social strategies (r = .41, p < .001) and internalized coping (r = .16, p = .01). Use of internalized coping was associated with utilization of angry coping (r = .20, p = .003). In terms of perceived efficacy, nearly all the children reported that at least one of the active/social and avoidant strategies was at least “a little” efficacious (96.2% active/social, 94.3% avoidant). Most of the children also endorsed that at least one of the internalized and angry strategies was at least “a little” efficacious (83.3% internalized, 74.3% angry).

Table 1.

Utilization and Perceived Efficacy of Coping Strategies.

Coping Strategy	M Use (SD)	% Used	M Efficacy (SD)
Avoidant (total)	3.92 (1.23)	98.5	1.31 (0.54)^a
I wished the problem had never happened	0.89 (0.31)	89.1	1.28 (0.85)
I just tried to forget it	0.85 (0.36)	84.7	1.27 (0.75)
I tried to see the good side of things	0.79 (0.41)	78.8	1.42 (0.68)
I did something like watch TV or played a game to forget it	0.69 (0.46)	69.3	1.44 (0.69)
I tried to calm myself down	0.73 (0.44)	73.2	1.30 (0.67)
Internalized (total)	1.60 (0.99)	87.6	1.16 (0.68)^b
I stayed by myself	0.33 (0.47)	33.2	1.11 (0.76)
I did not do anything because the problem could not be solved	0.34 (0.47)	33.8	0.97 (0.81)
I blamed myself for causing the problem	0.20 (0.39)	19.6	0.51 (0.75)
I kept quiet about the problem	0.75 (0.43)	75.4	1.17 (0.78)
Angry (total)	0.75 (0.77)	54.2	1.05 (0.77)^c
I blamed someone else for causing the problem	0.40 (0.49)	40.5	1.18 (0.78)
I yelled, screamed, or got mad	0.35 (0.47)	34.5	0.84 (0.81)
Active/social (total)	2.03 (0.94)	91.6	1.44 (0.51)^d
I tried to fix the problem by thinking of answers	0.56 (0.50)	55.5	1.17 (0.68)
I tried to feel better by spending time with others like family, grownups, or friends	0.80 (0.40)	70	1.66 (0.52)
I tried to fix the problem by doing something or talking to someone	0.70 (0.45)	70	1.47 (0.68)

198.

186.

109.

184.

Children’s age and race, parental marital status, and whether or not the family had involvement with CPS were not significantly related to any of the clinical outcomes. However, girls were reported to exhibit higher levels of PTSS and externalizing symptoms by their caregivers than boys, t(156) = −2.19, p = .03; t(186) = −2.40, p = .01, respectively. Gender was included as a covariate for all the regression models to ease interpretation of the results across the different dependent variables.

Regression Models for Children’s Coping and Symptoms

For caregiver-reported PTSS, the overall regression model was not a significant predictor of children’s trauma-related difficulties, F(5, 151) = 1.37, p = .23; r² = .04, adj. r² = .01 (see Table 2). Furthermore, the inclusion of coping strategies was not associated with a significant improvement in amount of variance, p = .75. Only child’s gender was a significant predictor of children’s level of PTSS.

Table 2.

Regression Models for Coping and Children’s Symptoms.

	B	SE	β	t	95% CI
	B	SE	β	t	LL	UL
Caregiver-reported PTSS^a
Gender	5.95	2.95	0.16	2.01*	0.12	11.77
Avoidant	−0.15	1.22	−0.01	−0.12	−2.58	2.26
Internalized	−0.32	1.35	−0.02	−0.24	−2.99	2.34
Angry	1.97	1.78	0.09	1.09	−1.58	5.52
Active/social	1.14	1.59	0.06	0.71	−2.01	4.30
Internalizing difficulties^b
Gender	0.28	2.10	0.01	0.13	−3.86	4.43
Avoidant	0.84	0.85	0.08	0.98	−0.84	2.51
Internalized	0.19	0.99	0.01	0.19	−1.76	2.15
Angry	−0.01	1.29	−0.001	−0.01	−2.56	2.53
Active/social	−0.42	1.13	−0.03	−0.37	−2.65	1.81
Externalizing difficulties^b
Gender	4.75	2.07	0.17	2.28*	0.65	8.85
Avoidant	−0.28	0.83	−0.02	−0.33	−1.93	1.37
Internalized	0.64	0.97	0.04	0.66	−1.28	2.57
Angry	0.50	1.27	0.03	0.39	−2.00	3.01
Active/social	1.30	1.11	0.09	1.17	−0.88	3.50
Child-reported PTSS^c
Gender	2.68	1.83	0.11	1.54	−0.74	6.11
Avoidant	1.11	0.70	0.12	1.50	−0.26	2.50
Internalized	2.82	0.77	0.26	3.64***	1.30	4.34
Angry	2.06	0.98	0.15	2.47*	0.41	4.05
Active/social	0.57	0.90	0.04	0.63	−1.20	2.34

Note. CI = confidence interval; LL = lower limit; UL = lower limit; PTSS = posttraumatic stress symptoms.

156.

188.

175.

p < .05. **p < .01. ***p < .001.

The regression model for children’s internalizing symptoms was not significant, F(4, 184) = 0.27, p = .89; r² = .01, adj. r² = .01. None of the coping subscales were significantly linked to internalizing problems.

Children’s levels of externalizing behaviors were also not significantly explained by children’s use of coping strategies, F(5, 183) = 1.67, p = .14; r² = .04, adj. r² = .01, nor did adding the coping strategies to the model result in a significant change, p = .68. Child’s gender remained a significant predictor of externalizing problems in the model.

Unlike the caregiver-reported symptoms, the regression model for children’s PTSS was significant, F(4, 171) = 7.44, p < .001; r² = .14, adj. r² = .13. Use of internalized and angry coping strategies were significant predictors of children’s PTSS, with higher utilization of these strategies corresponding with higher levels of traumatic stress symptoms.

Perceived Efficacy and Children’s Symptoms

Correlations were utilized to examine the relations between children’s perceptions of coping efficacy and their symptoms. As depicted in Table 1, not all the children utilized each of the Kidcope coping strategies, therefore, not all the children have scores for each of the subscales. Perceived coping efficacy was unrelated to caregiver-reported PTSS, and internalizing and externalizing symptoms (ps > .05). However, child-reported PTSS was inversely associated with perceived efficacy of avoidant strategies.

Discussion

Much of the current research regarding coping and trauma-related symptoms among survivors of childhood trauma suggests a relationship between coping style and symptom levels (Badour et al., 2012; Bal et al., 2009; Khamis, 2008; Marsac et al., 2016; Marsac et al., 2011; Stallard et al., 2001; Ullman et al., 2007; Walsh et al., 2010; Wright et al., 2005). However, this literature has mostly utilized samples of adults, which may not be generalizable to pediatric samples. There is also a significant lack of research examining children’s coping with interpersonal traumas and how that may relate to their symptoms. Furthermore, only one study investigated children’s perceived efficacy of their coping strategies in relation to trauma-related symptoms, and this study only focused on noninterpersonal trauma (Stallard et al., 2001). The purpose of the current study was to investigate whether both children’s utilization and perceived efficacy of coping strategies corresponded with child- and parent-reported clinical difficulties following CSA. Understanding coping strategies and their effectiveness from the child’s vantage point may provide valuable insight into strategies to treat trauma-related symptoms in the aftermath of CSA.

In line with previous findings, children utilized more than half of the 14 measured coping strategies (Chaffin et al., 1997; Lack & Sullivan, 2008; Marsac et al., 2011), reflecting a need for children to attempt a variety of strategies to cope with traumatic experiences. Children most frequently reported using avoidant coping and active/social coping, and utilized angry coping least often, findings that are consistent with the existing research (Chaffin et al., 1997). The utilization of some types of coping were related, supporting speculation presented by other studies that children essentially “try out” a large variety of strategies before determining which are effective and/or feasible (Chaffin et al., 1997; Khamis, 2008; Marsac et al., 2016; Marsac et al., 2011). Finally, almost all the children in the sample concluded that one or more active/social and one or more avoidant coping strategies were at least “a little” effective, and most indicated that at least one internalized and one angry coping strategies were at least “a little” effective. Various others have reported similar findings (Chaffin et al., 1997; Lack & Sullivan, 2008; Marsac et al., 2011; Stallard et al., 2001), and this contributes to the possibility that strategies considered to be maladaptive (e.g., avoidant coping) may provide some short-term relief for children in the aftermath of trauma. Some maladaptive strategies may become ineffective or harmful only after consistent, long-term use. Conversely, it may be more challenging for children to determine which of their coping attempts are indeed helping to reduce distress. Future research should, therefore, consider the utilization and perceived efficacy of avoidant coping strategies in the context of the length of time and frequency that the strategies are used to investigate this issue.

Although caregiver-reported symptoms were expected to correspond with use of each of the coping strategies, they were surprisingly unrelated to any of the coping strategies. In contrast to the current study, previous research has observed links between internalizing and externalizing symptoms and avoidant coping (Khamis, 2008; Walsh et al., 2010); however, these studies relied on self-reports as opposed to caregiver-reported symptoms utilized by the CBCL in the present study. Discrepancies in caregiver and child reports may, therefore, explain some inconsistencies. Caregiver-reported PTSS has not been previously included in the prior literature, and thus, these findings make a novel contribution. However, replication of the lack of association between children’s coping strategies and caregiver-reported PTSS is needed prior to drawing definitive conclusions. Collectively, the findings indicate that the use of children’s coping strategies appears largely unrelated to caregiver-reported symptoms.

A different pattern emerged for child-reported PTSS than caregiver-reported symptoms. Although it was expected that utilization of each of the coping strategies would be related to child-reported PTSS, only angry and internalized coping were positively associated with child-reported PTSS. Active/social and avoidant coping were unrelated to symptoms. It may be that the links found in the present study between child-reported PTSS and the utilization of angry and internalized coping were not significant enough to be observed across raters. Research has noted discrepancies between various raters of trauma-related symptoms, including between children and parents (Stover, Hahn, Im, & Berkowitz, 2010). Parents may have less awareness of the degree to which their child is experiencing symptoms, particularly as internalized coping may be less apparent. The findings also indicate that angry and internalized coping may be more relevant in understanding child-reported PTSS than avoidant or active/social strategies. This is noteworthy as previous work with both adults and children has emphasized that coping strategies such as angry and internalized coping may increase the likelihood of adverse outcomes (Bal et al., 2009; Khamis, 2008; Marsac et al., 2016; Marsac et al., 2011; Ullman et al., 2007; Walsh et al., 2010; Wright et al., 2005).

In the current study, caregivers reported higher levels of PTSS for girls than for boys, but no gender differences emerged for child-reported PTSS. Although prior research has noted that girls may be more likely to develop PTSD after a traumatic event (Cuffe et al., 1998; McLaughlin et al., 2013), the present findings may point to potential gender biases in the understanding of CSA. Prior research has found that although girls and boys did not experience different levels of abuse severity or PTSS, the abuse was more likely to be substantiated for girls than boys, and girls were perceived by caseworkers to be at a higher level of harm (Maikovich, Koenen, & Jaffee, 2009; Maikovich-Fong & Jaffee, 2010). It may be that caregivers perceive girls’ PTSS to be more severe than boys’ due to an influence of gender biases. Although it is outside the scope of the present study, future work should continue to examine gender differences among CSA survivors as caregivers’ perceptions of the child’s abuse experience can affect access to support and interventions.

Furthermore, the findings reinforce prior studies that have found a lack of relationship between active coping strategies and trauma-related symptoms (Cantón-Cortés & Cantón, 2010; Tremblay et al., 1999; Littleton et al., 2007; Marsac et al., 2011; Spaccarelli, 1994). Evidence-based trauma-focused interventions partially work to reduce internalizing strategies such as resignation and self-blame and encourage children to seek social support (Cohen et al., 2010). Research is needed to determine whether reductions in use of these coping strategies is associated with a reduction in symptoms. Conversely, children who are more distressed by the traumatic event may utilize coping strategies more often, albiet unsuccessfully, whereas other children who are less negatively affected may also utilize coping strategies in response to the trauma, but may be more effective in their implementation. This may then mask potential group differences. Prior work has also suggested that children’s environment has important implications in the implementation and efficacy of coping strategies (Cantón-Cortés & Cantón, 2010; Chaffin et al., 1997), and future research should consider environmental and abuse-specific factors in the context of children’s PTSS and perceived efficacy of their coping. Furthermore, the Kidcope has a restricted range of measurement for use of coping, and future research should utilize coping measures with an expanded range of utilization (e.g., multiple times per day, one a day, few times per week, weekly, monthly).

It was expected that children who perceived their coping, regardless of the strategy, to be more effective would report lower symptomology, due to what they perceive to be successful coping. This hypothesis was predominantly unsupported by the current study’s findings, as only one type of coping, avoidant coping, had perceived efficacy ratings inversely related to self-reported PTSS. This finding may support the notion that avoidant coping may be perceived by children to buffer trauma-related symptoms, at least initially (Walsh et al., 2010). Nonetheless, these findings are largely aligned with a previous study that reported no difference in perceived efficacy of coping strategies between children with and without a diagnosis of PTSD among children exposed to an MVA (Stallard et al., 2001). Children may have limited insight when considering the effectiveness of their coping, perceiving their strategies to be effective despite high levels of symptoms. Conversely, it is possible that coping strategies do not begin to influence symptoms until some time has passed and/or the child has utilized the strategy more habitually. Children experiencing more severe symptomology may also have more difficulty identifying which coping strategies they are implementing and/or their effectiveness due to the influence of such symptoms. To further complicate the relationship, passive coping strategies have some overlap with PTSD symptoms, such as avoidance. This commonality adds complexity when interpreting coping and symptoms, as it may not be clear whether reliance on passive coping strategies, such as avoidance, is related to PTSS via maladaptive coping attempts or is a product of PTSD (Stallard et al., 2001). Future research examining the timeline, duration, and frequency of the coping strategies used in relation to trauma-related symptoms may provide clarity.

The failure to find significant results may be a function of aspects of the present study. The findings are limited by a lack of knowledge regarding the duration and/or frequency in which the coping strategies have been utilized. The results may have been affected by the treatment-seeking sample in which a majority of the children are likely experiencing more severe difficulties, restricting the variance to higher levels of symptoms. Children with increased distress may also only benefit for short periods of time via active/social coping alone, requiring additional intervention methods to experience lower levels of symptoms (Stallard et al., 2001). Although the current findings suggest that children’s perceived efficacy of their coping is largely unrelated to their symptoms, replication utilizing non-treatment-seeking samples who experienced CSA is needed before any conclusions can be drawn.

Limitations and Conclusions

Although the results of the present study make several important contributions to the literature, these results should be understood in the context of the study limitations. Foremost, the study utilized a cross-sectional design with a treatment-seeking sample. A cross-sectional design prohibits determining the temporal relationships between coping and symptoms. As coping and symptoms likely have a bi-directional relationship, longitudinal research is critical to best understand how coping and symptoms may relate to one another. The cross-sectional nature of this study also makes it impossible to determine whether children who utilized certain coping strategies (i.e., internalized, angry) experienced higher levels of symptomology because these were ineffective strategies, if their degree of symptomology was initially higher than other children, or if children who are more likely to utilize these specific types of strategies are predisposed to experience greater distress in response to trauma. Furthermore, as some coping strategies overlap with symptoms commonly associated with trauma exposure (i.e., avoidance, withdrawal), it is difficult to delineate between symptom expression and strategy utilization. The use of a treatment-seeking sample is not generalizable to sexually abused children in general. For example, the treatment-seeking nature of the sample may have influenced levels of symptomology, as children and caregivers who are seeking trauma-focused treatment are likely experiencing some level of trauma-related symptoms. The use of this sample may have impacted the results, as noted above. Future studies should also consider characteristics of the abuse and other traumas participants may have experienced. Examining coping and symptoms in the context of trauma characteristics will further contribute to the understanding of the degree to which coping may influence trauma-related symptoms.

Furthermore, the study relied on child and caregiver-reported symptom measures, and research using clinician-rated measures would increase the confidence in predicting children’s levels of symptoms. Finally, the study was limited by a dearth of data regarding potentially important covariates, such as time since the CSA, initial symptom onset and level of symptomology, duration and frequency of coping strategy utilization, and onset of use of the coping strategy, among others, which are likely critically important for a complete conceptualization of coping strategy effectiveness. In addition, although the current study took note of children’s relationship to their perpetrator, small cell sizes did not allow for the examination of perpetrator relationship as a covariate. Research would benefit from examining this, among other likely influential abuse characteristics, in the context of children’s coping due to the importance of children’s relationship to their perpetrator in post-CSA symptomology (see Kendall-Tackett, Williams, & Finkelhor, 1993 for a review). Future research should prioritize including these variables to better elucidate the role of coping in predicting children’s symptoms.

Despite these limitations, the current study provides valuable information about children’s perceptions of the efficacy of their coping strategies in the aftermath of CSA and is one of the first studies to examine children’s perceived efficacy of their coping strategies in relation to their trauma symptoms. In addition, the present study was the first to investigate both utilization and perceived efficacy of coping strategies in the context of CSA among children. Relatively few relationships emerged between the utilization of active/social strategies and perceived efficacy of children’s coping strategies and PTSS, internalizing and externalizing symptoms, and relationships differed by reporter and symptom type. However, internalized and angry coping were related to children’s PTSS. These strategies may be a stronger predictor of post-CSA outcomes than active/social coping, which is in line with prior research (Cantón-Cortés & Cantón, 2010; Walsh et al., 2010; Wright et al., 2005). Nonetheless, as the results may be influenced by the nature of a treatment-seeking sample, replication utilizing non-treatment-seeking samples of children exposed to CSA is needed to further understand the degree to which children’s coping strategies may exacerbate or buffer against trauma-related symptoms. work should also more thoroughly assess children’s use, implementation, and perceived efficacy of various coping strategies in relation to both caregiver-, child-, and clinician-reported symptoms to further inform the current conceptualization of how children’s coping related to symptom trajectories after interpersonal traumas.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rachel Wamser-Nanney

Author Biographies

Claudia L. Campbell is a doctoral student in clinical psychology at the University of Missouri- St. Louis. Her research interests include identifying risk factors in children for posttraumatic stress and other behavioral difficulties as well as factors associated with complex trauma.

Rachel Wamser-Nanney is an assistant professor in the Department of Psychological Sciences at the University of Missouri–St. Louis. Her program of research is focused on traumatic stress, with a particular emphasis on childhood trauma.

Julia C. Sager is a doctoral student in clinical psychology at the University of Missouri- St. Louis whose research interests include responses to traumatic events and significant loss with a focus on how trauma exposure and grief affect interpersonal functioning. She is particularly interested in the bi-directional relationship between post-traumatic stress symptoms and close relationship factors.

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