Working With Nonoffending Caregivers of Children Who Have Been Sexually Abused: Common Challenges and Effective Strategies

Abstract

This research project is intended to address the dearth of information regarding best practice in clinical engagement and intervention with nonoffending caregivers of children who have been sexually abused. Utilizing an online survey, licensed clinicians were invited to respond to open-ended questions regarding (a) common challenges they face when working with caregivers of children who have been sexually abused and (b) strategies they have found to be effective when faced with these challenges. Their responses are presented and implications for social work training and practice are reviewed.

Keywords

abuse/neglect/violence subjects of practice parenting/motherhood/fatherhood family systems and functioning clinical practice modes of practice nonoffending caregivers child sexual abuse

Introduction

It is common practice for clinicians to include a child’s caregiver in the engagement, assessment, and treatment of child clients. This process brings about varying challenges, and best practices are needed for clinicians to know what to expect and how best to respond in service of their child client. Child sexual abuse (CSA) provides a unique example of the importance of including caregivers in treatment. Evidence-based interventions intended to serve child victims of sexual abuse often have a caregiver component, yet research outlining effective strategies to address the common challenges in this work is lacking. This research project is intended to address the dearth of information regarding best practice in clinical engagement and intervention with nonoffending caregivers. Recognizing the ever-changing landscape of clinical service delivery, there is an increased need for flexible and creative interventions to be implemented virtually. Clinicians should be armed with as much accurate information as possible. It is our hope that this research offers clinicians essential information to help them prepare and serve families impacted by CSA in both in-person and virtual settings.

Impact of CSA

The effects of CSA on child victims are often organized over multiple domains. Sexual abuse has been found to be associated with the diagnosis of depression (Dubowitz et al., 1993; Koverola et al., 1993; Maniglio, 2010; Romano et al., 2006), anxiety disorders, eating disorders, post-traumatic stress disorder (PTSD), sleep disorders, and suicidality, as well high rates of sexualized behavior (Dubowitz et al., 1993; Kendall-Tackett et al., 2001), poor academic performance (Chen et al., 2010; Paolucci et al., 2001; Trickett & Putnam, 1998), hyperactivity, delinquent behaviors, and aggressive behaviors (Browne & Finkelhor, 1986; Dubowitz et al., 1993; Nalavany et al., 2009; Swanston et al., 2003). Trauma, and specifically child maltreatment, has been found to upset the typical development of neurobiological processes, reducing the child’s ability to self-regulate emotions and increasing their sense of hypervigilance; over time, this hypervigilance becomes generalized to nonabuse triggers (Bloom & Courtois, 2016; Bolen & Gergely, 2014; DeBellis et al., 2013; McEwen, 2012; van der Kolk, 2003). In addition, research suggests that the emotional, behavioral, and physical symptoms for child victims continue to appear through adulthood (Browne & Finkelhor, 1986; Collin-Vézina et al., 2013; Dube et al., 2005; Irish et al., 2010; Rhode et al., 2008; Trickett & Putnam, 1998; van der Kolk, 2003; Waldrop et al., 2007).

Caregiver Support as a Mediating Factor

There is a general consensus that CSA is a risk factor for many long-term symptoms for victims, but there is also evidence that this risk may be moderated by the child’s family context and the quality of family relationships (J. A. Cohen & Mannarino, 2000; Collin-Vézina et al., 2013; Elliott & Carnes, 2001; Lynskey & Fergusson, 1997; Spaccarelli & Kim, 1995; Tremblay et al., 1999; Walsh et al., 2012). Family relationships have the potential to be a predictor of the child victim’s adjustment over time (Finkelhor & Kendall-Tackett, 1997; Ford & Saltzman, 2009; Ulrich et al., 2005), suggesting that family, particularly caregivers, may play a vital role in tempering the effects of CSA. Most caregivers believe and protect their children, and these supportive actions have the potential to help children cope with the consequences of the abuse (Cyr et al., 2014).

The reactions of caregivers may either support or hinder the cohesion of the family and the family’s ability to offer the help and protection that the child victim needs to cope with the trauma (Deblinger et al., 2015). Some caregivers find their child’s traumatic stress symptoms to be a traumatic experience for themselves. Many experience significant amounts of emotional and psychological distress (Fong et al., 2020), with the potential for the caregivers to develop their own post-traumatic stress symptoms (E. Cohen, 2008; Saltzman et al., 2008). Nonoffending caregivers often experience their child’s abuse as psychologically traumatic, with specific sources of distress including concerns about the child, and their parenting abilities, and the reactions and actions of the family system (Fong et al., 2020; Ford & Saltzman, 2009). Caregivers may also have their own histories of trauma or abuse. Together, these experiences may in turn impact the caregivers’ ability to support their child effectively. They may react with a preoccupation around the abuse and with overprotectiveness, which may indirectly lead to dysfunctional parenting styles that exacerbate the child’s symptoms (Scheeringa & Zeanah, 2001; Zvara et al., 2015). Caregivers may also react with denial and nonsupport, increasing a child’s feelings of helplessness and isolation (Ford & Saltzman, 2009).

On the contrary, the family’s reaction to abuse can also have a positive effect on the child victim (Ford & Saltzman, 2009; Godbout et al., 2014). Initial ambivalence is common, and a nonoffending caregiver’s initial doubt does not necessarily come from a place of not believing the child, but rather can indicate a sense of overwhelm around what the child has described with an added complexity of the common reality that the caregiver had invited the perpetrator into the child’s life (Bolen & Lamb, 2002). Even while experiencing multiple life stressors, nonoffending caregivers are often capable of providing support to children (Bolen & Lamb, 2002). Families that are consistent, considerate, and relationally attuned are the families that offer child victims of abuse the support they need to recover (Bolen & Lamb, 2002; Saltzman et al., 2008).

Inclusion of Caregivers in the Treatment of Children

Traumatic experiences such as CSA have been acknowledged to have significant impact on the child’s entire family/caregiving system, and a child’s positive attachment with a caregiver and/or adult mentor has been claimed to protect that system from the adverse impact of the trauma (Bellis et al., 2017, 2018). Because of their potential to serve as a promoter of a child’s well-being in the aftermath of abuse, several evidence-based interventions for children who have been sexually abused acknowledge and intentionally incorporate caregivers into the treatment. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; J. A. Cohen et al., 2017) and Parent Child Interaction Therapy (PCIT; Urquiza & Blacker, 2011) are two examples of evidence-based interventions that include a caregiver component, where clinicians are trained to incorporate nonoffending caregivers into the child client’s treatment by providing individualized parenting support to the caregiver. Both are well-researched treatment modalities, proven to be effective in helping children and families recover from child abuse. Clinicians trained in these interventions consider it best practice to recruit all available caregivers with intention and skill, benefiting the entire family system. And yet, although evidence-based interventions intended to serve child victims of sexual abuse often have a caregiver component, knowledge about effective strategies to address the common challenges associated with including caregivers in this work is lacking (Kiser et al., 2020).

This exploratory study is intended to provide information regarding best practice in clinical engagement and intervention with nonoffending caregivers. Utilizing an online survey, licensed clinicians were invited to respond to open-ended questions regarding (a) common challenges they face when working with caregivers of children who have been sexually abused and (b) strategies they have found to be effective when faced with these challenges.

Method

This study employed a qualitative phenomenological methodology, designed to collect personal and true descriptions of a phenomenon as it is perceived by those who have experienced it (Groenewald, 2004). The descriptions of phenomena, and also the meaning an individual ascribes to them, were recalled and described by responding to the open-ended survey (Groenewald, 2004; Padgett, 2008; Puckering & Breustedt, 2013). A survey with open-ended questions was utilized to collect descriptions from practicing clinicians about their experiences in working with nonoffending caregivers.

Recruitment

All procedures were reviewed and approved by Cabrini University’s IRB prior to beginning the study. Researchers emailed an invitation to complete an online survey to 3,259 members of the TF-CBT membership base, using email addresses listed on the TF-CBT public access website. These certified TF-CBT clinicians were chosen because the inclusion of caregivers is required within the TF-CBT protocol and the contact information of certified therapists is available to the public.

Participants received an email that contained a short paragraph stating the purpose of the survey and the ways in which the data would be used in the future. A link to the online survey was included at the end. Participants acknowledged informed consent and agreed to participate by opening and completing the survey. Participation was anonymous and voluntary.

Sample

Of the 3,259 members who had their emails listed on the TF-CBT public access website, 77 completed the survey over a period of 1 month (see Table 1). Of the 77 respondents, the majority self-identified as White, female and practiced as counselors (LPC) or social workers (LISW, LICSW, LCSW, MSSW, MSW, BSW). We also received responses from individuals practicing as family therapists (MFT, LMFT) and psychologists (PsyD, PsyM). We had respondents from 29 different states with Pennsylvania being the most highly represented with 12 respondents.

Table 1.

Self-Reported Descriptive Data of Sample (N = 77).

Race
White	60
Hispanic	5
African American	5
Mix-Race Native	2
Asian Indian	1
Did not answer	4
Gender
Female	68
Male	6
Nonbinary	1
Did not answer	1
Degree/Licensure
Counseling	29
Social Work	27
Psychology	10
Marriage and Family	7
Therapy	2
Did not answer	2
Years of Experience
More than 20	12
16–20	9
11–15	14
6–10	33
0–5	7

Those who responded had a wide range of experience levels and caseload sizes. The average reported years of experience was 12, while the range spanned from 3 years to more than 20 years of experience. The average reported caseload size was 24 cases, while the range spanned from 3 to 120 cases on one clinician’s caseload. Within these caseloads, an average of eight cases per clinician involved work with caregivers of a child who had been sexually abused. Caregivers were reported to be bio-parents, foster parents, or relatives of the child.

Data Collection

Participants completed an online survey that collected basic descriptive information about participants’ clinical practices and surveyed the participants’ clinical experiences of working with caregivers. All questions were open-response, where participants could write as little or as much as they wanted. Questions on the survey asked participants to describe (a) common challenges they face when working with caregivers of children who have been sexually abused and (b) strategies they have found to be effective when faced with these challenges. Most participants offered more than one answer for each question.

Data Analysis

Thematic analysis techniques (Padgett, 2008) were used by both researchers first independently, and then together, to explore the qualitative data obtained from the open-response survey questions. First, the researchers independently immersed themselves in the data and took notes on emerging themes that became apparent. Next, the two researchers met to create, discuss, and reexamine the thematic framework, resulting in clarification of thematic categories. Three initial themes became apparent among common challenges, including (a) caregiver not believing or blaming the child, (b) the caregiver’s emotional responses, and (c) logistics and systems. In regard to effective strategies, five initial themes were identified, including (a) psychoeducation, (b) separate support needed for the caregiver, (c) prioritizing engagement and building a relationship with the caregiver, (d) teaching the caregiver-specific skills, and (e) collaboration with colleagues and outside providers. Once these initial, major themes were identified, the researchers focused their attention on identifying distinct categories within each theme.

Both researchers have clinical experience working with children and families, and both had taken part in extensive education and research prior to conducting this study. To address potential bias, the authors utilized bracketing in the process of data collection and the interpretation of findings. The goal of bracketing was, whenever possible, to put aside preconceived notions and values to collect and interpret the participants’ experiences with greater accuracy (Chan et al., 2013; Creswell, 2013). The process of bracketing was intended to increase the dependability of the data collected, requiring the researchers to routinely address the rigor and trustworthiness of the research process, data collection, and the progression of data analysis. This required the practice of reflexivity, where the researchers are deliberately “attentive to and conscious of the cultural, political, social, linguistic, and economic origins of one’s own perspective and voice as well as the perspectives and voices of those on interviews and those to whom one reports” (Patton, 2015, p. 604).

Findings

A summary of the findings is presented in Table 2, including themes and related categories for (a) common challenges when working with caregivers of children who have been sexually abused and (b) effective strategies when faced with these challenges.

Table 2.

Common Challenges and Strategies When Working With Caregivers of Children Who Have Been Sexually Abused.

Common Challenges	Lack of Belief/Protection • Caregiver does not believe the child • Caregiver blames the child
	Caregiver’s Significant Emotional Responses • Caregiver’s trauma history is activated • Caregiver’s emotional response is impacting parenting • Caregiver’s emotional response is impacting child’s clinical process • Caregiver’s emotional response is impacting caregiver’s overall mental health
	Logistics and Systems • Scheduling/attendance challenges Navigation of complicated systems (criminal justice/legal, child protection/child welfare, school, etc.) • Lack of resources for family
Effective Strategies	Psychoeducation • Trauma and the process of disclosure • Sexual health • Child development
	Engagement, Rapport, and Relationship Building with Caregiver • Importance of validation and empathy • Normalizing caregiver reaction • Intentionally including caregivers in the child’s treatment
	Prioritizing Caregiver’s Need for Individualized Support
	Teaching Specific Skills to the Caregiver • Parenting skills • Cognitive reprocessing • Emotional attunement • Self-care strategies
	Reliance on Evidence-Based Treatments
	Collaboration • Collaboration with outside providers • Collaboration for consultation and professional/ethical development

Common Challenges

Caregiver not believing/blaming the child

Thirty-seven percent (n = 28) of participants named caregivers’ lack of belief and/or blaming the child as a significant challenge in their work. More specifically, for participants (n = 19) who identified the caregiver not believing the child as a significant challenge, their responses ranged from the caregiver staying in a place of denial, the caregiver defending the alleged perpetrator (AP), and the caregiver not believing that the abuse had occurred at all. It is important to note that denial is shock that leads a person to not be able to acknowledge the occurrence and/or the consequences of a significant life event (Schamess & Shilkre, 2011). The caregiver may be overwhelmed by the discovery that a beloved child, whom they were expected to protect, has been abused. Denial is common when someone is faced with danger or stress, and although it may have distinct consequences when employed in the role of parenting, it is significantly different than not believing the abuse occurred at all.

One participant wrote, “the ones that don’t believe the child are the most difficult.” Another participant named that the relationship of the AP was a significant factor, naming the challenge “if the AP is related, working through the family not believing the allegation.” In regard to the caregiver blaming the child for the abuse, one participant wrote, “they make the kids feel it is their fault for not telling sooner or not doing enough to stop it.” Here again, the relationship of the AP to the child and family seemed to matter, with one participant stating this is “especially challenging when it was the caregiver’s partner who abused their child.”

Caregiver’s significant emotional responses

The caregiver’s emotional response and its impact on the case was one of the most named challenges among participants. Four categories arose in this theme, all having a unique impact on the clinical experiences clinicians had with child clients and caregivers. The four categories within this theme included (a) impact on caregiver’s overall mental health (n = 30), (b) caregiver’s trauma history being activated (n = 20), (c) impact on child’s treatment (n = 21), and (d) impact on parenting (n = 18).

Thirty-nine percent (n = 30) of participants name caregivers’ emotional responses impacting their overall mental health as a common challenge. Many participants named “caregivers’ own mental health issues” as the challenge, where others named specific emotional responses that significantly impacted the work. Guilt, shame, and self-blame were the most commonly named impactful emotions, whereas others named anger and confusion as additional emotions that significantly challenged the work.

Twenty-six percent of participants (n = 20) reported that a significant challenge was the child’s abuse activating a trauma response in the caregiver, due to the caregiver’s own trauma history. One participant stated, “it often brings up the parents’ own unresolved issues of childhood abuse, so then I am also helping them address their own traumas, as well as deal with their [child’s trauma].” While other participants discussed how this impacted the work by stating, “[there is a] need for those caregivers to deal with their own history of trauma before being able to support their children” and “caregivers’ sexual abuse history colors how [a] caregiver sees/responds to [a] child,” and “the caregiver being able to handle their child’s trauma in addition to their own personal trauma that gets stirred up.”

Twenty-seven percent of participants (n = 21) reported that the caregiver’s emotional response complicated the child’s treatment in some way. The ways in which caregivers’ emotional responses impacted the child’s treatment ranged from creating a lack of consistency and commitment in the child’s therapy and/or a reluctance to engage in particular elements or all of a child’s therapy, pushing for the clinician to rush the therapy and “fix” the child, and a reluctance or discomfort when engaging with the topics of sex and sexual development. One participant stated that a significant challenge is when “caregivers want a ‘quick fix’ for their children or believ[e] that just not talking about the abuse and forgetting about it is the best thing for the child.”

Twenty-three percent of participants (n = 18) noted the impact that caregivers’ emotional responses had on parenting practices. One participant named this challenge as “parents who tend to be either overly permissive (not setting appropriate boundaries) or overly strict (out of fear and over-protection) after their child has experienced child sexual abuse.” Others noted caregivers’ lack of follow-through on established safety plans and caregivers’ difficulty in employing behavioral techniques and setting consequences and boundaries at home. Avoiding or denying the need for new parenting skills to address the impact the abuse had on the child was reported in several ways. One participant stated a common challenge was “[caregivers’ lack of] understanding of how the children are impacted and need to be cared for differently.” Another stated, “some caregivers also minimize the experience.” “Disconnection from child,” and “Difficulty with understanding the emotional impact on the child” were also named as common challenges.

Logistics and systems

Challenges with logistics and systems was a third theme (22% of participants; n = 17). Logistical challenges that impacted the work included transportation, scheduling, attendance, limited time/sessions, loss of family resources, and lack of access to basic needs. Systemic challenges were also named, including the child welfare system, the criminal justice system, and lack of available supportive resources for the caregiver and/or family. One participant stated, “helping parents navigate the child protective services system and scrutiny of young caseworkers is a big challenge.”

Effective Strategies

Psychoeducation with caregiver

The provision of psychoeducation was the effective strategy most named by participants (48%, n = 37). The majority simply named “psychoeducation” as the effective strategy, but other participants were more specific. One participant wrote, “Psychoeducation—educat[ing] them about the effects of the abuse, challenging their misconceptions.” Others reported that psychoeducation about sexual abuse dynamics and the disclosure process were effective. One participant summarized this by stating,

Psychoeducation often plays an important role. Parents learn about childhood sexual abuse to better understand why their child may not have disclosed the abuse initially or why they behave in ways at times that makes the parent question whether the event occurred.

Other participants reported the importance of psychoeducation about sexual health and safe relationships. Participants named effective psychoeducation focusing on, “discussion of sexual health, healthy sexual and non-sexual relationships with the entire family unit” and

having [caregivers] reflect in themselves how they enjoy sex and [the] child now understands those actions can be pleasurable, which means [the] child needs [to be] taught healthy safe boundaries about sexual encounters such as being alone in their room and not doing it at school.

Engagement, rapport, and relationship building with caregiver

Prioritizing rapport, engagement, and relationship building with the caregiver was another effective strategy named by participants, with 44% of participants (n = 34) reporting various ways they implemented this strategy. The expression of “validation” and “empathy” was frequently named, as well as normalizing caregivers’ reactions to their child’s disclosure. Participants stated the following, “normalize caregiver reactions,” “continuing to build rapport with the caregiver,” “building a strong relationship with the caregivers,” “extra time on parent engagement,” all emphasizing the prioritization of relationship building with caregivers. Intentionally including caregivers in the treatment of their child was also frequently named. One participant summarized caregiver involvement as a partnership by stating,

Partnering with parents is my most effective strategy. I view parents as experts on their child and myself as an expert on trauma. I work collaboratively with caregivers in order to give them a sense of control in their child’s treatment.

Prioritizing caregivers’ need for individualized support

Twenty-five percent of participants (n = 19) named prioritizing the caregivers’ need for individualized support as an effective strategy in responding to the caregivers’ emotional responses to their child’s abuse. This theme was focused on the clinician’s clear priority to have the caregiver’s needs addressed, as opposed to the actual method of addressing the need. While a small number of clinicians reported offering separate services to the caregiver, most of these clinicians (n = 16) named referrals to nonoffending caregiver support groups, parenting groups, and individual counseling as an effective strategy when working with caregivers. One participant wrote,

“when difficulties are due to [the] caregiver’s own trauma, I automatically talk to [the] caregiver about getting their own therapist.” Another wrote, “[I] encourage support groups . . . to balance their lives so they don’t drown under the pressures of the trauma they deal with.”

Teaching specific skills to the caregiver

More than half of the participants (52%, n = 40) named the process of teaching specific skills to caregivers as effective strategies in response to the common challenges they face in their work. This theme differs from psychoeducation, as it involves teaching, practice, and at-home implementation of specific skills. Four categories arose in this theme, all identifying the teaching of a unique skill to caregivers.

First, taking time to teach parenting skills was named by many participants as a direct means to address the child’s behavior outside of the therapy room. This included general recognition and support of the caregivers’ strengths, with examples including “building on their strengths and promoting the importance of their role in the recovery process” and “supporting the caregivers’ strengths and building upon them.” Behavioral parenting techniques were also named, with statements such as “teaching behavior management to address the behavior difficulties” and “implementing behavior management techniques, parents are offered individual sessions, where homework may be assigned.” A second strategy was teaching cognitive reprocessing to parents, often in relation to the caregivers’ feelings of guilt and shame. This was described by participants as “exploring cognitive behavioral techniques to change unhelpful thinking especially moving through guilt” and “support[ing] the parents processing of the traumatic event, working to process any of those core beliefs that may be unhelpful/inaccurate or distorted.”

Teaching caregivers skills in emotional attunement was also named by participants, specifically to increase their empathy for the child and to “. . . [confront] bias or falsehoods” when working with caregivers who do not believe the abuse occurred. One participant stated that in TF-CBT, “non-offending parents are coached on how to emotionally respond to their child during the trauma narrative conjoint session even if the parent does not believe the child,” clarifying one way this skill is implemented directly into treatment. The final skill participants named was teaching caregivers self-care strategies. One participant offered a summary of this skill by stating, “I encourage healthy lifestyle choices on all levels, including exercise and teach them things like . . . mindfulness/meditation practices . . . good nutrition . . . to help them self-regulate.”

Reliance on evidence-based treatments (EBTs)

Twenty-six percent of participants (n = 20) named specific EBTs as effective strategies in their work with caregivers. And although all participants were trained in TF-CBT, several other EBTs were also mentioned as resources for clinicians, including cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and dialectical behavior therapy (DBT). One participant suggested that the combination of therapy techniques/protocols was most effective, stating “EMDR has been the most effective treatment protocol for me when compared to TF-CBT and CBT alone.” Several treatment protocols and clinical methods were named as effective strategies, suggesting that clinicians are well served by knowing a variety of treatment approaches.

Collaboration

While only 9% of participants (n = 9) mentioned collaboration as an effective strategy, the ways in which it was described is worth noting. Some participants emphasized that collaboration with outside providers was key in working with and advocating for their clients. One participant noted the importance of “helping [caregivers] make links to support in their community.” Importantly, these links require a clinician to have their own network of service providers. This becomes relevant when considering the impact caregivers’ emotional responses have on the therapeutic process and the potential need for outside referral sources of caregiver support.

In addition, participants also mentioned collaborating in the form of consulting with supervisors and colleagues for professional and ethical development. One participant stated, “strong professional support and talking these situations through with colleagues. I don’t know if there is one right answer for these situations, but walking through clinical challenges with trusted clinicians has been the most helpful personally.” This form of collaboration is especially relevant, considering the varying ways challenges present themselves in this work.

Implications for Social Work Practice

This study’s examination of working with nonoffending caregivers offers varied perspectives on the common challenges clinicians experience and suggestions on what strategies are most effective in the face of such challenges. Contributing to existing evidence-based CSA interventions, the findings supply essential information in the implementation of the commonly used caregiver component. The study offers a compilation of common expectations and best practices, serving as validation to those clinicians already doing this work and a basic blueprint to those entering the field.

While the study has potential to be useful for clinical practice and training, it is essential to acknowledge its limitations. First, the sample for the study limits the findings’ generalizability, as only TF-CBT–certified clinicians were invited to participate, and the final sample included predominantly White, female clinicians. Future research should acknowledge the complexity of the sociocultural location of the clinician and aspire to have a more diverse, well-rounded representation of clinicians doing this work. Second, the study only considers the experiences of clinicians. Future research that explores the experiences of caregivers would contribute essential perspectives to our understanding of caregiver challenges and effective strategies. Fong et al. (2020) interviewed nonoffending caregivers, exploring the impact their child’s abuse had on them and their families. Their findings stress the emotional and psychological impact the abuse has on caregivers and the family system, but also highlight that caregivers see the usefulness in their own mental health support and desire to receive services. Expanding upon their and our research, it seems essential to survey nonoffending caregivers who have received support to assess what they felt they needed from providers and what they felt was or was not helpful. Finally, the study is exploratory, meaning it is intended to be a first step in the process of enhancing professional understanding of best practices in working with nonoffending caregivers. Continued research is needed to make connections between what strategies are most effective with particular challenges, and how best to integrate this knowledge into the training of clinicians.

Despite the study’s limitations, its findings have implications in the areas of clinical practice and training. In an effort to prepare clinicians to serve families who have been impacted by CSA, it is essential that both clinical training and implementation of engagement with nonoffending caregivers is informed by evidence-based knowledge. Research has shown direct caregiver interventions result in better outcomes for CSA victims and families, highlighting the importance of education and support services specifically individualized and designed for caregivers (Theimer et al., 2020; van Toledo & Seymour, 2013). The research study described here validates many of the strategies identified in Van Toledo’s review, but instead, in this exploratory study, it’s within the context of working within the child’s therapeutic framework.

This study also highlights the importance of practitioners to understand the significance of caregiver mental health and to prioritize the development of trust and rapport with caregivers in their work with children. Trauma-informed care emphasizes physical and emotional safety, intentionally attempting to prevent retraumatization through the application of strategies of choice, collaboration, empowerment, and trustworthiness (Bent-Goodley, 2019; Institute of Trauma Informed Care, University of Buffalo [ITTC], 2015; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). In context to working with nonoffending caregivers, the framework offers a space for clinicians to face the challenges identified in this study with curiosity and compassion, both hallmarks of a trauma-informed lens (Levenson, 2017). For example, this study found psychoeducation and prioritizing engagement and relationship building as effective strategies when working with caregivers. A trauma-informed approach could prove to be a powerful tool in employing these effective strategies, successfully addressing the common challenges of caregivers’ distress and resistance with empathy and care.

Clinicians who work with children and families should receive specific education and training on how best to include caregivers in their work with children, including the common challenges and most effective strategies. While specific implementations of effective strategies may vary by clinician, client, community, and practice, this exploratory study identified some core strategies that were consistent across the country through a variety of experience and practice levels. Specifically, clinicians would benefit from receiving training and support around engaging caregivers through a relational, trauma-informed approach that prioritizes the potential need for individualized support while also providing tangible skill-building opportunities.

Participants named psychoeducation, validating experiences, and offering a tangible set of skills and practices as the most effective strategies in working with nonoffending caregivers. It is our hope that the findings and dissemination of this information proves to offer the same sense of empowerment for clinicians as it has been demonstrated effective in working with clients. By empowering clinicians, we hope to indirectly empower nonoffending caregivers in the aftermath of childhood sexual abuse. This sense of empowerment becomes all the more important as the landscape of clinical work evolves, including virtual and distance settings. It is essential that clinicians have flexible, tangible practices that offer confidence. Just as with clients, accurate, validating information of what to expect and how to respond can be the empowerment clinicians need to move forward in this ever-changing clinical landscape.

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

Johanna Crocetto

Disposition editor: Cristina Mogro-Wilson

References

Bellis

M. A.

Hardcastle

Ford

Hughes

Ashton

Quigg

Butler

(2017). Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences - A retrospective study on adult health-harming behaviours and mental well-being. BMC Psychiatry, 17, 110. https://doi.org/10.1186/s12888-017-1260-z

Bellis

Hughes

Ford

Hardcastle

Sharp

Wood

Homolova

Davies

(2018). Adverse childhood experiences and sources of childhood resilience: A retrospective study of their combined relationships with child health and educational attendance. BMC Public Health, 18(1), 792. https://doi.org/10.1186/s12889-018-5699-8

Bent-Goodley

(2019). The necessity of trauma-informed practice in contemporary social work. Social Work, 64(1), 5–8.

Bloom

S. L.

Courtois

. (2016). Trauma-informed communities, trauma-responsive services, trauma-specific treatment [PowerPoint slides]. canvas.upenn.edu

Bolen

R. M.

Gergely

K. B.

(2014). Child sexual abuse. In Conte

Jon R.

(Ed.), Child abuse and neglect worldwide: Volume I understanding, defining, and measuring child. https://doi.org/10.1016/0145-2134(91)90045-F

Bolen

R. M.

Lamb

J. L.

(2002). Guardian support of sexually abused children: A study of its predictors. Child Maltreatment, 7(3), 265–276. https://doi.org/10.1177/1077559502007003008

Browne

Finkelhor

(1986). Impact of child sexual abuse: A review of the research. Annual Progress in Child Psychiatry & Child Development, 99, 66–77. https://doi.org/10.1037/0033-2909.99.1.66

Chan

Fung

Chien

(2013). Bracketing in phenomenology: Only undertaken in the data collection and analysis process? The Qualitative Report, 18, 1–9.

Chen

L. P.

Murad

M. H.

Paras

M. L.

Colbenson

K. M.

Sattler

A. L.

Goranson

E. N.

Elamin

M. B.

Seime

R. J.

Shinozaki

Prokop

L. J.

Zirakzadeh

(2010). Sexual abuse and lifetime diagnosis of psychiatric disorders: Systematic review and meta-analysis. Mayo Clinic Proceedings, 85(7), 618–629. https://doi.org/10.4065/mcp.2009.0583

10.

Cohen

(2008). Parenting in the throes of traumatic events: Risks and protection. In Brom

Pat-Horenczyk

Ford

J. D.

(Eds.), Treating traumatized children: Risk, resiliency, and recovery (pp. 72–84). Routledge. https://doi.org/10.4324/9780203893104

11.

Cohen

J. A.

Mannarino

A. P.

(2000). Predictors of treatment outcome in sexually abused children. Child Abuse & Neglect, 24(7), 983–994. https://doi.org/10.1016/s0145-2134(00)00153-8

12.

Cohen

J. A.

Mannarino

A. P.

Deblinger

(2017). Treating trauma and traumatic grief in child and adolescents (2nd ed.). Guilford Press. https://doi.org/10.1080/07317107.2017.1375719

13.

Collin-Vézina

Daigneault

Hébert

(2013). Lessons learned from child sexual abuse research: Prevalence, outcomes, and preventive strategies. Child and Adolescent Psychiatry and Mental Health, 7, Article 22. https://doi.org/10.1186/1753-2000-7-22

14.

Creswell

J. W.

(2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). SAGE.

15.

Cyr

Hébert

Frappier

Tourigny

McDuff

Turcotte

(2014). Parental support provided by nonoffending caregivers to sexually abused children: A comparison between mothers and fathers. Journal of Child Custody, 11(3), 216–236. https://doi.org/10.1080/15379418.2014.954688

16.

DeBellis

M. D.

Woolley

D. P.

Hopper

S. R.

(2013). Neuropsychological findings in pediatric maltreatment: Relationship of PTSD, dissociative symptoms, and abuse/neglect indices to neurocognitive outcomes. Child Maltreatment, 18, 171–183. https://doi.org/10.1177/1077559513497420

17.

Deblinger

Mannarino

Cohen

(2015). Child sexual abuse: A primer for treating children, adolescents, and their nonoffending parents (2nd ed.). Oxford University Press. https://doi.org/10.1093/med:psych/9780199358748.003.0006

18.

Dube

S. A.

Anda

R. F.

Whitfield

C. L.

Brown

D. W.

Felitti

D. J.

Dong

Giles

(2005). Long-term consequences of childhood sexual abuse by gender of the victim. American Journal of Preventive Medicine, 28, 430–437. https://doi.org/10.1016/j.amepre.2005.01.015

19.

Dubowitz

Black

Harrington

Verschoore

(1993). A follow-up study of behavioral problems associated with child sexual abuse. Child Abuse & Neglect, 17, 743–754. https://doi.org/10.1016/s0145-2134(08)80005-1

20.

Elliott

Carnes

(2001). Reactions of non-offending parents to the sexual abuse of their child: A review of the literature. Child Maltreatment, 6(2001), 314–331. https://doi.org/10.1177/1077559501006004005

21.

Finkelhor

Kendall-Tackett

(1997). A developmental perspective on the childhood impact of crime, abuse, and violent victimization. In Cicchetti

Toth

S. L.

(Eds.), Developmental perspectives on trauma: Theory, research, and intervention (pp. 1–32). University of Rochester Press.

22.

Fong

Bennett

Mondestin

Scribano

Mollen

Wood

(2020). The impact of child sexual abuse discovery on caregivers and families: A qualitative study. Journal of Interpersonal Violence, 35(21–22), 4189–4215.

23.

Ford

J. D.

Saltzman

(2009). Family systems therapy. In Courtois

C. A.

Ford

J. D.

(Eds.), Treating complex traumatic stress disorders: Scientific foundations and therapeutic models (pp. 391–414). Guilford Press

24.

Godbout

Briere

Sabourin

Lussier

(2014). Child sexual abuse and subsequent relational and personal functioning: The role of parental support. Child Abuse & Neglect, 38, 317–325. https://doi.org/10.1016/j.chiabu.2013.10.001

25.

Groenewald

(2004). A phenomenological research design illustrated. International Journal of Qualitative Methods, 3(3), 142–155. https://doi.org/10.1177%2F160940690400300104

26.

Institute of Trauma Informed Care, University of Buffalo. (2015). What is trauma informed care? https://traumainformedoregon.org/wp-content/uploads/2016/01/What-is-Trauma-Informed-Care.pdf

27.

Irish

Kobayashi

Delahanty

D. L.

(2010). Long-term physical health consequences of childhood sexual abuse: A meta-analytic review. Journal of Pediatric Psychology, 35(5), 450–461. https://doi.org/10.1093/jpepsy/jsp118

28.

Kendall-Tackett

Williams

L. M.

Finkelhor

(2001). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. In Bull

(Ed), Children and the law: The essential readings (pp. 31–76). Blackwell. https://doi.org/10.1037/0033-2909.113.1.164

29.

Kiser

L. J.

Miller

A. B.

Mooney

M. A.

Vivrette

Davis

S. R.

(2020). Integrating parents with trauma histories into child trauma treatment: Establishing core components. Practice Innovations, 5(1), 65–80. https://doi.org/10.1037/pri0000109.supp

30.

Koverola

Pound

Heger

Lytle

(1993). Relationship of child sexual abuse to depression. Child Abuse & Neglect, 17, 393–400. https://doi.org/10.1016/0145-2134(93)90062-a

31.

Levenson

J. S.

(2017). Trauma-informed social work practice. Social Work, 62(2), 105–113.

32.

Lynskey

M. T.

Fergusson

D. M.

(1997). Factors protecting against the development of adjustment difficulties in young adults exposed to childhood sexual abuse. Child Abuse & Neglect, 21(12), 1177–1190. https://doi.org/10.1016/s0145-2134(97)00093-8

33.

Maniglio

(2010). Child sexual abuse in the etiology of depression: A systematic review of reviews. Depression and Anxiety, 27, 631–642. https://doi.org/10.1002/da.20687

34.

McEwen

B. S.

(2012). Brain on stress: How the social environment gets under the skin. Proceedings of the National Academy of Sciences, 109(Suppl. 2), 17180–17185. https://doi.org/10.1073/pnas.1121254109

35.

Nalavany

Ryan

Hinterlong

(2009). Externalizing behavior among adopted boys with preadoptive histories of child sexual abuse. Journal of Child Sexual Abuse, 18, 553–573. https://doi.org/10.1080/10538710903183337

36.

Padgett

D. P.

(2008). Qualitative methods in social work research (2nd ed.). SAGE.

37.

Paolucci

Genuis

Violato

(2001). A meta-analysis of the published research on the effects of child sexual abuse. The Journal of Psychology, 135(1), 17–36. https://doi.org/10.1080/00223980109603677

38.

Patton

M. Q.

(2015). Qualitative research & evaluation methods (4th ed.). SAGE.

39.

Puckering

Breustedt

(2013). A qualitative evaluation of women’s experiences of the Mellow Bumps antenatal intervention. British Journal of Midwifery, 21(3), 100–107. https://doi.org/10.12968/bjom.2013.21.3.187

40.

Rhode

Ichikawa

Simon

G. E.

Ludman

E. J.

Linde

J. A.

Jeffery

R. W.

Operskalski

B. H.

(2008). Associations of child sexual and physical abuse with obesity and depression in middle-aged women. Child Abuse & Neglect, 32, 878–887. https://doi.org/10.1016/j.chiabu.2007.11.004

41.

Romano

Zoccolillo

Paquette

(2006). Histories of child maltreatment and psychiatric disorder in pregnant adolescents. American Academy of Child & Adolescent Psychiatry, 45(3), 329–336. https://doi.org/10.1097/01.chi.0000194563.40418.81

42.

Saltzman

W. R.

Babayan

Lester

Beardslee

W. R.

Pynoos

R. S.

(2008). Family-based treatment for child traumatic stress: A review and report on current innovations. In Brom

Pat-Horenxzyk

Ford

J.D.

(Eds.), Treating traumatized children (pp. 258–272). Routledge.

43.

Schamess

Shilkre

(2011). Ego psychology. In Berzoff

Flanagan

L.M.

Hertz

(Eds.), Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts (3rd ed.). Rowman & Littlefield.

44.

Scheeringa

M. S.

Zeanah

C. H.

(2001). A relational perspective on PTSD in early childhood. Journal of Traumatic Stress, 14(4), 799–815. https://doi.org/10.1023/a:1013002507972

45.

Spaccarelli

Kim

(1995). Resilience criteria and factors associated with resilience in sexually abused girls. Child Abuse & Neglect, 19, 1171–1182. https://doi.org/10.1016/0145-2134(95)00077-l

46.

Substance Abuse and Mental Health Services Administration. (2014). Guiding principles of trauma-informed care. SAMHSA News, 22(2). https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/guiding_principles.html

47.

Swanston

H. Y.

Plunkett

A. M. O.

Toole

B. I.

Shrimpton

Parkinson

P. N.

Oates

R. K.

(2003). Nine years after child sexual abuse. Child Abuse & Neglect, 27, 967–984. https://doi.org/10.1016/s0145-2134(03)00143-1

48.

Theimer

Mii

Sonnen

McCoy

Meidlinger

Biles

Huit

Flood

Hansen

(2020). Identifying and addressing barriers to treatment for child sexual abuse survivors and their non-offending caregivers. Aggression and Violent Behavior, 52, 101418.

49.

Tremblay

Hebert

Piche

(1999). Coping strategies and social support as mediators of consequences of CSA victims. Child Abuse and Neglect, 23, 929–945. https://doi.org/10.1016/s0145-2134(99)00056-3

50.

Trickett

Putnam

(1998). Development consequences of child sexual abuse. In Trickett

P. K.

Schellenbach

C. J.

(Eds.), Violence against children in the family and the community (pp. 39–56). American Psychological Association. https://doi.org/10.1037/10292002

51.

Ulrich

Randolph

Acheson

(2005). Child sexual abuse: A replication of the meta-analytic examination of child sexual abuse by Rind, Tromovitch, and Baserman (1998). The Scientific Review of Mental Health Practice, 4(2), 37–51.

52.

Urquiza

A. J.

Blacker

(2011). Parent-child interaction therapy for sexually abused children. In Goodyear-Brown

(Ed.), Handbook of child sexual abuse: Identification, assessment, and treatment (pp. 279–296). John Wiley. https://doi.org/10.1002/9781118094822.ch12.

53.

van der Kolk

B. A

. (2003). The neurobiology of childhood trauma and abuse. Child & Adolescent Psychiatric Clinic of North America, 12, 293–317. https://doi.org/10.1016/s1056-4993(03)00003-8

54.

Van Toledo

Seymour

. (2013). Interventions for caregivers of children who disclose sexual abuse: A review. Clinical Psychology Review, 33, 772–781. https://doi.org/10.1016/j.cpr.2013.05.006

55.

Waldrop

A. E.

Hanson

R. F.

Resnick

H. S.

Kilpatrick

D. G.

Naugle

A. E.

Saunders

B. E.

(2007). Risk factors for suicidal behavior among a national sample of adolescents: Implications for prevention. Journal of Traumatic Stress, 20, 869–879. https://doi.org/10.1002/jts.20291

56.

Walsh

W. A.

Cross

T. P.

Jones

L. M.

(2012). Do parents blame or doubt their child more when sexually abused by adolescents versus adults? Journal of Interpersonal Violence, 27(3), 453–470. https://doi.org/10.1177/0886260511421671

57.

Zvara

B. J.

Mills-Koonce

W. R.

Carmody

K. A.

Cox

(2015). Childhood sexual trauma and subsequent parenting beliefs and behaviors. Child Abuse & Neglect, 44, 87–97. https://doi.org/10.1016/j.chiabu.2015.01.012