K—SADS

A shortened version of the standardised, semi-structured K—SADS diagnostic interview was used. This is a valid and reliable schedule that has been widely employed with children aged 6-17 years, and has proved to be a reliable measure of depression, anxiety, emotional disorder and conduct disorder (Reference Kaufman, Birmaher and BrentKaufman et al, 1997) (see Appendix).

Global impairment of functioning

Assessment of global impairment of functioning (concerning social, psychological or school functioning) was achieved using the K—GAS (1986 version). This is based on the Children's Global Assessment Scale (C—GAS) (Reference Shaffer, Gould and GrasieShaffer et al, 1983). Impairment is rated on a scale of 1 to 9 (1-3, major impairment; 7-9, little impairment). In recent research using kappa (Reference CohenCohen, 1960; G. Kolaitis & T. Korpa, personal communication, 2001) satisfactory reliability has been reported (see Appendix).

Post-traumatic stress disorder

The 1989 version of Orvaschel's PTSD scale was used, which is an extension of the K—SADS instrument (Reference OrvaschelOrvaschel, 1989). The content is similar to the criteria outlined in DSM—IV (American Psychiatric Association, 1994), comprising 19 items with four domains: re-experiencing of trauma, inappropriate sexual behaviour, persistent avoidance of stimuli, and persistent increased arousal. The data are obtained by interviewing the child, apart from information on inappropriate sexual behaviour which (according to Orvaschel) is more reliably obtained from the child's carer. (Normally, inappropriate sexual behaviour is not collected as part of a PTSD profile; however, it has been included as such by Orvaschel.) The PTSD symptoms were coded in a number of different ways: for most analyses, a bimodal system of coding of ‘present’ or ‘absent’ was employed; when studying a change, in order to provide a wider range of scores, the three-point coding system was used; sub-scale or dimension scores were obtained by summation of the relevant items; and PTSD as a category was coded as present (1) or absent (0).

Changes

Patterns of change across time are demonstrated by cross-tabulations of relevant categories. Magnitude of change irrespective of the treatment group was explored using analysis of variance. In addition, the magnitude of reduction of the mean scores from baseline to the two follow-up points is indicated in terms of standard deviations.

Subjects

A CONSORT model (Reference Begg, Cho and EastwoodBegg et al, 1996) is shown in Fig. 1. A total of 94 participants were recruited initially from the authors' own clinics and from professional agencies in the community in north and south London, but the process proved slower than anticipated; 13 children proved ineligible, on the basis of information in the referral letters or telephone contact, or where there was unwillingness to participate in initial assessments. Owing to the absence of interview data for these 13 children, it was not possible to compare them with the trial participants. In all, 81 girls were interviewed, and of these 10 proved unsuitable for diverse reasons — because they were not in a safe family situation, or could not or would not commit themselves to regular attendance, or had been sexually abused but had little evidence of symptoms. One child objected to random allocation, as she felt unable to cope with the perceived intimacy of individual therapy. Four children were allocated randomly but did not attend. A total of 71 children entered therapy. These numbers are linked to available K—SADS and global assessment of impairment data. The number of participants with completed PTSD interviews was less than 71; this was because a few girls at the baseline refused to talk about the abuse and its aftermath.

Fig. 1 Modified CONSORT diagram: psychiatric disorders and global assessment of impairment data.

Allocation to treatment regimen and random allocation

The north London centre recruited 51 participants and the south London centre recruited 20. North London was responsible for random allocation to group and individual therapies. In north London, with its relatively high recruitment, the system worked well, although there were a few inevitable delays while awaiting a group to be constituted; however, in south London the delays proved greater. The group therapy supervisors decided that, in general, to have twins or sisters in the same group would be unhelpful to the group. Because of the number of abused siblings and twins, there were practical problems that had to be solved on a case-by-case basis to ensure attendance.

Consent

Prior to the baseline assessment, the nature of the project was explained to each child and her carer. This included an account of the duration of the treatment offered, the nature of the assessment before and after treatment and at second-year follow-up, and the randomisation. The children's carers were invited to commit themselves to the trial, and if the child was old enough she was invited to assent to the treatment package. If the legal carer or child did not wish to be part of the project, access was available to the ordinary resources at the referring clinics and hospitals; there were few refusals. At the end of the baseline assessment the allocation slot was revealed, and the families were invited to sign the consent forms and the child the assent forms.

Dropouts, losses and compliance with therapy

The characteristics of the participants are shown in Table 1. In addition, the patients' progress within the trial is illustrated in a modified CONSORT diagram. Of the final 71 patients, 35 were allocated to individual therapy and 36 to group therapy. The mean percentage of attended sessions for patients receiving individual therapy was 88% (s.d.=24.9, 95% CI 79.3-96.7); in group therapy, the mean percentage of attended sessions was again 88% (s.d.=21.6, 95% CI 80.7-95.3). Of those who did not complete the full course of therapy, ‘completers’ were defined as those who had attended at least 30% of the defined sessions for individual or group therapy.

Table 1 Demographic characteristics of the study sample

	Individual therapy		Group therapy		χ 2	P
	n	%	n	%
The child
Under 10 years old	17/34	49	17/36	47	0.001	NS
Attends secondary school	8/32	25	11/36	31	0.06	NS
Above average academically	23/33	70	24/36	67	0.00	NS
Has a known best friend	21/31	68	23/33	70	0.00	NS
Pre-school separation for longer than 3 months	7/31	23	5/31	15	0.19	NS
Legal order	13/33	39	14/34	41	0.00	NS
Abused by her parent	12/35	34	18/36	50	1.21	NS
More than one abuser	15/35	43	13/36	36	0.11	NS
More than 10 abuse incidents	22/35	63	17/36	47	1.18	NS
More than 2 years' duration	14/35	40	13/36	36	0.01	NS
Sexual abuse
Touching with or without clothes	8/35	23	4/36	11 [UNK]
Genital touching or simulated intercourse	12/35	34	15/36	42 [UNK]	6.02	NS
Oral, anal or vaginal penetration	15/35	43	17/36	47 [UNK]

Of the patients entering individual therapy, one did not receive treatment as defined (she attended less than 20% of sessions) and was considered to be a drop-out. However, most (29) received substantial treatment (i.e. attended 80% or more of the defined sessions), and five received adequate treatment, that is 30% or more of the defined sessions. Of those entering group therapy, one did not receive treatment as defined, most (29) received substantial treatment and six received adequate treatment. Thus, prior to the first follow-up, 34 children in individual therapy and 35 in group therapy received at least adequate treatment.

However, it will be noted that there were only 58 participants with K—SADS data at the first follow-up; thus, there were more completers than those who were assessed at follow-up. There were a number of reasons for this. Some patients declined assessment as they did not wish to be reminded of their traumatic experience; some families had moved and it proved difficult to track them down. Although much time was spent on encouraging families to attend, the resources were not always available to arrange repeated home visits or multiple clinic appointments. Social service departments felt that the children should not be pursued for follow-up. The net result was that although 34 families had received adequate treatment in the individual therapy sessions and 35 in the group therapy sessions, only 29 families in each of the treatments were assessed at first-year follow-up, and 66 at exit from the study. Losses on the PTSD measure were greater than on the K—SADS; for instance, 68 girls with PTSD data entered therapy (34 individual and 34 group); 56 attended the first-year follow-up (28 individual and 28 group); 49 attended the second-year follow-up (27 individual and 22 group); and 64 were available at exit (32 individual and 32 group). Some children refused to answer PTSD questions, they would not discuss the trauma.

It was not necessarily the children who missed the first follow-up who missed the second: some of those who missed the first follow-up had been encouraged to attend the second, and a number of children who attended the first follow-up did not attend the second. This compounded the problems for multivariate analyses, for which a complete set of data is necessary. To deal with missing values, we used the technique of replacing missing values at the second follow-up with the last available measure, which is the notion of the last observation carried forward (Reference Diggle, Everitt and DunnDiggle, 1998): the exit notion. As shown by the modified CONSORT diagram (Fig. 1), this technique gave rise to a larger sample (n=66 with K—SADS data) at the second-year follow-up (previously n=54).

Individual therapy plus carer support

Children allocated to individual therapy were seen once weekly for up to 30 sessions. The sessions lasted 50 minutes and took place at the same time on the same day each week, with the same therapist in the same room. Carers were seen by social workers (Reference Rushton and MilesRushton & Miles, 2000) in parallel, generally every 2 weeks; some carers chose not to attend, but most came for some sessions. The children were provided with play materials. The topics to be addressed were listed in the manual; the topics arose as they occurred to the girl, but the therapists and their supervisors ensured that over the time all the topics were raised. A checklist was completed after each session. The early sessions (usually the first five) were the engagement phase; the next 15 sessions were focused on the issues identified as relevant to that particular child; the final 10 sessions focused on separation and ending, while reworking any key topics that had emerged. Individual treatment was supervised every other week.

Group therapy plus carer work

The therapy groups, which were psychoeducational as well as psychotherapeutic, were led by co-therapists. All except one group had both a male and a female leader. There were up to 18 group sessions, involving generally five girls. Each group had a prearranged topic, the girls had notebooks and task sheets, and there were also play materials. Each session began with news and then the topic for the week; information and suggestions were given and explained in the group. The group also had time to tackle the relationships between the girls and their relationship with the co-therapists, and this was linked to past and current relationships, losses and disruptions. The groups were intense and the co-therapists required supervision after each session. Carers were worked with alongside the groups by carer workers, mostly separately. Carers' groups had some difficulties (Reference Rushton and MilesRushton & Miles, 2000), although some functioned well. However, when the carer groups were a mixture of parents and substitute carers, the members did not have a great deal in common.

Outside agencies

In many cases, local authority social workers supported the attendance by visiting the homes, paying fares, or bringing the family. Liaison with the schools was also important, as was attendance at case conferences and writing review reports. This work was undertaken by the team, not by the child therapists (group or individual).

Univariate analyses

Comparison of therapy groups. Four measures (the K—GAS impairment measure and the three PTSD dimensions) were subjected to univariate analyses (sexual behaviour will be reported elsewhere). Means, standard deviations and change scores from baseline with effect sizes were also studied. An effect size of 0.5 (following Reference CohenCohen, 1992) was used as the criterion of medium effect. The findings are noted in Tables 2 and 3. On the K—GAS impairment measure (Table 2) the between-group effect sizes never achieved 0.5. The same proved true for the PTSD dimension of ‘persistent symptoms of increased arousal’ (not shown in the tables). These latter data were not subjected to further analysis.

Table 2 Kiddie Global Assessment Scale (impairment measure): change in scores by therapy

	n	Score
		Mean	s.d.	95% CI
Baseline assessment
All cases	71	5.01	1.20	4.73-5.30
Individual therapy	35	5.14	1.37	4.67-5.62
Group therapy	36	4.89	1.01	4.55-5.23
First-year follow-up
Scores	58	6.40	1.36	6.02-6.74
Change from baseline
All cases	58	1.43	1.46	1.05-1.82
Individual therapy	29	1.48	1.57	0.88-2.08
Group therapy	29	1.38	1.37	0.86-1.90
Second-year follow-up
Scores	54	6.72	1.17	6.40-7.04
Change from baseline
All cases	54	1.57	1.41	1.19-1.95
Individual therapy	28	1.54	1.37	1.00-2.07
Group therapy	26	1.62	1.47	1.02-2.21
Exit from study
Scores	66	6.70	1.16	6.41-7.00
Change from baseline
All cases	66	1.70	1.49	1.33-2.06
Individual therapy	32	1.68	1.55	1.13-2.25
Group therapy	34	1.71	1.45	1.20-2.21

Table 3 Severity of post-traumatic stress disorder and persistent avoidance of stimuli: mean change scores by therapy

Symptom	n	Score			Effect size1
		Mean	s.d.	95% CI
Re-experience of traumatic event
Baseline scores
All cases	68	7.4	2.19	6.9-8.0
Individual therapy	34	7.9	2.14	7.1-8.6
Group therapy	34	7.0	2.18	6.2-7.7
Increase from baseline at first-year follow-up
All cases	56	1.16	2.5	0.48-1.83
Individual therapy	28	1.82	2.4	0.89-2.75	0.60
Group therapy	28	0.50	2.5	0.49-1.48
Increase from baseline at second-year follow-up
All cases	49	1.18	2.32	0.52-1.85
Individual therapy	27	1.96	2.08	1.14-2.79	0.79
Group therapy	22	0.22	2.28	0.79-1.24
Increase from baseline at exit from study
All cases	64	1.06	2.54	0.43-1.70
Individual therapy	32	1.78	2.43	0.90-2.66	0.65
Group therapy	32	0.34	2.48	0.55-1.24
Persistent avoidance of stimuli
Baseline scores
All cases	68	10.1	1.67	9.7-10.5
Individual therapy	34	10.2	1.56	9.7-10.8
Group therapy	34	10.0	1.80	9.4-10.6
Increase from baseline at first-year follow-up
All cases	56	2.1	2.5	1.4-2.7
Individual therapy	28	2.6	2.2	1.8-3.5	0.66
Group therapy	28	1.5	2.7	0.44-2.6
Increase from baseline at second-year follow-up
All cases	49	1.8	2.1	1.2-2.4
Individual therapy	27	2.1	2.3	1.2-3.0	0.36
Group therapy	22	1.5	1.8	0.72-2.3
Increase from baseline at exit from study
All cases	64	2.0	2.5	1.4-2.6
Individual therapy	32	2.5	2.4	1.6-3.3	0.60
Group therapy	32	1.5	2.6	0.6-2.5

Table 3 indicates that, at baseline, there were no significant differences between the mean scores on the two PTSD dimensions for the two groups of active therapy. However, at follow-up, the mean change scores on individual therapy in comparison with group therapy were associated with effect sizes of 0.5 or greater, which represents at least a medium effect in favour of individual therapy, with the exception of baseline to second-year follow-up and to exit in the case of the ‘persistent avoidance’ dimension; therefore, five of the six effect sizes listed in Table 3 meet Cohen's criterion of medium effect and one suggests a large effect.

Comparison of ‘at home’ and ‘looked after’ groups. There is one difference at the first-year follow-up with effect size on the K—GAS score. The mean score of the ‘at home’ group at the first-year follow-up was 6.59 (s.d.=1.31, 95% CI 6.16-7.02); for the ‘looked after’ group the mean score was 5.95 (s.d.=1.39, 95% CI 5.28-6.62) (higher scores imply less impairment) with an effect size of 0.53. No other effect size achieved the criterion level.

Multivariate analyses

Analysis of covariance: change scores. Two-way analyses of covariance were undertaken, using as separate main effects (a) the treatment category (individual or group) and (b) the placement of the child, either at home or away from home; and adjusting for three covariates. The first of these was the K—GAS measure of global impairment at baseline (log transformed) or, where focusing on PTSD, the impairment score (log transformed); in addition, a further analysis was undertaken using the specific PTSD dimension at baseline (log transformed). The second was an index of the number of therapy sessions. The third was an index of severity of abuse.

The analyses were based on measures of change available at three time points: baseline assessment to first-year follow-up; baseline to second-year follow-up; and finally baseline to exit, which incorporated the last assessment undertaken of each participant. Changes in score constituted the dependent variables. The analyses were confined to the global impairment index (K—GAS) and the two main PTSD dimensions of re-experience of traumatic events and persistent avoidance of stimuli.

GAS impairment index: change from baseline to first-year follow-up. There was no significant main effect in relation to the two main treatment groups (individual v. group therapy). When analysis of covariance was undertaken in relation to the ‘at home’ and ‘looked after’ group, the effect size picture was not supported. Of the covariates, only the baseline score of the impairment index proved significant (F=20.2; significance of <0.001).

PTSD dimensions. For the re-experience of trauma dimension when the K—GAS impairment measure (log transformed) was used as a covariate, the findings are presented in Table 4. A significantly greater effect of individual therapy emerged in relation to change scores on this PTSD dimension at the first-year follow-up stage, baseline to second-year follow-up and baseline to exit from the study. Of the covariates, only the baseline score of impairment proved significant at second-year follow-up and at exit from the study. When the impairment index, as a covariate, was replaced by the initial score of the re-experience of trauma dimension (log transformed), and focusing on change from baseline, all the significant differences were reduced: baseline to first-year follow-up proved not significant; for baseline to second-year follow-up and exit from the study the F values and significance of F were 5.1 withP<0.03 and 4.82 with P<0.032, respectively. Reexperience of trauma (log transformed) at baseline as a covariate hadF values and significance of F as 33.2 withP<0.001 and 40.6 with P<0.001, respectively. There were no significant interactions.

Table 4 Post-traumatic stress disorder: summary of analysis of covariance

	Time point	F	Significance of F	Covariate: impairment score at baseline
				F	Significance of F
Re-experience of trauma	Baseline to first-year follow-up	4.3	P < 0.05	3.1	NS
	Baseline to second-year follow-up	7.5	P < 0.01	4.15	P < 0.05
	Baseline to exit from study	7.3	P < 0.01	14.5	P < 0.001
Persistent avoidance of stimuli	Baseline to first-year follow-up	5.5	P < 0.03	4.43	P < 0.05

For the persistent avoidance of stimuli dimension, on analysis of covariance when the impairment index (log transformed) was a covariate, there was only one significant difference at the first-year follow-up (see Table 4). When the impairment index was replaced by the initial score on the persistent avoidance dimensions at baseline (log transformed), there was no significant difference.

Univariate analyses

The K-GAS impairment data were split into three levels consisting ofmajor or serious impairment (categories 2-5); moderate impairment (category 6); and, finally, some subjects with disorders or with multiple symptoms but only little impairment — that is, ‘usually functions well’ (categories 7-9) (Table 5). At first-year follow-up there was a substantial shift away from major or ‘serious’ impairment towards ‘moderate’ or ‘little’ impairment: 62% to 28%. Of the 36 participants with ‘major’ or ‘serious’ impairment at baseline, 23 moved into categories of lesser degrees of impairment. Of the 18 children with ‘moderate’ impairment at baseline, this shift is compounded by movements in both directions: three moved to more serious degrees of impairment, and 10 moved to lesser degrees of impairment. Finally, for the few children who were symptomatic but who were considered to have little impairment of functioning at baseline, there was no change. Notably, at baseline, 7% fell into the ‘little impairment’ category; at first-year follow-up; this figure was 47%. Table 6 illustrates the pattern of shift away from impairment over the course of time: ‘major’ or ‘serious’ impairment of 62% at baseline, to 27% at first-year follow-up, to 13% at second-year follow-up, to 14% at exit. In contrast, ‘little’ impairment increased from 7% at baseline to 47% at first-year follow-up, to 54% at second-year follow-up, and to 51% at exit.

Table 5 Change in impairment of overall functioning from baseline to first-year follow-up

Baseline	First-year follow-up			Total
	Major or serious impairment (K—GAS category 2-5)	Moderate impairment (K—GAS category 6)	Little impairment (K—GAS category 7-9)
Major or serious impairment (K—GAS category 2-5)	13	10	13	36 (62)
Moderate impairment (K—GAS category 6)	3	5	10	19 (31)
Little impairment (K—GAS category 7-9)	0	0	4	4 (7)
Total	16 (28)	15 (26)	27 (47)	58

Table 6 Global assessment of functioning: shift in impairment categories across time

Category group	n (%) of children in group
	Baseline	First-year follow-up	Second-year follow-up	At exit from study
A. Major impairment (K—GAS 2-4)	21 (30)	6 (10)	2 (4)	2 (3)
B. Serious impairment (K—GAS 5)	23 (32)	10 (17)	5 (9)	7 (11)
C. Moderate difficulty (K—GAS 6)	22 (31)	15 (26)	18 (33)	23 (35)
D. Limited impairment (K—GAS 7-9)	5 (7)	27 (47)	29 (54)	34 (51)
Sample size (n)	71	58	54	661

Shift of psychiatric disorders over time. The psychopathological shift could be confined to the specific presence of psychiatric disorders at baseline (time 1) and at first-year follow-up (time 2); however, this would obscure the shifts that occur in both directions, namely disorder at time 1 and no disorder at time 2; no disorder at time 1 and at time 2; and finally no disorder at time 1 and disorder at time 2 (Reference Oates, O'Toole and LynchOates et al, 1994). Table 7 shows that 26 children (45%) had a general anxiety disorder at time 1, which reduced to 10 (17%) at time 2. However, the 17% is a combination of a reduction in disorder in the children who had a disorder at baseline and new disorders in children who had no disorder at baseline.

Table 7 General anxiety disorder: psychopathological disorder shifts from baseline to first-year follow-up

Baseline	First-year follow-up
	No disorder	Disorder	Row total
No disorder	27 (84)	5 (16)	32 (55)
	(56)	(50)
Disorder	21 (81)	5 (19)	26 (45)
	(44)	(50)
Column total	48 (83)	10 (17)	58 (100)

Overall, the pattern consists of a systematic reduction in psychopathological symptoms from baseline to the first-year follow-up in all the listed disorders, with a small increase in psychopathological disorders in those who were free from such disorders at baseline. This pattern of shift is noted with all disorders and proved significant using McNemar's test (Reference McNemarMcNemar, 1949) for three of them: general anxiety (P < 0.01), depression (P < 0.001) and separation anxiety (P < 0.001). This is exemplified as follows in relation to these three disorders:

1. (a) Of the 26 participants with a general anxiety disorder at baseline, 21 no longer had this disorder at the first-year follow-up (a reduction of 81%); of the 32 without this disorder initially, five developed a disorder at the first-year follow-up (an increase of 16%) (Table 7).

2. (b) Of the 32 participants with depressive disorder at baseline, 22 were no longer depressed at the first-year follow-up (a reduction of 69%); of the 26 without this disorder, none developed a new disorder at the first-year follow-up (data not tabulated).

3. (c) Of the 36 participants with separation anxiety disorder at baseline, 18 no longer had this disorder at the first-year follow-up (a reduction of 50%); of the 22 without this disorder, two developed a disorder at the first-year follow-up — an increase of 9% (data not tabulated).

4. (d) Overall, the rates of disorder at the first-year follow-up were as follows: general anxiety 17%, depression 17%, separation anxiety 23%, conduct 13% and simple phobias 10%.

Another way of studying change in psychiatric disorder is to note any changes in the mean comorbidity score over time. At baseline the mean comorbidity score was 2.59 (s.d.=2.03, 95% CI 2.10-3.07); at the first-year follow-up the mean score was 1.19 (s.d.=1.52, 95% CI 7.1-1.62), which is a reduction of 54% (or 0.7 s.d.); at the second-year follow-up the mean score was 0.92 (s.d.=1.1, 95% CI 0.61-1.23), which is a further reduction of 10%, making a 64% reduction over the 2 years (or 0.8 s.d.). Most of the reduction occurred over the first year.

Experimental studies

The outcome study by Deblinger et al (Reference Deblinger, Lippmann and Steer1996, Reference Deblinger, Steer and Lippman1999) of cognitive—behavioural therapy gives reasonable confidence of scientific soundness. The differential effects of child or non-offending mother participation were explored in a cognitive-behavioural intervention designed to treat PTSD and other emotional difficulties in school-aged sexually abused children. Those presenting for treatment were likely to have more overt and worrying symptoms complicated by comorbidity. Children and their families were assigned to one of four experimental conditions: these were child only; mother only; mother and child; and a standard community care situation, where parents were provided with information about where to seek therapy. The three active interventions were designed to target sexually abused children's PTSD symptoms, as well other emotional problems. Twenty-five children were allocated to each of the four experimental conditions. The therapy was conducted by mental health therapists trained in cognitive—behavioural interventions. Evaluations before and after treatment included standard measures of children's behavioural problems, anxiety, depression and PTSD symptoms, as well as measures of parenting practices. Three months after the inception of specific treatment, where there was active intervention, the mothers described significantly greater decreases in their children's externalising behaviour and an improvement in their own parenting skills; their children showed significantly greater decreases in their self-reported levels of depression. Further, there was a significantly greater reduction in PTSD symptomatology for children assigned to active treatment. An important relevant implication was a need to engage non-offending mothers in the treatment of their sexually abused children. In London, this policy was standard practice and complemented both the individual and group therapy.

The follow-up suggests that the improvements following treatment were stable across the 2-year follow-up period on the measures of psychopathological disorders that had significantly decreased at the end of therapy in the original study: externalising behaviour problems, depression and PTSD symptoms (Reference Deblinger, Steer and LippmanDeblinger et al, 1999). However, questions remain about subsequent input such as booster sessions or other clinical interventions between the end of therapy and the 2-year follow-up; also, the rate of loss of data is high and a formula for correcting such substantial losses can give rise to distortions. Nevertheless, the Deblinger et al study does support the notion that ‘specific’ therapy is far more helpful than non-specific community approaches. Whereas the Deblinger et al study demonstrates that active therapy is more helpful than ‘inactive’ approaches, the London study demonstrates a few significant between-group differences when comparing two active therapies. Thus, the Deblinger et al study and the London study provide evidence that demonstrable improvement with active therapy does not reduce over time. Further, Jones & Ramchandani (Reference Jones and Ramchandani1999) made a contribution to this debate when reviewing psychological treatments: they indicate that, despite the view that any improvement noted may have been due to the passage of time, the results of some studies strongly suggest a treatment effect (Reference Cohen and MannarinoCohen & Mannarino, 1996; Reference Deblinger, Lippmann and SteerDeblinger et al, 1996).

Short-term therapy and long-term outcome

A crucial implication for outcome studies is that short-term therapy has to be viewed against both medium-term and longer-term outcome to ascertain whether treatment effects are maintained and whether new psychopathological problems emerge, balanced against selectivity in recruitment of the treatment sample (Kolvin et al, Reference Kolvin, Garside and Nicol1981, Reference Kolvin, Macmillan and Nicol1988). For example, the London cohort contained more seriously abused and seriously disturbed children with chronic disorders than are found in many other studies. Over 30% had been exposed to multiple perpetrators, compared with 7% in the study by Deblingeret al (Reference Deblinger, Lippmann and Steer1996). The Deblinger et al referral and inclusion criteria related to PTSD; not surprisingly, therefore, the psychiatric psychopathology at baseline was moderate. As the London inclusion criteria were that the child should be symptomatic, there were high rates of DSM-IV psychiatric disorders (Reference Trowell, Ugarte and KolvinTrowell et al, 1999); additionally, there is evidence of serious family dysfunction (further details available from the author upon request). These issues are discussed by Tebbutt et al (Reference Tebbutt, Swanston and Oates1997), who pointed out that most prospective outcome studies did not extend their second follow-up period beyond 18 months; furthermore, when there is a follow-up assessment (beyond 18 months) the attrition rates are usually high — for example 46% (Reference ConteConte, 1987) — and only occasionally low — for example 20% (Reference Oates, O'Toole and LynchOates et al, 1994), 19% (Reference Tebbutt, Swanston and OatesTebbutt et al, 1997); and in the current London study the rates were about 20% at first follow-up and under 10% at exit from the study. Such factors may compromise the generalisability of the findings.

Removal of children from home

Current practice is to remove children from an ‘unsafe’ abusive environment. The London research shows only a few outcome differences between children remaining in a prescribed ‘safe’ home environment and those removed that are in favour of the child remaining at home. Clinical practice indicates that there are both positive and negative effects of relocating some children. When such decisions are made, it is important that due weight is given to the disruptive effect of removal. What is remarkable in the London study is the equivalent outcome for children removed from home — they had been abused for longer, at a younger age of onset and by more abusers (further details available from the author upon request). It is impossible to predict what the outcome for them would have been if they had remained in the home situations in which abuse had occurred and where they would most probably have been vulnerable to some form of further abuse.

Severity of impairment of global functioning and psychiatric disorder

Irrespective of treatment, there was a substantial and systematic reduction in both levels of impairment and extent of psychiatric disorder over the 2 years of the study. However, although there was a major reduction in impairment by the first-year follow-up, only about half of the children studied had moved into the category of ‘limited’ impairment or ‘generally functioning pretty well’. The same was true for the psychiatric disorders: for instance, at the first-year follow-up, depression was substantially reduced, and by the second-year follow-up (although some children still had some depressive symptoms) none was considered to have a disorder. With general anxiety disorder there was a major reduction of disorder in participants who had presented with a disorder at the baseline assessment, but a minor movement towards the disorder in children who had showed little or no evidence of general anxiety disorder at baseline. This phenomenon of psychopathological shifts in two directions in children who have been seriously sexually abused has only recently been studied and reported (Reference Oates, O'Toole and LynchOates et al, 1994; Reference Tebbutt, Swanston and OatesTebbutt et al, 1997; and the current study), and can easily be missed if the focus is to explore remission in only those subjects who present with a specific disorder at an earlier point.

Overall, the rates of major depressive disorder, general anxiety disorder and separation anxiety disorder at first-year and second-year follow-up were dramatically reduced. The pattern for PTSD was complicated (as reported above): there was a highly significant reduction in mean scores on the main dimensions by the first-year follow-up and this picture was confirmed at the second-year follow-up. It is evident that most of the change had occurred by the first-year follow-up.

There were few significant differences between the two forms of treatment and this may be attributed to the shared qualities of the interventions: sensitivity, understanding and concern, plus abuse-specific therapy (Reference Jones and RamchandaniJones & Ramchandani, 1999).

Dissociation

The findings showed that a small number of girls experienced an increase in symptomatology and impairment over the treatment period. This may be linked to the phenomenon of dissociation when individuals appear to be cut off from their traumatic experiences and where therapy allows them to process previous events. Short-term therapy may open up these experiences but be insufficient, and therapy of longer duration may be required.

What is known about spontaneous improvement?

Kendall-Tackett et al (Reference Kendall-Tackett, Williams and Finkelhor1993), in their community-based study, reported that about a third of sexually abused children failed to exhibit overt psychological symptoms, or their symptoms might have already resolved by the time of initial assessment. About 55% of such children show substantial recovery from psychological symptoms over the subsequent 18 months, but 10-24% appear to become worse (Reference Kendall-Tackett, Williams and FinkelhorKendall-Tackett et al, 1993). Until recently, little information has been available about spontaneous remission in subjects in whom the psychopathology is more complex or severe, as in the current study where children are referred for treatment.

Untreated control group

There is no rigorous study of the efficacy of psychotherapy in sexually abused girls; ideally, such a study would have a randomised design including an untreated control group, with all participants of school age, a sample size per group of 25 or more, with the therapy specified, and of appropriate duration with the subjects monitored for a year from intake into treatment, and the research would be published in a peer-reviewed journal (Reference Finkelhor and BerlinerFinkelhor & Berliner, 1995; Reference StevensonStevenson, 1999). One of the reasons for the absence of such a study is that ethical considerations preclude the withholding of treatment from abused children for such a long time (Reference Trowell, Berelowitz, Kolvin, Aveline and ShapiroTrowellet al, 1995). In drawing conclusions about ‘spontaneous’ improvement, reviewers need to consider (a) the severity of the abuse experiences, (b) the nature and complexity of associated family dysfunction, (c) the length of time since the last abuse episode, (d) whether the children were adequately protected after disclosure, and (e) the severity of psychopathological disorder at intake. Without such information it is difficult to draw general inferences that may aid clinicians.

Clinicians will be most interested in the evidence from the current study of the magnitude of changes in psychopathological disorders and impairment over time irrespective of the type of treatment given, but would appreciate explanations for these changes or even theoretical speculations. For example, Tebbutt et al (Reference Tebbutt, Swanston and Oates1997) asserted that their study sample consisted of more severely abused children than those of a similar age reported by Gomes-Schwartz et al (Reference Gomes-Schwartz, Horowitz, Cardarelli, Gomes-Schwartz, Horowitz and Cardarelli1990). It is argued that this is true, too, of the study reported here. This gives rise to an enigma: on the one hand, a high proportion of children in the London sample had severe and chronic disorders; according to Oates et al (Reference Oates, O'Toole and Lynch1994) and Tebbutt et al (Reference Tebbutt, Swanston and Oates1997) such subjects do not improve over time, irrespective of treatment; furthermore, other research indicates that such disorders in sexually abused children do not improve unless treated (Reference Deblinger, Steer and LippmanDeblinger et al, 1999). On the other hand, statistical experts, when viewing the London findings of changes over time irrespective of treatment, which are of considerable magnitude, are likely to see them either as representing spontaneous improvement or as regression to the mean. However, this sample with its high levels of acute and chronic psychopathologies contains the very set of psychological problems that the two therapies have targeted, so clinicians deduce that therapy has contributed to the rapid decline of psychopathology. Without a control group, neither a statistical nor a clinical hypothesis can be fully or partially supported or rejected. On balance, none of the above explanations is fully convincing and this phenomenon of change merits further research.

Engagement and participation

The finding of Deblinger et al (Reference Deblinger, Lippmann and Steer1996) was that there was a need to engage non-offending mothers in the treatment of sexually abused children. Given the high levels of psychopathological problems in the children in the present study, and of parental and family dysfunction in the birth families (Reference Rushton and MilesRushton & Miles, 2000; further details available from the author upon request), there was surprisingly good engagement with the children and their carers, and comparatively low rates of drop-out. The majority of parents in the study were satisfied with the support they received, which probably was crucial in both the engagement and the maintenance of treatment. However, follow-up assessments proved more problematic.

Is major depression in sexually abused girls an intransigent disorder?

There is evidence that childhood major depressive disorder is not a transitory condition; it is a high-risk factor in parasuicide and may persist into adulthood (Reference KovacsKovacs, 1997). Other work emphasises this theme in relation to sexually abused children (Reference Tebbutt, Swanston and OatesTebbutt et al, 1997). Two studies have found no change in symptoms of depressive disorders over time even with treatment (Reference Oates, O'Toole and LynchOates et al, 1994; Reference Tebbutt, Swanston and OatesTebbutt et al, 1997). In contrast, in the London study, irrespective of the specific treatment given, there is evidence of substantial reduction in rates of major depressive disorder, at the second-year follow-up. This suggests that, under certain conditions, major depression in sexually abused girls is not intransigent, despite the severity and chronicity of the psychopathological problems in the London sample. These are matters of clinical importance and merit further research.

Are PTSD symptoms transient phenomena?

A crucial issue concerns the extensive presence of PTSD in various studies of psychological trauma. In adult subjects with exposure to psychological trauma (such as war trauma in veterans who sought psychiatric treatment 4-6 years afterwards), extensive PTSD comorbidity was diagnosed (Reference Bleitch, Koslowsky and DolevBleitch et al, 1997). Both lifetime (100%) and current (87%) PTSD was diagnosed, with major depressive disorder being the most prevalent comorbid diagnosis (95% lifetime, 50% current). This pattern does not differ greatly from that reported in childhood sexual abuse: PTSD is known to show a tendency to continuity across time, is often resistant to treatment, and has an impact on behaviour and social development; thus, children who develop PTSD may be at considerable risk for more prolonged dysfunction (Reference McLeer, Callaghan and HenryMcLeer et al, 1994). Of clinical importance is the response in favour of individual psychotherapy on one of the PTSD dimensions.

Design

The design consisted of a comparison of two active treatment groups. Two ethical committees declined the use of a no treatment or minimal treatment control group. However, some authorities may express uncertainty about whether any intervention works (Reference StevensonStevenson, 1999), and further argue that it is mandatory for all trials of psychotherapy in sexually abused subjects with psychiatric problems to include an untreated control group. This is a theoretical view, but the study by Deblinger et al (Reference Deblinger, Steer and Lippman1999) has demonstrated that a control group is not always a feasible option, and also has provided some convincing evidence that specialised psychotherapy has much to commend it. This remains a contentious matter.

Sample size

The treatment groups were small, which resulted in reduced power in statistical analysis. The original intention was to recruit 90 subjects to therapy; however, eventually 81 children were assessed and, of these, 71 entered therapy. Although most participants had a sufficiency of therapy, engaging them in follow-up did not prove easy and eventually only 58 children were assessed at the first-year follow-up. Thus, whereas on some measures (with the exception of PTSD dimensions), the two therapies appear equally effective, the low sample size has the drawback that absence of a statistical difference does not mean that such a difference does not exist, because a larger sample might well give rise to one.

Attrition

The attrition level was higher than hoped (18% by the end of the first year; 24% by the end of the second year); nevertheless, members of the research team were in contact with 66 participants (93%) at either the first-year or the second-year follow-up.

Masking

The therapies were so different that masking of subjects was impossible (Reference Day and AltmanDay & Altman, 2000). Masking of assessors was likely to be compromised because the children and their mothers often mentioned the specific therapy during assessment. This was accepted as an unavoidable limitation for the interview data (but not for the self-report inventories).

Level of dysfunction

This was a cohort with a high level of psychological disturbance and family dysfunction, and so the results can be generalised only to patients attending similar specialist child and family mental health clinics.