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A Multisite, Randomized Controlled Trial for Children With Sexual Abuse–Related PTSD Symptoms
Open accessAbstract
Objective To examine the differential efficacy of trauma-focused cognitive-behavioral therapy (TF-CBT) and child-centered therapy for treating posttraumatic stress disorder (PTSD) and related emotional and behavioral problems in children who have suffered sexual abuse.Method Two hundred twenty-nine 8- to 14-year-old children and their primary caretakers were randomly assigned to the above alternative treatments. These children had significant symptoms of PTSD, with 89% meeting full DSM-IV PTSD diagnostic criteria. More than 90% of these children had experienced traumatic events in addition to sexual abuse.Results A series analyses of covariance indicated that children assigned to TF-CBT, compared to those assigned to child-centered therapy, demonstrated significantly more improvement with regard to PTSD, depression, behavior problems, shame, and abuse-related attributions. Similarly, parents assigned to TF-CBT showed greater improvement with respect to their own self-reported levels of depression, abuse-specific distress, support of the child, and effective parenting practices.Conclusions This study adds to the growing evidence supporting the efficacy of TF-CBT with children suffering PTSD as a result of sexual abuse and suggests the efficacy of this treatment for children who have experienced multiple traumas.
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“In particular, cognitive behavioral therapy (CBT) including trauma exposure techniques has proven to be effective for child victims of sexual abuse [8-10] and other forms of violence [11,12].”
From Treating children traumatized by war and tsunami: a comparison between exposure therapy and meditation-relaxation in north-east Sri Lanka (2009) · cites this paper as [8]
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Equine Facilitated Therapy for Complex Trauma (EFT-CT)
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Salloum, A., Robst, J., Scheeringa, M. S., Cohen, J. A., Wang, W., Murphy, T. K., Tolin, D. F., & Storch, E. A. (2013) · Child Psychiatry & Human Development · doi:10.1007/s10578-013-0378-6 · Cited by 41
Self-citationTrauma-focused CBT with maltreated children: A clinic-based evaluation of a new treatment manual
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“Parents’ reactions and functioning are intertwined with child functioning and reactions (Lynskey & Fergusson, 1997), and parental distress has been demonstrated to correlate with better child outcomes (Cohen et al., 2004).”
BackgroundSelf-citationTrauma-Focused Cognitive Behavioral Therapy
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“34 Specifically, trauma-focused cognitive behavioral therapy 35 is commonly used to address issues related to childhood sexual and physical abuse and also targets enhancing self-esteem, which may indirectly reduce high-risk behaviors, such as substance misuse and risky sexual behaviors.”
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“with Cohen et al. (2000) who also failed to find differences in effects for various components of CBTs for traumatized children and youth.”
BackgroundMethodInfluentialIntergenerational Child Abuse and Coping
Robboy, J., & Anderson, K. G. (2011) · Journal of Interpersonal Violence · doi:10.1177/0886260511403758 · Cited by 38
“Most early interventions for sexually abused children involve the nonoffending parent(s) in some capacity (e.g., Cohen et al., 2004; Deblinger, Steer, & Lippman, 1999; Neubauer et al., 2007; van Fleet, Ryan, & Smith, 2005).”
BackgroundEmpirically Supported Treatments, Evidence‐Based Treatments, and Evidence‐Based Practice
Duncan, B. L., & Reese, R. J. (2012) · Wiley eBooks · doi:10.1002/9781118133880.hop208021 · Cited by 37
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“Given the evidence that youth who experience one type of maltreatment very frequently experience another type of maltreatment (e.g., Cohen et al. 2004; Finkelhor et al. 2007; Hamby et al. 2010), the dearth of research examining cumulative types of maltreatment as a predictor of youth mental health…”
Background“Systemic Trauma”: The Impact on Parents Whose Children Have Experienced Sexual Abuse
Kilroy, S., Egan, J., Maliszewska, A., & Sarma, K. M. (2014) · Journal of Child Sexual Abuse · doi:10.1080/10538712.2014.920458 · Cited by 39
“In terms of knowledge about efficacious treatment modalities, trauma focused cognitive-behavioral therapy (TF-CBT) was developed by Cohen and colleagues (Cohen & Mannarino, 2000; Cohen et al., 2004) for children who have experienced trauma, including sexual abuse, and has generally been adapted for parents of these ch…”
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“The authors emphasized that the studies of children with PTSD symptoms (and without asymptomatic children) showed a positive outcome on this measure (Cohen et al. 2004; Deblinger, Steer, and Lippman 1999; King et al. 2000).”
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“Other trauma treatments that have also been successful with children and youth who have experienced trauma in the child welfare system by strengthening skills of adoptive parents to help children deal with past trauma, loss and grief, including: Briere’s Integrated Treatment of Complex Trauma for Children and Adolesce…”
BackgroundKane, J. C., Murray, L. K., Cohen, J. A., Dorsey, S., Skavenski, S. V. W., Henderson, J. G., Imasiku, M. L., Mayeya, J., & Bolton, P. A. (2016) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12623 · Cited by 36
“A master list of randomization assignments for each ID number was generated a priori by a U.S.-based statistician.”
InfluentialSelf-citationTreatments for Early Childhood Trauma: Decision Considerations for Clinicians
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“…violence, traumatic loss, motor vehicle accidents) or who have unique trauma histories may experience reductions in their own posttraumatic stress symptoms, emotional distress, and depression by participating in TF-CBT with their children (Cohen et al. 2004a, b, 2006; Deblinger et al. 2006).”
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Tichelaar, H., Deković, M., & Endendijk, J. (2020) · Children and youth services review · doi:10.1016/j.childyouth.2020.105519 · Cited by 28
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“…the robustness of TF-CBT in decreasing symptoms when compared to other treatment approaches including non-directive supportive therapy (Cohen & Mannarino, 1996); supportive group therapy (Deblinger, Stauffer, & Steer, 2001); and child-centered therapy (Cohen et al., 2004; Cohen & Mannarino, 1997).”
MethodPsychological Interventions for Pediatric Posttraumatic Stress Disorder
Hoppen, T. H., Wessarges, L., Jehn, M., Mutz, J., Kip, A., Schlechter, P., Meiser‐Stedman, R., & Nexhmedin Morina, B. (2024) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2024.3908 · Cited by 37
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“You can do it!”: The role of parental encouragement of bravery in child anxiety treatment
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“Cohen et al. (2004) found that although CBT was more effective than CCT in the treatment of children with PTSD, CCT was also associated with a significant decrease in PTSD symptoms at post-treatment.”
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“TF-CBT has been demonstrated to effectively improve various behavioral and emotional problems associated with CSA, including anxiety; trauma sympomatology, such as dissociation, hypervigilance, nightmares, intrusive thoughts, and flashbacks; and depression ( Cohen, Deblinger, Mannarino, & Steer, 2004 ; Cohen & Mannari…”
Skar, A. S., Braathu, N., Jensen, T. K., & Ormhaug, S. M. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08497-y · Cited by 34
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Impact Evaluation of a Cognitive Behavioral Group Therapy Model in Brazilian Sexually Abused Girls
Habigzang, L. F., Damásio, B. F., & Koller, S. H. (2013) · Journal of Child Sexual Abuse · doi:10.1080/10538712.2013.737445 · Cited by 31
“The reduction of PTSD symptoms found in this work resonates with other studies pointing to the efficiency of CBT in improving this condition (Cohen et al., 2001; Cohen et al., 2004).”
ResultHardner, K. L., Wolf, M. R., & Rinfrette, E. S. (2017) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2017.10.007 · Cited by 31
Trauma-Focused Cognitive Behavior Therapy for School Psychologists
Fitzgerald, M. M., & Cohen, J. A. (2012) · Journal of Applied School Psychology · doi:10.1080/15377903.2012.696037 · Cited by 32
“Effectively treating children's trauma-related problems alleviates suffering for impacted children and families, and significantly improves child behavior problems and academic performance in affected children (Cohen, Mannarino, & Knudsen, 2004 ; Stein et al, 2003 ).”
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Evidence Based Intervention: Trauma-Focused Cognitive Behavioral Therapy for Children and Families
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Self-citationTrauma Focused Cognitive Behavioral Therapy with Children of Incarcerated Parents
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“The core components of TF-CBT are psychoeducation about the child’s identified trauma and PTSD symptoms; affective modulation skills; individualized stressmanagement skills; an introduction to the cognitive triad (relationships between thoughts, feeling and behaviors); creating a trauma narrative (a gradual exposure i…”
Interventions that address institutional child maltreatment: An evidence and gap map
Finch, M., Featherston, R., Chakraborty, S., Bjørndal, L. D., Mildon, R. L., Albers, B., Fiennes, C., Taylor, D., Schachtman, R., Yang, T., et al. (2021) · Campbell Systematic Reviews · doi:10.1002/cl2.1139 · Cited by 32
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“All but one [33] of these RCTs were used as an evidential basis in the Clinical Practice Guideline for Management of PTSD in Adults and Children [20].”
BackgroundMethodInfluentialSilk, J. S., Sequeira, S. L., Jones, N. P., Lee, K. H., Dahl, R. E., Forbes, E. E., Ryan, N. D., & Ladouceur, C. D. (2022) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2021.2019048 · Cited by 30
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Paul, L., Gray, M. J., Elhai, J., Massad, P., & Stamm, B. (2006) · Trauma, Violence, & Abuse · doi:10.1177/1524838006292521 · Cited by 32
“TFCBT also benefits parents of traumatized children as it has been shown to improve parentalreported levels of self-depression, abuse-specific distress, support of the traumatized child, and effective parental practices (Cohen et al., 2004).”
BackgroundAn algorithm for determining use of trauma-focused cognitive–behavioral therapy.
Lang, J. M., Ford, J. D., & Fitzgerald, M. M. (2010) · Psychotherapy · doi:10.1037/a0021184 · Cited by 29
Child-Centered Play Therapy for Youths Who Have Experienced Trauma: a Systematic Literature Review
Humble, J. J., Summers, N. L., Villarreal, V., Styck, K. M., Sullivan, J. R., Hechler, J. M., & Warren, B. S. (2018) · Journal of Child & Adolescent Trauma · doi:10.1007/s40653-018-0235-7 · Cited by 29
“Individuals in these types of therapies may not spontaneously mention or address their traumatic experience (Cohen et al. 2004).”
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“Multiple randomized controlled trials (RCT) demonstrate that TF-CBT yields greater improvement than rapport-focused treatment for PTSD and a variety of other concerns (Cary & McMillen, 2012; Cohen et al., 2004, 2011).”
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“Finally, Trauma-focused Cognitive Behavioral Therapy (TF-CBT) has been found effective in simultaneously addressing PTSD, depression, and behavior problems in children and adolescents with a history of sexual abuse ( Cohen, Deblinger, Mannarino, & Steer, 2004 ; Deblinger, Lippmann, & Steer, 1996 ).”
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Self-citationClinical Considerations for the Treatment of Latency Age Children in Residential Care
Knoverek, A. M., Briggs, E. C., Underwood, L. A., & Hartman, R. L. (2013) · Journal of Family Violence · doi:10.1007/s10896-013-9536-7 · Cited by 33
“In a study of 229 children ages 8–14 who had PTSD resulting from abuse, results indicated that children who received TF-CBT compared to childcentered therapy demonstrated greater improvement in behavior problems as well as symptoms of depression and PTSD (Cohen et al. 2004).”
ResultAn Integrated Approach to Treating Non-Offending Parents Affected by Sexual Abuse
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“Cohen et al. (2004) showed in another study that interventions helping parents resolve emotional distress optimized the parent’s ability to be supportive of the child, and were likely to improve the child’s outcome.”
Trauma-Focused Treatment in a State System of Care: Is It Worth the Cost?
Greer, D., Grasso, D. J., Cohen, A., & Webb, C. P. M. (2013) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-013-0468-6 · Cited by 28
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Evidence-Based Psychosocial Treatments in the Juvenile Justice System
Sukhodolsky, D. G., & Ruchkin, V. V. (2006) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2005.11.005 · Cited by 27
“Several controlled studies evaluated psychosocial interventions for PTSD in children and adolescents from the general population [99–101].”
BackgroundSantiago, C. D., Kataoka, S., Hu-Cordova, M., Alvarado-Goldberg, K., Maher, L., & Escudero, P. (2013) · Journal of Emotional and Behavioral Disorders · doi:10.1177/1063426613503497 · Cited by 27
“For example, Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), a highly effective trauma intervention, includes parent management skills, in addition to teaching parents communication skills to enhance trauma-related discussions between parents and children (Cohen et al., 2004).”
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Rossouw, J., Yadin, E., Alexander, D., Mbanga, I., Jacobs, T., & Seedat, S. (2016) · Trials · doi:10.1186/s13063-016-1677-6 · Cited by 26
“Variants of SC are widely used in rape crisis centres and other community settings to treat sexually abused children [25].”
BackgroundWorking with the Multidisciplinary Team
MacLeod, K. J. (2015) · Springer eBooks · doi:10.1007/978-3-319-21097-1_3 · Cited by 26
Stepped and Standard Care for Childhood Trauma
Salloum, A., Small, B. J., Robst, J. M., Scheeringa, M. S., Cohen, J. A., & Storch, E. A. (2015) · Research on Social Work Practice · doi:10.1177/1049731515601898 · Cited by 26
“Based on CBT for childhood trauma (Cohen et al., 2004; Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011), the use of minimal therapist assistance (Salloum, 2010), telehealth, bibliotherapy (Lyneham & Rapee, 2006), computer-assisted treatments (Khanna & Kendall, 2008), and a stepped care…”
BackgroundMethodInfluentialSelf-citationScheeringa, M. S. (2019) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000000639 · Cited by 29
“The most commonly used criterion that has been used to enroll youths in RCTs for tests of EBTs has been the presence of 5 or more PTSD symptoms.(12) At the time that this study was conducted, the DSMIV(8) was the current taxonomy.”
Martin, C. G., Everett, Y., Skowron, E. A., & Zalewski, M. (2019) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-019-00290-4 · Cited by 26
“For the two childhood traumatic grief pilot studies, the 16-session version yielded significant improvement for caregiver depression and PTSD symptoms (Cohen et al. 2004), while the modified 12-session version produced significant improvement for caregiver PTSD only (d = − .”
BackgroundPiotrowski, C. C. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-816065-7.00015-x · Cited by 26
Thomas, F. C., Puente-Durán, S., Mutschler, C., & Monson, C. M. (2020) · Child and Adolescent Mental Health · doi:10.1111/camh.12435 · Cited by 32
PTSD symptom cluster profiles of youth who have experienced sexual or physical abuse
Runyon, M. K., Deblinger, E., & Steer, R. A. (2013) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2013.08.015 · Cited by 26
Self-citationPost-Traumatic Stress Disorder and Quality of Life in Sexually Abused Australian Children
Gospodarevskaya, E. (2013) · Journal of Child Sexual Abuse · doi:10.1080/10538712.2013.743953 · Cited by 26
Schudlich, T. D. R., Youngstrom, E. A., Martínez, M., KogosYoungstrom, J., Scovil, K., Ross, J. M., Feeny, N. C., & Findling, R. L. (2014) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-014-9924-3 · Cited by 26
“Trauma-Focused Cognitive Behavioral Therapy (Cohen et al. 2004), which is designed to decrease interpersonal stress associated with abuse and to improve family functioning, may be warranted.”
Testing the Community-Based Learning Collaborative (CBLC) implementation model: a study protocol
Hanson, R. F., Schoenwald, S. K., Saunders, B. E., Chapman, J. E., Palinkas, L. A., Moreland, A. D., & Dopp, A. R. (2016) · International Journal of Mental Health Systems · doi:10.1186/s13033-016-0084-4 · Cited by 26
Allen, B. (2017) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.07.001 · Cited by 26
Understanding and Treating Children Who Experience Interpersonal Maltreatment: Empirical Findings
Lawson, D. M. (2009) · Journal of Counseling & Development · doi:10.1002/j.1556-6678.2009.tb00569.x · Cited by 25
Evidence-Base Update of Psychosocial and Combination Treatments for Child and Adolescent Depression
Weersing, V. R., Goger, P., Schwartz, K. T. G., Baca, S. A., Angulo, F., & Kado-Walton, M. (2024) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2024.2384022 · Cited by 24
Münzer, A., Fegert, J. M., & Goldbeck, L. (2016) · Journal of Child Sexual Abuse · doi:10.1080/10538712.2016.1137667 · Cited by 25
Trauma-focused cognitive behavioural therapy for young children: clinical considerations
Pollio, E., & Deblinger, E. (2017) · European Journal of Psychotraumatology · doi:10.1080/20008198.2018.1433929 · Cited by 25
Self-citationTrauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Separation
Cohen, J. A., & Mannarino, A. P. (2019) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2019.03.006 · Cited by 29
Self-citationRobin, M., Douniol, M., Pham‐Scottez, A., Gicquel, L., Delvenne, V., Nezelof, S., Speranza, M., Falissard, B., Silva, J., & Corcos, M. (2021) · Journal of Personality Disorders · doi:10.1521/pedi_2021_35_523 · Cited by 26
Springer, C. I., & Misurell, J. R. (2010) · Journal of Child & Adolescent Trauma · doi:10.1080/19361521.2010.491506 · Cited by 29
Interventions Targeting Exposure to Community Violence Sequelae Among Youth: A Commentary
Voisin, D., & Berringer, K. R. (2015) · Clinical Social Work Journal · doi:10.1007/s10615-014-0506-1 · Cited by 29
Rosenberg, H. J., Jankowski, M. K., Fortuna, L. R., Rosenberg, S. D., & Mueser, K. T. (2010) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/a0019889 · Cited by 25
Rudd, B. N., Last, B. S., Gregor, C., Jackson, K., Berkowitz, S., Zinny, A., Kratz, H. E., Cliggitt, L., Adams, D. R., Walsh, L. M., et al. (2019) · American Journal of Community Psychology · doi:10.1002/ajcp.12370 · Cited by 24
Dauber, S. E., Lotsos, K., & Pulido, M. L. (2015) · Child and Adolescent Social Work Journal · doi:10.1007/s10560-015-0393-5 · Cited by 24
“In interpreting the findings, it is important to note that the average number of sessions attended in the current study (39 sessions) is much higher than in most trauma treatment studies, which generally report average number of sessions attended in the 12–16 range (Cohen et al. 2004a, 2005).”
BackgroundResultReview of Evidence-Based Psychotherapies for Pediatric Mood and Anxiety Disorders
Verdeli, H., Mufson, L. H., Lee, L., & Keith, J. A. (2006) · Current Psychiatry Reviews · doi:10.2174/157340006778018102 · Cited by 25
“Three of the above trials, 2 individual [75, 76] and 1 group one [77] were based on Deblinger’s treatment manual.”
BackgroundMethodInfluentialTrauma Intervention in Sub-Saharan African Children: A Systematic Literature Review
Katsonga-Phiri, T., Grant, K. E., & Brown, M. M. (2017) · Trauma Violence & Abuse · doi:10.1177/1524838017717747 · Cited by 24
Márquez, Y. I., Deblinger, E., & Dovi, A. T. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2019.10.001 · Cited by 24
Self-citationChildhood Sexual Abuse and Sexual Motivations – The Role of Dissociation
Gewirtz‐Meydan, A., & Lahav, Y. (2020) · The Journal of Sex Research · doi:10.1080/00224499.2020.1808564 · Cited by 24
“Studies have found significant short- and longterm effects of CSA, including post-traumatic stress disorder (Cohen et al., 2004; Widom, 1999); psychiatric disorders, such as depression, anxiety, suicide and substance abuse (Fergusson et al., 1996; Kendler et al., 2000; Putnam, 2003);…”
BackgroundYancey, C. T., Naufel, K. Z., & Hansen, D. J. (2012) · Journal of Family Violence · doi:10.1007/s10896-012-9485-6 · Cited by 24
“However, existing therapeutic interventions can ameliorate symptoms by focusing on those factors that are amenable to change (Bagley and LaChance 2000; Cohen et al. 2004; Grosz et al. 2000).”
Evidence Based Trauma Treatment for Children and Youth
Racco, A., & Vis, J. (2014) · Child and Adolescent Social Work Journal · doi:10.1007/s10560-014-0347-3 · Cited by 36
Fleming, J. (2012) · Journal of EMDR Practice and Research · doi:10.1891/1933-3196.6.1.16 · Cited by 24
Cognitive-Behavioural Interventions for Children Who Have Been Sexually Abused: A Systematic Review
Macdonald, G. M., Higgins, J. P. T., Ramchandani, P. G., Valentine, J. C., Bronger, L. P., Klein, P., O'Daniel, R., Pickering, M., Rademaker, B., Richardson, G. B., et al. (2012) · Campbell Systematic Reviews · doi:10.4073/csr.2012.14 · Cited by 27
Metadata
- Authors
- Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A.
- Affiliations
- Allegheny General Hospital (US)
- Corresponding author
- Cohen, Judith A.
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2004-04
- Volume
- 43
- Issue
- 4
- Pages
- 393-402
- ISSN
- 0890-8567 (ISSN-L)
- PMC
- PMC1201422
- OpenAlex
- W1987755633
- Semantic Scholar
- e7e2575d79a4663a3567a3968e82ee3b300677a3
- Cited by
- 1,123
- References
- 32
- Citations by year
- 2026: 14 · 2025: 17 · 2024: 26 · 2023: 24 · 2022: 40 · 2021: 47 · 2020: 65 · 2019: 53 · 2018: 55 · 2017: 42 · 2016: 108 · 2015: 90 · 2014: 63 · 2013: 77 · 2012: 66
- FWCI
- 42.39
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- NIMH (R10 MH55963, R10 MH56224)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Child Therapy and Development
- Keywords
- post-traumatic stress disorder, child sexual abuse, trauma-focused cognitive behavioral therapy, child-centered therapy, depression, behavioral problems, shame, parental depression, parenting practices, polytrauma, children
- MeSH terms
- Adolescent, Analysis of Variance, Child, Child Abuse, Sexual, Female, Humans, Male, Stress Disorders, Post-Traumatic, Cognitive Behavioral Therapy
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