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Journal of Child Sexual Abuse, 20:1436, 2011 Copyright Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679

9 online DOI: 10.1080/10538712.2011.540000

Game-Based Cognitive-Behavioral Therapy (GB-CBT) Group Program for Children Who Have Experienced Sexual Abuse: A Preliminary Investigation
JUSTIN R. MISURELL
Fordham University, New York, New York, USA

CRAIG SPRINGER
Newark Beth Israel Medical Center, Newark, New Jersey, USA

WARREN W. TRYON
Fordham University, New York, New York, USA

This preliminary investigation examined the efcacy of a game-based cognitive-behavioral therapy group program for elementary school-aged children who have experienced sexual abuse. Treatment aimed to improve: (a) internalizing symptoms, (b) externalizing behaviors, (c) sexually inappropriate behaviors, (d) social skills decits, (e) self-esteem problems, and (f) knowledge of healthy sexuality and self-protection skills. Results indicate that game-based cognitive-behavioral therapy was effective for improving internalizing and externalizing symptoms, reducing sexually inappropriate behaviors, and improving childrens knowledge of abuse and self-protection skills. Although results pointed in a positive direction for social skills and self-perception, these ndings were not statistically signicant. Clinical signicance was also evaluated to assess the clinical utility of treatment effects. Treatment implications of the ndings and future research directions are discussed.
Submitted 26 February 2010; revised 4 June 2010; accepted 4 June 2010. This study was conducted by the rst author under the guidance of the second and third authors and submitted to the Graduate School of Arts and Sciences of Fordham University in partial fulllment of requirements for the degree doctor of philosophy. Address correspondence to Craig Springer, Metropolitan Regional Diagnostic and Treatment Center, Newark Beth Israel Medical Center, Wynonas House Child Advocacy Center, 185 Washington Street, Newark, NJ 07102. E-mail: cspringer@sbhcs.com. 14

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KEYWORDS child sexual abuse, cognitive-behavioral therapy, group therapy, developmentally appropriate games Child sexual abuse (CSA) is a pervasive societal problem (Newcomb, Munoz, & Carmona, 2009; U.S. Department of Health and Human Services, 2007). One in four females and one in seven males are estimated to experience an act of sexual abuse prior to the age of 18 (Cohen, Mannarino, & Deblinger, 2006; Putnam, 2003). Victims of CSA have been found to experience a host of psychological, behavioral, and emotional problems (King et al., 2003; Putnam, 2003). However, there does not seem to be a typical symptom prole following abuse, and instead symptoms can vary widely between victims (Kendall-Tackett, Williams & Finkelhor, 1993). CSA victims have been found to experience various combinations of internalizing symptoms, externalizing behavioral problems, sexually inappropriate behaviors, and social skill decits. Common internalizing symptoms resemble those associated with post-traumatic stress disorder, including elevated anxiety, depressive symptomatology, nightmares/sleep difculties, social withdrawal, experiential avoidance, hypervigilance to various stimuli, somatic complaints, and feelings of shame and guilt (King et al., 1999, 2003; Maikovich, Koenen & Jaffee, 2009; Nurcombe, Wooding, Marrington, Bickman, & Roberts, 2000). Externalizing problems include aggression, anger, conduct problems, oppositional deance, and school problems (Kendall-Tackett, et al., 1993; Pereda, Guilera, Forns, & GomezBenito, 2009a, 2009b). Adolescents with a CSA history have been found to experience higher rates of drug and alcohol abuse, running away from home, bulimia (Hibbard, Ingersoll, & Orr, 1990), teen pregnancy, and social dysfunction (Berliner & Elliott, 1996; Finkelhor, 1990). Sexually inappropriate behaviors, which include boundary problems, exhibitionism, gender role confusion, excessive self-stimulation, heightened sexual anxiety, increased sexual interest, sexual intrusiveness, age-inappropriate sexual knowledge, and voyeuristic behaviors, often occur and are a unique characteristic of CSA (Baker, Schneiderman, & Parker, 2001; Friedrich, 1997; Friedrich et al., 1992). Children who have experienced sexual abuse have also exhibited decreased social competencies and increased rates of social withdrawal compared to their nonabused peers (Friedrich, Beilke, & Urquiza, 1987). Some children have been found to perceive themselves, their competencies, and their level of social acceptance as poorer following abuse (Berliner & Elliott, 1996). Preliminary research investigating reasons for self-perception difculties among CSA victims nd that they tend to have higher levels of self-blame and misattributions of negative life events than nonabused children (Mannarino, Cohen, & Berman, 1994). Over the years, a number of individual, group, and family interventions utilizing various theoretical orientations (cognitive-behavioral, psychodynamic, client-centered, and play therapy) have been developed for treating

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symptomotology associated with CSA. While the provision of therapy has been demonstrated to be more effective than no treatment, few models have been studied with empirical rigor (Cohen et al., 2006; Corcoran & Pillai, 2008; Kazdin & Weisz, 1998; Phillips & Landreth, 1998; Skowron & Reinemann, 2005). Moreover, only one treatment meets Chambless and Hollons (1998) criteria for empirically supported treatments for treating CSA: trauma-focused cognitive-behavioral therapy (TF-CBT; King et al., 1999; Saunders, Berliner, & Hanson, 2004). TF-CBT consists of social skills training, emotional regulation skills training, coping and relaxation strategies, psychoeducation about personal safety and child abuse, and gradual exposure (Cohen & Mannarino, 1996a, 1998; Cohen et al., 2006; Deblinger, Lipmmann, & Steer, 1996). 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 ashbacks; and depression (Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen & Mannarino, 1996a; 1996b; Cohen & Mannarino, 1997; Cohen & Mannarino, 1998; Cohen, Mannarino, Berliner, & Deblinger, 2000; Deblinger & Hein, 1996; Deblinger et al., 1996; Deblinger, McLeer, & Henry, 1990; Deblinger, Stauffer, & Steer, 2001). Although other models have not been studied as rigorously as TF-CBT, several appear to contain important therapeutic components that may contribute to therapeutic change above and beyond TF-CBT. For instance, group therapy facilitates change through the commonality of experience and serves to reduce the stigma, alienation, and isolation that often accompany victimization (De Luca, Boyes, Furer, Grayston, & Hiebert-Murphy; 1991; Yalom, 1995). Group therapy also provides opportunities for experiential learning and a forum for self-expression, which may enhance interpersonal functioning (Avinger & Jones, 2007; Hazzard, King, & Webb, 1986; Johnson & Young, 2007; Knittle & Tuana, 1980; Peake, 1987; Tourigny, Hebert, Daigneault, & Simoneau, 2005). Play therapy is another commonly used treatment with children who have been sexually abused (Gallo-Lopez, 2006; Gil, 1991; Kelly & Odenwalt, 2006) and provides children with the opportunity to learn and develop their skills and abilities through the primary and natural way that children explore and interact with the external world. It enables children to experientially and symbolically learn important skills and provides them with opportunities for nonverbal expression (Gallo-Lopez, 2006; Gil, 1991; Kelly & Odenwalt, 2006). The current study represents a preliminary investigation of game-based cognitive-behavioral therapy (GB-CBT; Springer & Misurell, 2010). GB-CBT is an integrative model that incorporates and draws on theory and techniques from TF-CBT (Cohen & Mannarino, 1998; Cohen et al., 2000; Cohen et al., 2006), play therapy (Gil, 1991; Reddy, Files-Hall, & Schaefer, 2005), and group therapy (De Luca et al., 1991; Johnson & Young, 2007) to address the myriad consequences of CSA. TF-CBT components include skill building, psychoeducation, and gradual exposure. GB-CBT incorporates elements of

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play therapy through the use of developmentally appropriate games (DAGs), which provide a mechanism for treatment to be administered in a fun and engaging manner. The group therapy format encourages the development of cohesion, interpersonal learning, catharsis, and commonality of experience.

METHOD Participants
Participants were recruited from the Metropolitan Regional Diagnostic and Treatment Center at Newark Beth Israel Medical Center, a hospital-based outpatient clinic specializing in child abuse and maltreatment. Participants were required to meet four inclusion criteria that were similar to criteria used in other studies (e.g. Cohen & Mannarino, 1998; Cohen et al., 2006; Deblinger et al., 2001). The criteria were that (a) the child was between 5 and 10 years old and was an alleged victim of sexual abuse and/or sexually inappropriate behavior, (b) the child either disclosed the incident(s) of sexual abuse or there was undeniable evidence that such abuse occurred (e.g., sexually transmitted disease), (c) the child and caretaker completed pre- and posttreatment assessment batteries, and (d) the child attended a minimum of 8 out of 12 group therapy sessions. Although a number of participants appeared to be asymptomatic at the time of pretreatment testing, these children were included in the group program in order to prevent the emergence of future behavioral problems and to provide them with selfprotection skills to help prevent revictimization. These participants were also included because symptom proles vary considerably among victims of CSA (Kendall-Tackett et al., 1993); while some participants showed clinical elevations on some measures but not others, treatment should be benecial for a wide range of children. Participants were excluded from the study if (a) the child had signicant cognitive impairment, active psychotic symptoms, and/or severe behavioral problems that were expected to interfere with his or her ability to participate in treatment (e.g., autism), (b) the child was revictimized during his or her participation in treatment, or (c) the child missed more than four group sessions. Children who were ineligible for participation in group treatment were provided with referrals for appropriate services. A total of 60 participants (37 female, 23 male) initially entered the study. Of these 60, there were 12 who did not successfully complete treatment due to missing more than eight group therapy sessions. Of the 48 participants who successfully completed treatment, 30 were female and 18 were male. The mean age of the children who participated in the study was 7.28 years old (SD = 1.78). The majority of the sample was African American (77.1%), with Latinos comprising the second largest group (18.8%). In terms of socioeconomic status, approximately half of the families involved in the study (45.8%) earned less than $30,000 annually, and 20.8% earned household

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incomes of less than $15,000, suggesting that a substantial proportion of the studys sample was impoverished. Both children and their nonoffending parents/caretakers were involved in completing pre- and posttreatment measures. Of the parents/caretakers completing measures, 64.6% were biological mothers, 25% were foster parents, 8.3% were biological fathers, and 2.1% were stepparents.

Parent/Caretaker Completed Measures


Two versions of the Child Behavior Checklist (CBCL; Achenbach, 1991) were administered to assess clinical problems: the CBCL 1.55 year-old version (CBCL/1.5-5) and the CBCL 618 year-old version (CBCL/618). This instrument has demonstrated high test-retest reliability (.93) over one week and good interrater reliability (.76; Achenbach, 1991). Studies have shown the CBCL to have high discriminant validity in terms of differentiating between children with clinical problems and those without clinical problems (Achenbach, 1991; Achenbach & Rescorla, 2001). Concurrent validity with other youth behavioral measures (e.g., Conners [1997a] Parent Rating ScaleRevised, Conners [1997b] Teacher Rating Scale-Revised, and the Behavior Assessment System for Children [BASC] Parent [Reynolds & Kamphaus, 1992a] and Teacher [Reynolds & Kamphaus, 1992b] Rating Scales) was evidenced by high correlation coefcients, ranging from .56 to .86 (Achenbach, 1991). The Child Sexual Behavior Inventory (CSBI) was used to assess age-inappropriate sexualized behavior among all children in the sample (Friedrich, 1997; Friedrich et al., 1992). The CSBI is comprised of 38 items that are organized into three clinical scales: the CSBI total scale, the developmentally related sexual behaviors scale, and the sexual abuse specic items scale (Friedrich, 1997). Caretakers are asked to rate their childs behavior on a four-point Likert scale ranging from never (0) to at least once a week (3). Reliability analyses of the CSBI total scale yielded sufcient internal consistency (.72). Additionally, it has shown good test-retest reliability for normative samples (.83) and for clinical samples (.93) (Friedrich et al., 1992). The CSBI has been shown to be helpful in discriminating between sexually abused and nonabused schoolchildren (Hewitt & Friedrich, 1991; Hewitt, Friedrich, & Allen, 1994). The Social Skills Rating SystemParent Form (SSRS-PF; Gresham & Elliott, 1990) was used to assess social competencies, social skills decits, and problematic behaviors. In order to evaluate the social competencies of all children in this study, two versions of the test were administered: (a) the Preschool Version, containing 49 questions, which was administered to all ve-year-old participants and others who had not yet reached kindergarten, and (b) the 55 item Elementary School Version, which was utilized among children enrolled in kindergarten through 6th grade. The SSRS-PF

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asks caretakers to rate the frequency of various behaviors observed in their child according to a three-point Likert scale, ranging from never (0) to very often (2). This instrument yields two overall scales, including the Social Skills Scale and the Total Problems Scale. The SSRS-PF has shown high test-retest reliability for the Social Skills scale (.87) as well as for the Total Problems scale (.65). In addition, this instrument has been found to have high internal consistency for both the Social Skills scale (.90) and the Total Problems scale (.94). Gresham and Elliott (1990) also found high convergent validity for the social skills scales of the CBCL (Achenbach, 1991). Additionally, the SSRS has shown high discriminant validity from measures of internalizing and externalizing behavior problems (Gresham & Elliott, 1990).

Child Self-Report Measures


The Trauma Symptom Checklist for Children (TSCC; Briere, 1996) was used to assess a range of behavioral and emotional symptoms that are associated with experiencing trauma. The measure is comprised of 54 items that include two validity measures, Underresponse and Hyperresponse. The clinical scales include anxiety, depression, anger, posttraumatic stress, dissociation, and sexual concerns. Items are rated on a 4-point Likert scale, ranging from never (0) to almost all the time (3). The TSCC is applicable to males and females between the ages of 8 and 16 years and therefore was administered only to children who were eight years and older. Reliability analysis has found that the TSCC scales have high internal consistency (Briere, 1996). Five out the six clinical scales demonstrated high internal consistency, ranging from .82 to .89. The last scale, sexual concerns, was found to have moderate reliability (.77). Studies have shown that that the measure has sufcient convergent validity with other measures of internalizing behavior problems, such as the CBCL, as well as good construct validity (Briere & Lanktree, 1995). The TSCC has been utilized in a number of clinical studies involving children who have been sexually abused (Briere, 1996; Briere & Elliott, 1997). Harters Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (PSPC; Harter, 1982; Harter & Pike, 1983, 1984) was used to assess four domains of self-perception among children in prekindergarten to 2nd grade. These domains included Cognitive Competence, Physical Competence, Peer Acceptance, and Maternal Acceptance. Harter and Pike (1984) found that the preschool and kindergarten versions of the PSPC have high internal reliability (.76 for Competence and .88 for Acceptance). Similarly the 1st and 2nd grade versions had internal reliability scores of .77 for Competence and .87 for Acceptance. Furthermore, Harter and Pike found that the PSPC had high discriminant and convergent validity in that it was highly correlated with other measures of self-esteem and perceived

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competence such as the Scale of Intrinsic Versus Extrinsic Orientation (Harter, 1981) and the School Concerns Scale (Buhrmester, 1980). Harters Self-Perception Prole for Children (SPPC; Harter, 1985) was used to assess self-perception among children in the 3rd and 4th grades. The measure yields six subscales including Scholastic Competence, Social Acceptance, Athletic Competence, Physical Appearance, Behavioral Conduct, and Global Self-Worth. Harter (1985) found the SPPC was found to have high internal consistency (ranging between .73 and .86). Additionally, all subscales of the SPPC were found to have high test-retest reliability over a nine-month period (ranging between .75 and .87; Harter, 1985). The Childrens Knowledge of Abuse Questionnaire (CKAQ) was used to assess childrens knowledge of abuse-related situations, age-appropriate sexual behavior, knowledge of private parts, and personal safety skills (Tutty, 1992, 1994, 1997). It consists of 33 true or false items that can either be read to the participant or be completed independently (depending on the childs reading ability). The test items comprise two scales: Inappropriate Touch and Appropriate Touch. Norms for the measure were developed based on a representative sample of children between the ages of 6 and 12 years. The CKAQ has shown high test-retest reliability and good internal reliability (Tutty, 1992). The Personal Safety Questionnaire (PSQ) was also used to assess childrens knowledge of abuse related situations, age-appropriate sexual behavior, knowledge of private parts, and personal safety skills (Wurtele, Gillispie, Currier, & Franklin, 1992; Wurtele, Kast, & Melzer, 1992; Wurtele & Owens, 1997). The test yields one overall score that ranges from 011. Two-month test-retest reliability (Pearson r ) was .54, p < .02 (Wurtele, Kast, et al., 1992).

Procedures
CLINICAL TRAINING The GB-CBT program was administered by at least three group clinicians per session. Group clinicians involved over the course of the study included one full-time clinical psychologist (the group program director), one full-time masters level clinician, and doctoral-level graduate students who cofacilitated group therapy sessions. Although various clinicians implemented treatment, the group program director was present during all sessions in each cohort in order to ensure consistent implementation of the model. Each member of the clinical team received two comprehensive and interactive training seminars that covered both the research and clinical aspects of the program. New members of the clinical team were rst trained in the administration of the screening measures and observed screenings prior to their involvement. They then performed screenings themselves and were

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observed and rated by experienced clinical team members for consistency. Members of the clinical team also participated in a comprehensive training seminar that reviewed the theoretical underpinnings of the GB-CBT model, presented a session-by-session breakdown of the group therapy curriculum, and discussed a number of frequently encountered clinical problems. During the training process, trainees participated in a number of experiential role-plays and learning exercises. In addition to these trainings, group clinicians received pre- and postgroup supervision, held by the program director, during which specic cases were discussed and direct feedback regarding clinical performance was provided. GB-CBT COMPONENTS The GB-CBT treatment model includes 12 sessions. Each session is 1.5 hours long and is highly structured. The games utilized in the GB-CBT model are rule-governed, typically team-based, and rely on friendly competition as an incentive for participation. Structured play provides the children with multiple opportunities to rehearse the various skills that are taught throughout the course of the group, thereby facilitating greater learning and retention (Reddy, Files-Hall, et al., 2005; Reddy, Spencer, Hall, & Rubel, 2001; Reddy, Springer, et al., 2005). Structured play also serves to enhance group cohesion through active participation and enables the process of therapy to become more uid, reducing defensiveness (Gil, 1991; Kelly & Odenwalt, 2006). Each game is structured in such a way as to encourage behavioral repetition of various social and emotional skill sets in a manner that is fun, engaging, and maintains the childs attention. This is particularly important within the context of child abuse and maltreatment, where the topics discussed during therapy are often painful and anxiety provoking. GB-CBT emphasizes the learning and acquisition of social and emotional skills to help children who have been sexually abused manage various behavioral problems, cope with trauma, and deal with other negative affective symptoms. During GB-CBT sessions, therapists present social and emotional skill sequences to the group through behavioral modeling, role-playing, and performance feedback. Through behavioral modeling, the group therapists demonstrate appropriate behavioral skill sets and effective ways of managing various social situations (e.g., implementing anger management techniques when one is provoked by a peer). Role-playing is utilized as a tool for teaching skill sets and modeling the behavior that is expected of the group members. Performance feedback allows group therapists to communicate with group members about how well they were able to imitate the group therapists behavioral example. GB-CBT is represented by two broad interventional components: social skills training and CSA education/treatment. This two-pronged approach to treatment is designed to systematically improve group members social skills

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(e.g., self-regulation, anger management, emotional expression), address the traumatic symptoms and internalizing problems associated with CSA, provide education that serves to challenge cognitive distortions (e.g., that the child was responsible for the abuse), and improve the group members self-protection abilities. During the rst half of the program, children are socialized to the group, develop rapport and cohesion, learn about personal space and boundaries, develop emotional expression and recognition skills, and acquire anger management and self-regulation strategies. The second half of the program deals specically with CSA and is comprised of the following components: psychoeducation about CSA, gradual exposure for trauma and anxiety related symptoms, self-protection skills education and training, and building stress-coping skills. During exposure sessions, group members participate in DAGs that facilitate disclosure of their abuse experiences. Initially, this is accomplished through passive disclosure games, in which children are asked to nonverbally acknowledge various aspects of their abuse. As the group proceeds, children participate in games that elicit a detailed narrative description of their abuse experiences. Disclosure activities are conducted in an atmosphere of support and openness. Sufcient time is provided for children to processing their feelings about disclosing in the group. For a more detailed description of the GB-CBT model, see Springer and Misurell (2010).

Experimental Design
A single-group design with repeated measures was used to assess the clinical efcacy of a GB-CBT group. Participants in the study were assessed at two time periods: (a) pretreatment testing, which occurred less than one month before the start of treatment, and (b) posttreatment testing, which occurred within one month after the end of group treatment. Assessments during the two time periods included the same battery of measures.

RESULTS Internalizing Behaviors


Our expectation that participants would experience a reduction in internalizing symptoms was assessed using paired sample t-tests between Time 1 and Time 2 on the CBCL/618 Internalizing Problems scale, the CBCL/1.55 Internalizing Problems scale, the TSCC Anxiety scale, the TSCC Depression scale, and the TSCC Posttraumatic Stress scale. Table 1 shows that participants had lower scores on the CBCL/618 Internalizing Problems scale and the TSCC Anxiety scale at Time 2. The three remaining variables (i.e., CBCL/1.55 Internalizing Problems scale, TSCC Depression scale, and TSCC

Game-Based CBT Group Program TABLE 1 Internalizing Behaviors Scale CBCLa Internalizing Problems CBCLb Internalizing Problems TSCC Anxiety Scale TSCC Depression Scale TSCC Posttraumatic Stress Scale
a

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Time 1 M = 53.4 SD = 13.32 N =10 M = 55.27 SD = 12.02 N = 37 M = 51.00 SD = 8.84 N = 17 M = 48.94 SD = 7.76 N = 17 M = 49.94 SD = 7.39 N = 17

Time 2 M = 46.90 SD = 14.04 N = 10 M = 49.59 SD = 11.75 N = 37 M = 46.59 SD = 7.35 N = 17 M = 45.41 SD = 6.34 N = 17 M = 47.71 SD = 8.13 N = 17

Difference M = 6.50 SD = 9.71 N = 10 M = 5.95 SD = 8.83 N = 37 M = 4.41 SD = 6.23 N = 17 M = 3.53 SD = 8.03 N = 17 M = 2.24 SD = 9.37 N = 17

r .749 .724 .719 .364 .274

t 2.12 4.10 2.92 1.81 .98

p, d p =.063 d = .67 p = .001 d = .67 p = .010 d = .71 p = .089 d = .44 p = .340 d = .24

Indicates statistical signicance at p < .05. Designates the Child Behavior Checklist (CBCL/1.5 5). b Designates the Child Behavior Checklist (CBCL/6-18). TSCC = Trauma Symptom Checklist for Children.

Posttraumatic Stress scale) showed some improvement between Time 1 and Time 2, but this change was not statistically signicant. The effect size of .67 for the CBCL/618 Internalizing Problems scale and the effect size of .71 for the TSCC Anxiety scale are both in the moderate range.

Externalizing Behaviors
Our expectation that participants would show a reduction in externalizing behavior problems (e.g., inattention, hyperactivity, aggression, oppositional and conduct disordered behaviors) was assessed using paired t-tests between Time 1 and Time 2 for the CBCL/618 Externalizing Problems scale and the CBCL/1.55 Externalizing Problems scale. Table 2 shows
TABLE 2 Externalizing Behaviors Scale CBCLa Externalizing Problems CBCLb Externalizing Problems
a

Time 1 M = 51.60 SD = 16.23 N = 10 M = 60.78 SD = 10.86 N = 37

Time 2 M = 47.00 SD = 13.41 N = 10 M = 57.54 SD = 12.20 N = 37

Difference M = 4.6 SD = 8.99 N = 10 M = 3.24 SD = 7.70 N = 37

r .832 .783

t 1.62 2.56

p, d p = .140 d = .51 p = .015 d = .42

Indicates statistical signicance at p < .05. Designates the Child Behavior Checklist (CBCL/1.5-5). b Designates the Child Behavior Checklist (CBCL/6-18).

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that participants had lower externalizing behavior scores on the CBCL/6 18 Externalizing Problems scale at Time 2. The CBCL/1.55 Externalizing Problems scale showed a trend in the positive direction, but this nding was not signicant. The effect size of .42 for CBCL/618 Externalizing Problems scale is in the small range.

Total Behavior Problems


Our expectation that participants would show a reduction in their overall behavioral problems was assessed using paired sample t-tests between Time 1 and Time 2 on the CBCL/618 Total Problems scale, the CBCL/1.5 5 Total Problems scale, the SSRS-PF-Elementary form Total Problems scale, and the SSRS-PF-Preschool form Total Problem scale. Table 3 shows that the results for two of the four variables demonstrated statistically signicant improvement between Time 1 and Time 2 (i.e., CBCL/618 Total Problems scale and the SSRS-PF-Elementary form Total Problems scale). The other variables that were tested (i.e., CBCL/1.55 Total Problems and the SSRS-PFPreschool form Total Problems) showed some improvement between Time 1 and Time 2 on these scales. However, the paired sample t-tests were not signicant. The effect size for the CBCL/618 Total Problems scale (.61) was in the moderate range. The effect size for the SSRS-PF-Elementary form Total Problems scale was .56, which was also in the moderate range.

TABLE 3 Total Behavior Problems Scale CBCL Total Problems CBCLb Total Problems SSRSc Total Problems SSRSd Total Problems
a

Time 1 M = 53.30 SD = 14.58 N = 10 M = 58.89 SD = 12.5 N = 37 M = 98.69 SD = 12.29 N =10 M = 109.14 SD = 17.75 N = 35

Time 2 M = 46.40 SD = 13.62 N = 10 M = 53.95 SD = 12.42 N = 37 M = 97.00 SD = 13.45 N = 10 M = 102.00 SD =16.40 N = 35

Difference M = 5.90 SD = 9.17 N = 10 M = 4.95 SD = 8.08 N = 37 M = 1.60 SD = 11.89 N = 10 M = 7.14 SD = 12.64 N = 35

r .832 .783 .576 .729

t 2.03 3.72 .426 3.34

p, d p = .072 d = .64 p = .001 d = .61 p = .680 d = .31 p = .002 d = .42

Indicates statistical signicance at p < .01. Designates the Child Behavior Checklist (CBCL/1.5-5). b Designates the Child Behavior Checklist (CBCL/6-18). c Designates the Social Skills Rating SystemParent Form Preschool version (SSRS-PF-Preschool version). d Designates the Social Skills Rating SystemParent Form Elementary version (SSRS-PF-Elementary version).
a

Game-Based CBT Group Program TABLE 4 Sexually Inappropriate Behaviors Scale CSBI Total scale Time 1 M = 57.83 SD = 20.14 N = 48 Time 2 M = 52.79 SD = 14.05 N = 48 Difference M = 5.04 SD = 15.59 N = 10 r .636 t 2.24

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p, d p = .03 d = .32

Indicates statistical signicance at p < .05. CSBI = Child Sexual Behavior Inventory.

Sexually Inappropriate Behaviors


Our expectation that participants would show a reduction in sexually inappropriate behaviors was assessed using paired sample t-tests on the CSBI total scale. The results in Table 4 demonstrated statistically signicant improvement between Time 1 and Time 2 for the CSBI total scale. The effect size for the CSBI total scale was .32, which places it in the small range.

Social Skills Decits


Our expectation that participants would demonstrate an improvement in their social skills was assessed using paired sample t-tests on the Total Social Skills scales of the SSRS-PF-Preschool form and SSRS-PF-Elementary form. Some improvements on these variables were found between Time 1 and Time 2; however, the paired sample t-tests were not signicant (see Table 5).

Self-Perception
Our expectation that participants would experience an improvement in their self-perception was assessed using paired sample t-tests on the PSPC and the SPPC. Table 6 presents the results of the three variables that showed statistically signicant improvements (see Table 7 for the remaining nonsignicant self-perception variables). Participants showed improved perceptions of
TABLE 5 Social Skills Scale SSRSc Total Social Skills SSRSd Total Social Skills Time 1 M = 89.90 SD = 20.65 N = 10 M = 84.45 SD = 17.70 N = 33 Time 2 M = 94.10 SD = 15.44 N = 10 M = 88.58 SD = 21.16 N = 33 Difference M = 5.20 SD = 17.86 N = 10 M = 4.12 SD = 16.27 N = 33 r .542 .663 t .921 1.46 p, d p = .381 d = .29 p = .155 d = .25

Designates the Social Skills Rating SystemParent form Preschool version (SSRS-PF-Preschool version). Designates the Social Skills Rating SystemParent Form Elementary version (SSRS-PF-Elementary version).

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TABLE 6 Self-Perceptions and Self-Protection Skills Scale Time 1 Time 2 M = 3.72 SD = 3.12 N = 33 M = 3.62 SD =.82 N = 34 M = 3.54 SD =.48 N = 12 M = 9.59 SD = .20 N = 41 M = 24.89 SD = .85 N = 29 Difference M = .20 SD = .42 N = 33 M = 2.18 SD = .58 N = 34 M = .43 SD = .62 N = 12 M = 2.72 SD = 3.87 N = 10 M = 1.19 SD = 1.50 N = 29 r t p, d

PSPC Cognitive Competence M = 3.52 SD = 4.99 N = 33 PSPC Peer Acceptance M = 3.40 SD = .10 N = 34 SPPC Physical Appearance M = 3.11 SD = .79 N = 12 PSQ M = 8.39 SD = .27 N = 41 CKAQ M = 22.17 SD = .66 N = 29

.525 2.34 p = .05 d =.47 .401 2.21 p = .034 d = .38 .629 2.40 p = .035 d = .6 .573 3.78 p = .001 d = .70 .536 5.10 p = .001 d = .79

Indicates statistical signicance at p < .05. Indicates statistical signicance at p < .01. PSPC = Harters Pictorial Scale of Perceived Competence and Social Acceptance for Young Children. SPPC = Harters Self Perception Prole for Children. PSQ = Personal Safety Questionnaire. CKAQ = Childrens Knowledge of Abuse Questionnaire.

TABLE 7 Nonsignicant Self-Perception Variables Scale PSPC Physical Competence PSPC Maternal Acceptance SPPC Scholastic Competence SPPC Social Acceptance SPPC Athletic Competence SPPC Behavioral Conduct SPPC Global Self-Worth Time 1 M = 3.42 SD = .12 N = 34 M = 3.01 SD = .14 N = 34 M = 2.56 SD = .79 N = 12 M = 2.68 SD = .70 N = 12 M = 2.82 SD =.69 N =12 M = 2.73 SD = .81 N = 12 M = 3.03 SD = .91 N = 12 Time 2 M = 3.48 SD = .10 N = 34 M = 2.93 SD = .12 N = 34 M = 2.89 SD = .77 N = 12 M = 3.05 SD = .71 N = 12 M = 3.03 SD = .35 N = 12 M = 3.04 SD = .85 N = 12 M = 3.37 SD = .51 N = 12 Difference M = .07 SD = .78 N = 34 M = .08 SD = .76 N = 34 M = .33 SD = .64 N = 12 M = .37 SD = .81 N = 12 M = .22 SD = .68 N = 12 M = .31 SD = .82 N = 12 M = .35 SD = .75 N = 12 r .242 .536 .664 .349 .2.62 .514 .565 t .49 .58 1.77 1.57 1.09 1.29 1.59 p, d p = .630 d = .08 p = .567 d = .11 p = .105 d = .52 p = .144 d = .46 p = .299 d = .32 p =.224 d = .38 p = .138 d = .47

PSPC = Harters Pictorial Scale of Perceived Competence and Social Acceptance for Young Children. SPPC = Harters Self Perception Prole for Children.

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their cognitive abilities, peer acceptance, and physical appearance posttreatment. The PSPC cognitive competence scale effect size was .47, which was in the small range. The effect size for the PSPC peer acceptance scale was .38, which was in the small range. The effect size for the SPPC physical appearance scale was 0.69, which was in the moderate range.

Self-Protection Skills
Our expectation that participants would show an increase in their knowledge of child abuse and maltreatment and self-protection skills was assessed using paired sample t-tests for the PSQ and the CKAQ. Table 6 shows statistically signicant improvement between Time 1 and Time 2 for the PSQ Total Score and the CKAQ Total Score. The change in PSQ Total Score resulted in an effect size of .70, while the CKAQ resulted in an effect size of .79. Both effect sizes were in the moderate range.

Clinical Signicance
Changes in the six dependent variables that showed statistical signicance (e.g., CBCL/618 Internalizing Problems scale, TSCC Anxiety scale, CBCL/618 Externalizing Problems scale, CBCL/618 Total Problems scale, SSRS-PF-Elementary form Total Problems scale, and the CSBI Total scale) were assessed using the Jacobson and Truax (1991) method. The level of change for each individual case was evaluated by comparing the difference between each participants Time 1 and Time 2 scores to the standard error of measurement of difference between those two scores. A Reliable Change Index (RCI) was calculated for each measure, based on the correlation coefcients and normative data obtained from each measures instruction manual. Participants were classied into ve categories: deterioration (D), no change (NC), minimal change (MC), reliable change (RC), and reliable change with recovery (RCR). Participants demonstrate RC when they had a RCI score exceeding 1.96 or 2 standard deviations above the mean. Participants who had scored in the clinical range at Time 1 had moved into the nonclinical range by Time 2 and had improved by two standard deviations above the mean were considered to have achieved RCR. MC was dened as change that was above one standard deviation in the positive direction but not greater than two standard deviations. Participants were classied in the NC category if they demonstrated change that was below one standard deviation in the positive direction or below two standard deviations in the negative direction. Deterioration (D) was dened by two standard deviations or greater in the negative direction. After initial calculations were performed, it was discovered that a large number of the participants who were classied in the NC category were in the nonclinical range at Time 1 and remained in the nonclinical range at

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TABLE 8 Clinical Signicance Results with Asymptomatic Participants Excluded Scale CBCL Internalizing Problems TSCC Anxiety CBCL Externalizing Problems CBCL Total Problems SSRS Total Problems CSBI Total Problems Total N N = 26 N=8 N = 25 N = 24 N = 22 N = 34 D N=1 4% N=0 0% N=2 8% N=1 4% N=0 0% N = 13 38% NC N = 4% N = 0% N = 28% N = 17% N = 23% N = 0% 1 0 7 4 5 0 MC N = 38% N = 38% N = 36% N = 21% N = 9% N = 3% 10 3 9 5 2 1 RC N = 31% N = 50% N = 12% N = 25% N = 64% N = 41% 8 4 3 6 9 14 RCR N = 23% N = 12% N = 16% N = 33% N = 27% N = 18% 6 1 4 8 6 6

Note: deterioration (D), no change (NC), minimal change (MC), reliable change (RC), and reliable change with recovery (RCR); CBCL = Child Behavior Checklist/6-18; TSCC = Trauma Symptom Checklist for Children; SSRS = Social Skills Rating SystemParent Form-Elementary version; CSBI = Child Sexual Behavior Inventory.

Time 2. Since the inclusion of these participants in the analyses would have obscured the importance of the clinical signicance ndings, the clinical signicance ndings were retabulated with the exclusion of these participants from the sample of each scale. After the asymptomatic participants were eliminated, the proportion of participants who demonstrated MC to RCR notably increased. The clinical signicance ndings are presented in Table 8.

DISCUSSION
This study examined the efcacy of GB-CBT as a therapeutic model for children who have been sexually abused. The results indicated that GBCBT may be an effective approach for alleviating a number of problems commonly exhibited by children who have experienced sexual abuse including internalizing symptoms, externalizing behaviors, overall behavioral problems, and sexually inappropriate behaviors. In addition to reducing problematic behaviors, the GB-CBT program resulted in improvements in childrens knowledge of healthy sexuality and self-protection skills. Findings for improvements in social skills and self-esteem trended in the positive direction. Clinical signicance testing revealed that between 62% and 100% of the symptomatic children demonstrated MC to RCR on internalizing symptoms, externalizing symptoms, and total behavior problems as well as on sexually inappropriate behaviors.

Internalizing Problems
The studys results were similar to those of other empirical studies examining the efcacy of TF-CBT for internalizing problems (Cohen & Mannarino,

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1998; Cohen et al., 2000; Saywitz, Mannarino, Berliner, & Cohen, 2000). The current ndings suggest that GB-CBT may be able to successfully implement traditional CBT procedures (e.g., psychoeducation, affect regulation, and graded exposure) through the game-based model to alleviate internalizing problems. The GB-CBT program utilizes graded exposure techniques that have been found to be effective in reducing trauma-related symptoms (Cohen et al., 2006; Foa, Hembee, & Rothbaum, 2007; Foa & Kozak, 1986; Foa, Steketee, & Rothbaum, 1989; Saywitz et al., 2000) and in cognitive techniques (e.g., challenging cognitive distortions and reprocessing emotionally salient material) that have been found to be useful in reducing anxiety and trauma and in reframing feelings of self-blame, shame, and embarrassment among CSA victims (Cohen et al., 2006; Deblinger et al., 2001; Johnson & Young, 2007). Additionally, this study showed a superior effect size (d = .67) for treating internalizing problems when compared to those found in a metaanalytic study of group treatment outcomes for victims of CSA (d = .54; Reeker, Ensing, & Elliott, 1997).

Externalizing Problems
This GB-CBT program also showed some promise in reducing externalizing behaviors. The GB-CBT model places a strong emphasis on the development of social skills training (e.g., conversation building skills, respecting personal space and boundaries) and emotional regulation/self control skills (e.g., emotional expression and regulation skills, anger management training, and relaxation techniques). These skills appear to be helpful for children presenting with externalizing behavioral problems in other clinical populations (Martin & Pear, 2007; McMullin, 2000).

Sexually Inappropriate Behaviors


The current study demonstrated that GB-CBT might help to reduce the frequency of sexually inappropriate behaviors. This is a critical nding given that sexually inappropriate behavior is one of the common symptoms exhibited among children who have experienced sexual abuse (Berliner & Elliott, 1996; Kendall-Tackett et al., 1993). While the ndings lend support to the assertion that GB-CBT may be effective at reducing the incidence of sexually inappropriate behavior among this population, the results should be interpreted with caution since the effect size (d = .32) for this nding was in the small range, smaller than that found in prior research on group TF-CBT for the CSBI (d = .74; Deblinger et al., 2001). However, the superior effect size demonstrated in the Deblinger et al. (2001) study might be due to the high level of parent involvement in their study. In contrast, most of the children involved in the present study did not have an actively participating parent or caretaker.

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Self-Perception
GB-CBT may help to improve a number of self-perceptions (i.e., cognitive abilities, peer acceptance, and physical appearance) for participants in the study. The GB-CBT program employs the use of developmentally appropriate games, which provide opportunities for participants to gain condence in their intellectual abilities and to develop strong bonds with their peers (Reddy et al., 2001, 2005). Additionally, the group therapy process in general fosters a greater sense of acceptance within the peer group, which may account for these positive ndings (De Luca et al., 1991). As well, exposure therapy facilitates reprocessing of negative emotions and helps to reframe feelings of self-blame (Foa & Kozak, 1986). This process may also help to increase feelings of self-worth and childrens self-perceptions.

Self-Protection Skills
The children who participated in the GB-CBT program exhibited statistically signicant improvements in their knowledge of abuse and self-protection skills as measured by the PSQ and CKAQ. These ndings support the assertion that GB-CBT may be an effective method for teaching self-protection skills. It is presumed that these skills will be instrumental in decreasing the incidence of future sexual abuse for these children.

Clinical Considerations
During the GB-CBT group program, children are asked to share their trauma narratives in a structured, supportive atmosphere. Special consideration is given during disclosure sessions to minimize anxiety and promote a positive corrective experience. Group clinicians facilitate trust and cohesion by providing supportive responses. Children are also encouraged to make supportive comments to one another, to ask constructive questions, and to focus on the commonality of their experiences. Substantial time is allocated during disclosure sessions to process feelings regarding the trauma narratives and for group clinicians to assess each childs emotional state prior to the conclusion of each session. In the event that a child has an adverse emotional reaction during or subsequent to the disclosure activities, one or more of the group facilitators provides individualized attention outside of the group setting.

Limitations
As a single-group design, a number of limitations exist. The primary concern is that there was a lack of a comparison group. The structural realities of the data collection site prevented the researchers from collecting comparison

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data. Random assignment into multiple treatment groups was also not feasible. As a result, the ndings of this study cannot rule out the possibility that the positive change that was observed among the participants was due to the procession of time and spontaneous remission. This study was conducted in an inner city outpatient setting, in the heart of a community that had been decimated by poverty, drugs, and gang activity for more than four decades. Furthermore, many of the families involved in the current study were impacted by multiple stressors such as poverty and lack of resources in terms of money, transportation, time, and education. These factors, which were largely out of the scope of the GB-CBT model, may have posed barriers to recovery and clinical improvement. Also, there was a lack of parent and caretaker involvement, which research has indicated is important for improvement among children who have been sexually abused (Cohen et al., 2000; Cohen et al., 2006; Corcoran & Pillai, 2008). Last, the inclusion of asymptomatic children in the study may have watered down the results since their scores were subclinical at Time 1 and had little to no room for improvement on the behavioral measures.

Conclusions and Future Research


Despite the limitations inherent in conducting a single-group research design in a clinical setting, the GB-CBT model has demonstrated promising results and appears to be an effective intervention for children who have been abused. TF-CBT was initially studied in a similar manner utilizing a singlegroup design (Deblinger et al., 1990). Precedence exists for developing and expanding the research base for treatment models beyond the pilot stage or the stage of the uncontrolled study when positive and promising results are demonstrated. The next step in the research of GB-CBT includes studying three-month follow-up data to determine if treatment gains have been maintained. Additionally, as more children participate in the program, the number of participants in the dataset will increase, thereby improving power to detect statistical improvements. The positive ndings of the present, single-group design with repeated measures justify the development of more rigorously controlled studies in the future. Furthermore, the unique and innovative nature of the game-based approach, along with the costeffective potential of the group modality, strongly justies ongoing research and development of this model.

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AUTHOR NOTE
Justin R. Misurell, PhD, Department of Psychology, Fordham University, Bronx, NY. Craig Springer, PhD, Metropolitan Regional Diagnostic and Treatment Center, Newark Beth Israel Medical Center, Newark, NJ. Warren W. Tryon, PhD, Department of Psychology, Fordham University, Bronx, NY.

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