A Developmental Trauma Perspective on Childhood Sexual Abuse

Child sexual exploitation (CSE) has a long and ignominious history and continues to emotionally and physically injure and adversely alter the development, sense of self, relationships, and life course of millions of children and adolescents worldwide.¹ The systematic review and meta-analysis by Laird et al² provides a thorough and rigorous evaluation of international research on risk and protective factors for sexually exploited children and adolescents. Consistent with findings from recent systematic reviews,^3,4 this review suggests that CSE is associated with sexual exposure, including sexual risk taking, multiple sexual partners, exposure to child or rape pornography, child sexual abuse, and sexting. However, these experiences may be aspects or consequences of CSE, as well as risk factors possibly associated with CSE, and they may have complex associations with one another and with other factors (eg, serving as mediators or moderators) that require careful longitudinal study and the ascertainment of varied individual trajectories and subgroups (eg, latent class or profile analysis).

Many other factors associated with CSE are not specific to sexual exposure but instead reflect potentially traumatic adversities that have in common the disruption of primary relational bonds (ie, single-parent family, intimate partner violence, running away, homelessness, poverty, social isolation, household antisocial behaviors, physical and emotional abuse, revictimization, family involvement in sex work, and child protective services [CPS] involvement). Interestingly, most of these factors showed low to moderate heterogeneity (ie, 0%-74%) across studies: only single-parent family, running away, and CPS involvement showed highly variable risk levels, which could be associated with those factors not being singular vulnerabilities to CSE but instead having a mixture of both risk and protective features. For example, although single-parent families might confer vulnerability because of only 1 parent provides care and monitors the children, they might alternatively be protective because they expose children to less parental conflict than in intact families in which intimate partner dissension or violence is occurring. Similarly, running away might serve as an escape from abusive or violent families, while also exposing the youth to the risk of homelessness and exposure to CSE. CPS involvement may confer risk as a proxy for child maltreatment, but also could be protective in providing positive support, safety, and external monitoring. The variability of the latter factor’s associations with CSE is a reminder that what appear to be unidirectional risk factors for CSE should be carefully unpacked to identify potential protective features that should be incorporated into interventions and services designed to prevent or promote recovery from CSE.¹⁰

In the meta-analysis by Laird et al,² the homogeneity of risk findings for the remaining factors that appear to represent aspects of disrupted attachment with caregivers stands in contrast to the generally high levels of heterogeneity found for the sexual exposure factors that were most strongly associated with CSE (ie, risk behaviors, multiple partners, and child or rape pornography). Interestingly, the 2 sexual exposure factors that had moderate homogeneity in findings across studies—sexual abuse and sexting—are particularly likely to occur in a context of disrupted or compromised attachment relationships with primary caregivers. A potential implication is that risk of CSE may be particularly of concern when a child has been exposed to sexual (and potentially also physical or emotional) victimization combined with major disruption or an absence of secure attachment in primary caregiving relationships. This is consistent with a fundamental premise of developmental trauma disorder (DTD) theory,⁵ which posits that a combination of traumatic victimization and significant disruption of primary attachment bonding puts children at risk for problems with emotion regulation, interpersonal relatedness, identity development, and posttraumatic stress disorder(PTSD). Results from a field trial study⁶ showed that exposure to violence in the home or community and disruption of relationships with primary caregivers were uniquely associated with DTD-related impairment. Sexual abuse or adolescent sexual trauma alone were not associated with DTD or PTSD, but they often occurred in combination with family violence and attachment disruption and, therefore, may not have contributed unique variance to predicting DTD or PTSD despite being related to both.

The association of a number of psychosocial and behavioral problems with CSE risk in the meta-analysis by Laird et al² also is consistent with DTD theory and research. Those CSE associations include symptoms that are integral to DTD (eg, emotion dysregulation, risky behavior, interpersonal problems, hopelessness, suicidality, external locus of control, and distress) or that are comorbidities of DTD (eg, PTSD, externalizing problems, anxiety, and depression).⁷ Substance use problems occurred too rarely in the DTD field trial to be meaningfully evaluated as a comorbidity of DTD, but they tend to co-occur with other DTD features (eg, emotion dysregulation, risky and impulsive behavior, and distress) and thus could reflect additional contributions of DTD to risks associated with or outcomes of CSE.

As noted by Laird and colleagues,² the development of approaches to CSE prevention and safety and therapeutic interventions for sexually exploited children and adolescents will benefit from integrating empirically derived risk factors into screening, assessment, and treatment in primary pediatric health care and mental health services. However, with dozens of relevant factors to consider, an organizing theoretical framework is needed to guide clinical practice, policy, and science by consolidating risk (and also protective) factors in manageable and meaningful domains. A plethora of theories could be relevant, as illustrated by a review⁸ that mapped factors associated with CSE onto more than a dozen frameworks, including life-course, ecological, ecodevelopment, general strain, informal social control, career criminal, economic, feminist, rights-based, revictimization, traumagenic dynamics, and multilevel models. DTD theory provides a potential meta-theory that could parsimoniously account for the constructs posited by all of the aforementioned psychosocially focused theoretical frameworks. Given the crucial role that social norms and attitudes play in conferring risk for and perpetuating CSE,⁹ in addition to DTD, it will be important to consider economic, political, and cultural factors involved in placing children at risk for CSE—as articulated in the economic, feminist, and multilevel models of CSE.

In conclusion, the meta-analysis by Laird and colleagues² makes an important contribution to developing a coherent initial empirical evidence base of factors associated with CSE. The array of factors identified provides a foundation for more systematic and theoretically informative prospective research on the risk and protective factors, concurrent effects, and long-term outcomes in childhood, adolescence, and across the life span of CSE. The findings point to the need for a consolidated meta-theory that accounts for not only sexual exposure but also other developmental, relational, and traumatic precursors that may place children at risk for, protect against, and exacerbate or mitigate the adverse impact of CSE.

Published: September 22, 2020. doi:10.1001/jamanetworkopen.2020.18272

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Ford JD. JAMA Network Open.

Corresponding Author: Julian D. Ford, PhD, Department of Psychiatry, University of Connecticut School of Medicine, MC1410, 263 Farmington Ave, Farmington, CT 06030 (jford@uchc.edu).

Conflict of Interest Disclosures: Dr Ford reported receiving grants from the Substance Abuse and Mental Health Services Administration during the conduct of the study and personal fees from the University of Connecticut outside the submitted work. Dr Ford is the developer of the TARGET curriculum and intervention copyrighted by the University of Connecticut. No other conflicts were reported.