The association between child sexual abuse and subsequent maternal parenting, and opportunities for intervention
Keywords: qualitative
Child sexual abuse
abuse
parenting
mixed-methods
systematic review
mother

Background: Child sexual abuse (CSA) is prevalent worldwide and represents a significant public health burden given the adverse outcomes associated with it. While CSA has been linked to multiple adverse outcomes, including poorer mental and physical health, it has also been linked to women’s subsequent parenting of their own offspring.
Objectives: This thesis seeks to 1) synthesize existing literature on the association between CSA and the subsequent parenting practices these women engage in; 2) determine what mechanisms may underlie this association, according to the existing literature; 3) determine what parenting interventions are currently available for mothers who experienced CSA (MCSA) and if these interventions are efficacious; 4) conduct surveys with a diverse sample of MCSA to determine how they perceive their experiences to have affected their parenting, what they may want from an intervention to address any consequences of these experiences, and to determine how they define CSA.
Methods: To address objectives one and two above, a series of linked systematic reviews of the existing qualitative and quantitative literature on the association between CSA and the subsequent parenting practices of these women were conducted. Potential studies were located through seven academic databases, a review of the grey literature, by reviewing the reference lists of included studies, and by reviewing the titles of studies that cited studies included in this review. Results were divided into three papers by study design (qualitative or quantitative), and the quantitative results were further divided by content (whether parenting was abuse related or non-abuse related). Qualitative data were synthesized using thematic analysis, while quantitative data were narratively synthesized. To address objective three, a systematic review of existing evaluations of interventions for MCSA was conducted. Potential studies were located by searching nine academic databases, grey literature, the reference lists of included studies, and the titles of studies that cited studies included in this review. To address objective four, and to fill gaps in the existing literature identified in the systematic reviews, an online mixedmethods survey was created to assess the past experiences, mental health, and parenting of MCSA. Further, as part of this survey, MCSA were asked about what they may want from an intervention designed to address their experiences and how they would define CSA.
Results: Results related to objective one indicated that CSA affects the parenting behaviors of MCSA. Specifically, qualitative results of the review found that MCSA desire to protect their children from abuse. Despite this, many did have children who experienced abuse, with abuse being perpetrated by both the mother and others. CSA was also perceived to both positively and negatively affect the mother-child relationship, breastfeeding, child-rearing practices, perceptions of their child, and perceptions of motherhood. Additionally, MCSA discussed aspects of the parenting experience that helped them cope with their past CSA experiences. Quantitative results also found associations between CSA and the parenting behaviors listed previously, though much heterogeneity existed, especially with results related to general parenting. In most instances, significant findings were in the expected direction, with MCSA experiencing more parenting difficulties than Mno-CSA. However, in several instances, MCSA were found to have fewer parenting difficulties than Mno-CSA. Mechanisms that may explain the quantitative associations (objective two) included mediators and moderators, such as mental health, physical health, and substance misuse. Theories prominently used to explain this association in the qualitative and quantitative literature included attachment theory, trauma theory, systems theory, and social learning theory. Only four interventions have currently been evaluated to address the parenting needs of this population (objective three). The majority of these evaluations had small sample sizes, lacked a comparison group, or contained components lacking a sufficient evidence base. The mixed-methods online survey was completed by 35 women recruited from a diverse range of organizations (objective 4). MCSA reported that many aspects of their parenting, including the ones described previously, had been affected by their CSA experiences. Perceived effects of CSA on parenting often did not vary based on demographic characteristics, mental health, and specific aspects of the CSA experience in subgroup analyses. MCSA reported being open to interventions to address their experiences, suggesting that these interventions provide information related to parenting and take place in a group setting. Finally, MCSA provided their own definitions of CSA (objective 4). These definitions often included both contact and non-contact forms of abuse, defined a child as being under 16 or under 18, and did not require the perpetrator to be a certain number of years older than the child, a definition often used in the literature.
Conclusions: The reviews in this thesis represent the first attempt to synthesize the vast literature on CSA and the subsequent parenting of mothers who have had these experiences. These reviews informed the primary research conducted as part of this thesis, allowing gaps in the literature to be filled. Ultimately, studies in the four systematic reviews (270 studies reviewed in total) and online survey demonstrated that experiences of CSA can negatively affect parenting behaviors, with these findings being demonstrated both quantitatively and qualitatively, though there was significant heterogeneity in the quantitative studies. Given the pernicious effect that CSA can have on parenting for some MCSA, and the potential negative effect that parenting difficulties can have on the children of these women, it is critical that interventions address these issues. Further, given issues surrounding the definition of CSA found throughout this thesis, efforts should be made to standardize this definition. The results of this thesis form a strong basis for the development of future parenting interventions and research with this population.