Emotional regulation and alexithymia as mediators in TF-CBT for sexually abused children

<b>Background:</b> Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based intervention designed to address trauma-related symptoms in children. However, ways changes occur within TF-CBT are still understudied. Alexithymia and emotional regulation could be promising mediators.<b>Objective:</b> This study evaluated the effectiveness of TF-CBT in reducing post-traumatic stress symptoms (PTSS), dissociation, and internalizing and externalizing difficulties, while also exploring the mediating roles of emotional regulation and alexithymia.<b>Method:</b> A sample of 234 sexually abused children (mean age = 9.06) received TF-CBT at a Child Advocacy Center. Parents reported on children's dissociation, internalizing and externalizing behaviour problems, emotional regulation, and alexithymia. PTSS were assessed by both parents and clinicians.<b>Results:</b> Participants showed significant improvements in PTSS (<i>d</i> = .67 and 1.61 for parent- and clinician-reported, respectively), dissociation (<i>d</i> = .62), and internalizing (<i>d</i> = .70), and externalizing (<i>d</i> = .61) behaviour problems from pretest to post-test. A series of within-subject parallel mediation models assessed whether changes in emotional regulation and alexithymia were associated to changes in outcomes. Gains in emotional regulation capacities significantly mediated improvements in PTSS, dissociation, and both internalizing and externalizing difficulties. In contrast, alexithymia was a significant mediator only for PTSS reported by clinicians, dissociation and internalizing difficulties, suggesting that reductions in alexithymia were linked to symptom alleviation in these areas. Changes in alexithymia were not significantly related to changes in parent-reported PTSS or externalizing difficulties.<b>Conclusion:</b> These findings highlight the critical role of emotional regulation in TF-CBT's effectiveness across multiple symptom domains and underscore alexithymia's specific influence on dissociation and internalizing difficulties. Understanding these mediating mechanisms can help refine treatment approaches, leading to more targeted interventions that enhance therapeutic outcomes for sexually abused children.