Understanding and Treating Children Who Experience Interpersonal Maltreatment: Empirical Findings David M. Lawson Child maltreatment (CM) is a major health problem in U.S. society, with 872,000 substantiated cases reported in 2004 and unofficial rates ranging from 2 to 10 million cases per year. Depending on the severity, CM can negatively affect a child’s physical, emotional, and psychological functioning and development immediately following an abuse incident or incidents; in severe cases, it can affect adult functioning. The author examines the empirically supported research related to the incidence, consequences, treatment effectiveness, and models of treatment for CM.
Since the early 1970s, legal and scholarly interest in child maltreatment (CM; includes children and adolescents) has increased dramatically, largely due to the Child Abuse Prevention and Treatment Act of 1974 (CAPTA). Prior to this time, CM was viewed as a family problem and most outside involvement was considered intrusive. CAPTA required states to develop criteria for mandated reporting and gave states the right to remove children from homes if they were viewed as being in danger. CM is defined by CAPTA and amended by the Keeping Children and Families Safe Act of 2003 as any act or failure to act on the par t of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or An act or failure to act which presents an imminent risk of serious harm. (National Clearinghouse on Child Abuse and Neglect Information, 2004b)
The U.S. Department of Health and Human Services (DHHS; 2006) identifies four types of CM: neglect, physical abuse, sexual abuse, and psychological abuse. Although they are defined as distinct forms of maltreatment, in reality, they often co-occur (Cohen, Mannarino, Murray, & Igelman, 2006). In 2004, DHHS (2006) substantiated 872,000 reported cases of CM. However, retrospective reports of child abuse indicated that when asked, approximately 25% to 35% of women and 10% to 25% of men in the general U.S. population had experienced some form of child sexual abuse and 10% to 20% of these adults also reported incidences of physical abuse as a child (Briere & Elliott, 2003; Finkelhor, Hotaling, Lewis, & Smith, 1990). Furthermore, studies estimate that between 3.3 and 10 million children witness interparental violence in the United States, resulting in effects that are similar to those experienced by victims of physical and emotional abuse (Straus, 1992). The majority of child abusers are family members.
CM causes serious problems that can have a negative impact on a child’s overall physical health as well as on psychological, emotional, behavioral, cognitive, and neurological functioning (Berliner & Elliott, 2002). Children who experience severe and prolonged maltreatment and fail to receive adequate treatment often experience symptoms well into adulthood (Cloitre, Stoval-McClough, Miranda, & Chemtob, 2004). In particular, the longer the period between the occurrence of maltreatment and treatment, the more time and effort are necessary to alter the negative effects of that maltreatment (Perry, 2006). Conversely, early intervention results in healthier children as well as fewer economic and human resources. A thorough knowledge of CM is critical for all counselors but especially those who work with children. In this article, I review the empirical literature on major aspects of CM. The first part of the article is focused on the consequences of, symptoms of, and the context for maltreatment; the latter part of the article is a review of the literature on effective treatment of CM.
Consequences of Child Maltreatment Maltreated children are at risk for significant psychological and physical symptoms. These include anxiety, depression, somatic complaints, suicide, impulsivity, hyperactivity, interpersonal problems, intrusive thoughts, hyperarousal, and dissociation (Berliner & Elliott, 2002; Kolko, 2002). Maltreated children develop posttraumatic stress disorder (PTSD) at rates ranging from 20% to 63% (Kendall-Tackett, Williams, & Finkelhor, 1993; Spinazzola et al., 2005). Furthermore, up to 70% of sexually abused children meet partial or full criteria for PTSD (Wolfe, Sas, & Wekerle, 1993). Research has identified several characteristics associated with increased risk of PTSD after exposure to traumatic stress (see Briere & Scott, 2006): (a) little or no positive attachment and support by caregivers; (b) being female; (c) being younger; (d) race, with African Americans, Hispanics, and Native Ameri-
David M. Lawson, Department of Human Services, Stephen F. Austin State University. Correspondence concerning this article should be addressed to David M. Lawson, Department of Human Services, Counseling Program, Stephen F. Austin State University, PO Box 13019, Nacogdoches, TX 75962-3019 (e-mail:
[email protected]). © 2009 by the American Counseling Association. All rights reserved.
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Understanding and Treating Children Who Experience Interpersonal Maltreatment cans at higher risk than Caucasians; (e) physical and emotional proximity; (f) lower socioeconomic status; (g) previous psychological problems; (h) subfunctional coping skills; (i) history of family dysfunction; and (j) prior history of trauma. Although the general clinical profile of children with PTSD is similar to that of adults with PTSD, there are some distinctions in how it may be exhibited for each of these two groups. This is evident in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR; American Psychiatric Association, 2000) which provides specific PTSD diagnostic criteria for children in addition to the general ones for adults. In Criterion A, the adult definition of trauma is limited to an event that involves actual or threatened death or serious injury. For children, the definition is expanded to include developmentally inappropriate sexual experiences without threat or actual violence or injury. Furthermore, for children, the trauma-related fear, helplessness, or horror experience may be expressed by disorganized or agitated behavior. Likewise, the intrusive, reoccurring trauma experience that characterizes Criterion B may be exhibited in repetitive play with trauma themes. Also, the trauma-specific content of adult nightmares may occur in children as frightening dreams but without recognizable content. Finally, the flashbacks that adults report may appear in children as re-enactments of the trauma-specific experience. (See DSMIV-TR, pp. 464, 467–468.) Similar to the situation for adults, the presentation of PTSD in children can vary depending on trauma severity, chronicity, and number of symptoms (Faust & Katchen, 2004). For example, the more pervasive and chronic the maltreatment environment, the more likely it is that the child’s trauma-organizing responses will become generalized hyperreactive and hypersensitive to a broad range of stress-inducing cues beyond the original traumatic event or events (Perry, 2006). Complex PTSD In addition to PTSD, children who experience severe, frequent, and long-term abuse, especially by caregivers, may develop a host of personality-related problems such as difficulty maintaining a consistent sense of self or identity, diminished boundary awareness, and interpersonal problems (Cook, Blaustein, Spinazzola, & van der Kolk, 2003; Kinniburgh, Blaustein, Spinazzola, & van der Kolk, 2005). These symptoms go beyond PTSD and are referred to as complex PTSD or “Disorders of Extreme Stress Not Otherwise Specified” (Brieve & Scott, 2006, p. 000). Severe victimization may result in enduring impairment in multiple domains of functioning: “(a) self-regulatory, attachment, anxiety, and affective disorders in infancy and childhood; (b) addictions, aggression, social helplessness and eating disorders; (c) dissociative, somataform, cardiovascular, metabolic, and immunological disorders; (d) sexual disorders in adolescence and adulthood; and (e) revictimization” (as cited in Cook et al., 2003, p. 5). Approximately 55% of traumatized children have more than one diagnosis (Target & Fonagy, 1996).
Severe child abuse is highly correlated with borderline personality disorder (BPD), with some research indicating that up to 91% of BPD patients report a history of severe child abuse (Zanarini, 2000). Because of the negative connotation associated with BPD, many prefer to use the complex-PTSD designation. Both terms refer to a pervasive pattern of disruption in self and other relationships and emotional dysregulation (Briere & Scott, 2006). Effects of Trauma on Neurobiology Childhood trauma and particularly intense and prolonged traumatic experiences interfere with neurobiological development and functioning (Cook et al., 2005; Perry, 2006). In some severe cases, unless timely intervention occurs, neural activated responses that lead to fight or flight responses may become chronic, resulting in sustained hyperarousal, reexperiencing, panic, and aggression (Perry, 2006). The effects of severe and chronic trauma compromise the cortex’s ability to regulate cortical and autonomic processes. This disrupts the body’s natural ability to return to a normal level of arousal, altering the normal developmental course of the immature brain. These changes are reflected in alterations in brain chemistry, hormonal activity, myelination, and size and/or symmetry of various brain structures (Perry, 2006). The more persistent and intense the traumatic experiences, the less social support, and the younger the child, the more ingrained and prolonged are the brain alterations and concomitant nonadaptive behaviors (Schore, 2003). Disruption in normal neural development can lead to compromised functioning in multiple domains (e.g., health, attachment, cognitive functioning, and impaired memory) throughout life (Perry, 2006). Conversely, children who experience a supportive environment with structure, predictability, nurturing, and a sense of safety are less vulnerable to long-term, negative effects on their neurodevelopment. The plasticity of the brain and related structures of children makes them particularly vulnerable to PTSD as compared with adults. Children are 1.5 times more likely than adults to be diagnosed with PTSD following a traumatic experience (Fletcher, 1996).
Protective and Risk Factors All children do not react in the same manner to abuse and neglect, with some experiencing long-term consequences and others experiencing little or no apparent ill effects. For example, some studies indicate that one half to two thirds of sexually abused children appear to improve over time (Kendall-Tackett et al., 1993; Oates, O’Toole, Lynch, Stern, & Cooney, 1994), with physically abused children improving at similar or slightly higher rates (Wolfe, 1999). A child’s ability to recover and cope with abuse (i.e., resilience) is moderated by several protective factors. However, resilience is not a single, global characteristic; instead, it is multidetermined based on the interaction between factors related to the individual, family, and larger social en-
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Lawson vironment (Cook et al., 2003). Thus, a child may function at a fairly high level in some areas of his or her life but be highly distressed and much less functional in other areas. Several variables foster resilience: (a) secure attachment and connection with emotionally supportive adults; (b) cognitive and self-regulation skills; (c) positive self-concept; (d) internal and external motivation to behave efficaciously; (e) parenting warmth, structure, and high expectations for the child (Masten, 2001); and (f) peer support (Ezzell, Swenson, & Brondino, 2000). A predictable, caring, and consistent caregiver is the most critical factor in the development of resilience (Schore, 2003) because it promotes the acquisition of self-regulatory abilities and fosters a secure attachment that blunts the effects of trauma. Treatment difficulties increase in the absence or insufficiency of these factors. Conversely, research indicates that there are a number of family factors that mitigate the child’s resiliency in the face of trauma. At-risk families tend to be isolated with little external support, they lack cohesion, and they have multiple problems (Crittenden, 1999). The parents often have poor relationships with their children and interact with them in a hostile and nonnurturing manner (Coohey, 1995). Additionally, research supports the importance of coping skills in responding to childhood trauma. These skills act as defense mechanisms to block, limit, or emphasize certain internal and external perceptions in managing trauma (Cook et al., 2003). The more severe the trauma, the more a child uses coping skills. The skills associated with more successful management of trauma include optimism, intelligence, humor, altruism, and suppression. In contrast, poor functioning is related to dissociation, projection, passive aggression, and hypochrondriasis.
Treating CM In 2002, 59.4% (518,000) of individuals with verified cases of CM sought psychological treatment (National Clearinghouse on Child Abuse & Neglect, 2004a). However, all treatments are not equally effective. The following discussion focuses on empirically supported treatment concepts. In addition, the discussion focuses on treatments for children who meet partial or full criteria for PTSD. Similar treatments are used with cases of acute stress disorder (ASD; Briere & Scott, 2006). Children who experience a single case of mild to moderate maltreatment may experience low or negligible symptoms. These children likely would benefit from abbreviated forms of the treatment model that is discussed later in this article. With few exceptions, the majority of treatment models only include nonoffending parents. Offending parents who have committed sexual abuse or severe physical abuse are not viewed as eligible participants in initial treatment with the child and the nonoffending parent.
Creating a Context for Treatment The combination of empirical literature and informed clinical wisdom consistently support several conditions under which
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effective treatment can occur (Cohen, Mannarino, & Deblinger, 2006; Cook et al., 2003). The following elements are common across empirically supported treatment models. Any threat of perpetration must be removed from the child’s environment. Ongoing exposure to traumatizing circumstances not only exacerbates the child’s symptoms but hampers treatment effectiveness (Faust & Katchen, 2004). Safety measures may include involvement with child protective services, the legal system, school personnel, and other support people. It also may mean moving to another location, removal of a family member from the home, and obtaining a protective order. The family will also need to develop a safety plan regarding any threatening situations outside the home (e.g., always stay in the company of other children). Therapeutic Alliance The counselor must provide a warm and trusting emotional environment for the child to feel safe enough to process intense trauma material, especially interpersonal victimization cases. A strong therapeutic alliance in the initial phase of treatment predicts success in midphase trauma processing (Cloitre, Koenen, Cohen, & Han, 2002), whereas a weak alliance is associated with less positive treatment outcomes (Dalenberg, 2000). This also applies to the child’s parents. A traumatized child may sustain actual damage to the corticolimbic and orbitofrontal regions of the brain (Schore, 2003) as well as disruption in the coherence between the right and left hemispheres (Siegel, 2003). These disruptions are associated with emotional dysregulation and the inability to transform a traumatic experience into a coherent, integrated autobiographical memory. A therapeutic relationship enhances the cortical circuitry and neural integration of these structures, which, in turn, enhance emotional regulation and the ability to relate a coherent trauma story (Siegel, 2003). The therapeutic alliance alone is a unique component of healing beyond its facilitative properties of successful exposure interventions: “Far from being the nonspecific placebo effect or inert ingredient suggested by some advocates of short-term therapy, the relationship between client and therapist can be seen as directly and specifically curative” (Briere & Scott, 2006, p. 155). Studies have indicated that both children and therapists rate the therapeutic relationship as more important than specific techniques (Kazdin, Siegel, & Bass, 1990; Kendall & Southam-Gerow, 1996). Attachment Pattern Attachment research has suggested that anger (Klohnen & John, 1998) and dissociation (Lyons-Ruth & Jacobovitz, 1999) are commonly associated with abused children and later predict hostile-aggressive behavior. These reactions are often associated with anxious-ambivalent and disorganizeddisoriented attached children who engage in demand–withdraw or incoherent reactions when they encounter disruption in a significant relationship (Schore, 2003). These children may
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Understanding and Treating Children Who Experience Interpersonal Maltreatment reject counselors’ attempts to establish closeness by demonstrating avoidance and distrust. Failing to understand the child’s rejecting response, counselors’ might respond with anxiety or even anger, thereby validating the child’s expectation of abandonment (Dalenberg, 2000). Counselors should provide nondemanding warmth with appropriate structure without reacting to the child’s rejection and anger. Sociocultural Issues The treatment process should occur within a culturally sensitive context. Gender and race are associated with the increased likelihood of posttraumatic stress. Although trauma does not affect all groups equally, discrimination is associated with negative psychological effects (Loo et al., 2001) and circumstances that increase the risk of trauma (Breslau, Wilcox, Storr, Lucia, & Anthony, 2004). Culturally sensitive approaches for trauma assessment have been developed for adults (Loo et al., 2001) and children (Saltzman, Layne, Steinberg, Arslanagic, & Pynoos, 2003). Yet, these approaches should not be applied categorically to a particular cultural variable (e.g., ethnic group) without considering the variation within each group and the differences in trauma-related constructs both between and within ethnic groups. Counselors should learn specifics about the particular ethnocultural group(s) with whom they are working and adapt their treatment accordingly. Personal Strengths and Posttraumatic Growth A child’s strengths can be easily overlooked given the magnitude of the negative aspects of trauma. However, identifying and exploring the child’s strengths can aid in developing the therapeutic alliance and identify existing scaffolding upon which to build coping skills. Such a focus also enhances client hope and self-esteem (Cryder, Kilmer, Tedeschi, & Calhoun, 2006). The possibility of posttraumatic growth (PTG) has been documented in studies with adults and children (Milam, RittOlson, & Unger, 2004; Tedeschi & Calhoun, 2004) although no study currently exists with CM. PTG is a positive change and transformation experienced as a result of struggle with major loss or trauma and seems related to (a) one’s ability to cognitively process negative events to derive positive appraisals, (b) the availability and use of positive support sources, and (c) competency or positive appraisals of a person’s ability to manage and adjust to a stressful situation (Cryder et al., 2006). A child’s realization that he or she has “done some things right” can challenge thoughts that emphasize failure, self-blame, and discouragement.
Treatment Process The majority of CM treatment models focus on trauma symptoms and particularly PTSD and related symptoms such as depression, anxiety, intrusive thoughts, arousal, and avoidance
behaviors (Cohen, Mannarino, & Deblinger, 2006). These models address symptom reduction with abuse-specific cognitive behavioral techniques, psychoeducational interventions, coping-skills training, and parent/family participation (Saywitz, Mannarino, Berliner, & Cohen, 2000). Multimodal treatment (individual and family) and integration of a limited number of empirical approaches (i.e., cognitive behavioral, family systems, and psychodynamic) are the most widely used techniques (Cohen, Mannarino, Murray, et al., 2006; Cook et al., 2005). Assessment The goal of assessment is to obtain a general picture of the trauma event, resulting symptoms, and general history (Cohen et al., 2006). Greater detail can be obtained during later phases after the child has developed anxiety-management skills. Assessment information should include (a) developmental history of the child, family, and trauma; (b) primary attachments; (c) involvement of child protective services; (d) illnesses, losses, separation/abandonment by parents; (e) family mental illness; (f) substance abuse; (g) legal history; (h) child and family coping skills; and (i) extrafamily stressors (e.g., economic issues; Cook et al., 2003). To assess for traumatic experiences, Pynoos, Steinberg, and Goenjian (1996) suggested obtaining the following: (a) objective and subjective aspects of the trauma; (b) type and frequency of trauma reminders and their expected future occurrence; and (c) secondary stressors such as resulting medical care, relocation, change of financial support, or functioning in school. Other information should include the circumstances under which the trauma was disclosed, the responses of the family, safety, and the child’s feelings about the traumatic experience (Cook et al., 2005). This information assists counselors in appropriately modulating their relational intensity, the timing of interventions, and establishing expectations for the child’s and the family’s progress in treatment. It is particularly important to appreciate the child’s subjective experience and response following the trauma. Subjective factors that predict overall severity of PTSD include intense fear of dying or being harmed, distress over others’ reactions to the child’s trauma, guilt about behavior that may have endangered others, perceived probability of reoccurrence, self-attributional responses to the trauma, and trauma-related coping styles (Feiring, Taska, & Lewis, 2002). Beyond subjective aspects, there are a number of objective factors that are associated with the onset and continuation of posttraumatic reactions (Briere & Elliott, 2003; Epstein, Fullerton, & Ursano, 1998; Ullman & Filipas, 2001): (a) exposure to a direct, life threatening event; (b) injury to self; (c) witnessing a mutilating injury or grotesque death, especially as related to family or friends; (d) hearing unanswered screams for help and cries of distress; (e) being trapped or without assistance; (f) proximity to violent threat such as interparental violence; (g) unexpectedness and duration of the experience(s); (h) use of violent force and the use of a weapon
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Lawson or injurious object; (i) number and nature of threats during a violent episode; (j) a relationship to the assailant and victims; (k) use of physical coercion; (l) sexual rather than nonsexual victimization; and (m) degree of brutality and malevolence. Counselors can assess for the presence of these factors as one method of gauging the severity of the traumatic experience and, thus, the likelihood of PTSD or ASD. Caregiver behavior is often a major challenge in treating a traumatized child. Caregivers may be secondarily traumatized by the continual awareness of the child’s trauma or they may be simultaneously dealing with their own trauma reactions (Cohen, Mannarino, & Deblinger, 2006). Thus, they may overreact to the child’s stress with overprotection or withdrawal. For example, the use of guilt and anxiety-provoking parenting methods is correlated with increasing levels of PTSD symptoms and significant misbehavior with sexually abused children (Deblinger, Lippman, & Steer, 1996). Furthermore, a higher level of parental distress predicts less effective treatment outcome with sexually abused children (Cohen & Mannarino, 1996). Conversely, appropriate peer and parent support predict fewer psychological symptoms for sexually abused adolescents. Cook et al. (2003) emphasized the following as critical parental responses: (a) believing and validating the child’s trauma experience, (b) tolerating the child’s affect, and c) managing their own emotional responses. Interview Process Parents often provide more objective information than a child about the trauma incident, the injuries incurred, and the collateral effects of the trauma at home and beyond. Conversely, children may underreport or deny the abuse to avoid the aversive aspects of traumatic events, shame, and to protect parents from hearing the details of the trauma, particularly in instances of sexual abuse and when the perpetrator is known by the caregiver. In particular, young children may lack understanding of the interview questions and/or the verbal skills to clearly describe their symptoms and the trauma circumstances (Cohen, Mannarino, Murray, et al., 2006). Additionally, young children and those who were victims of severe and prolonged abuse are likely to take longer to complete the assessment than older, less severely abused children. Thus, both conjoint and individual sessions are necessary for assessment. Finally, counselors should provide an overview of the interview process, including the goals, an age-appropriate explanation of the effects of trauma and symptoms, and how the interview information will be used to help them in the treatment process (Cohen, Mannarino, Murray, et al., 2006). Accurate information about trauma and its effects often begins the healing process as unfamiliar symptoms are placed in a logical and meaningful context. Victims who derive some meaning from the experience are better able to regain a sense of control and hope. Assessment Instruments Standardized instruments often elicit information from clients that interviews alone do not. They are often used in conjunc-
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tion with a semistructured clinical interview. The following are a number of standardized instruments with adequate reliability and validity that are widely used with children and adolescents to assess general and specific symptoms related to posttraumatic stress. The Child Behavior Checklist (Achenbach, 1991) and the Behavior Assessment System for Children (Reynolds & Kamphaus, 1992) are two established instruments for assessing general psychological distress with children and adolescents. They assess internalizing and externalizing symptoms using self-report, parent-report, and teacher-report versions. The Trauma Symptom Checklist for Children (Briere, 1996) is used to assess self-reported trauma symptoms for children between the ages of 8 and 16 years. The Trauma Symptom Checklist for Young Children (Briere et al., 2001) is a caretaker report instrument for children between the ages of 3 and 12 years. The UCLA PTSD Index for DSM-IV (Pynoos, Rodriquez, Steinberg, Stuber, & Fredrick, 1998) is the most widely used child self-report instrument for PTSD. Several other instruments measure specific symptoms related to CM: Child Sexual Behavior Inventory (Friedrich, 1998), Children’s Depression Inventory (Kovacs, 1985), and the StateTrait Anxiety Inventory for Children (Spielberger, 1973). It is important to assess multiple areas of functioning from multiple sources (i.e., parents, teacher, and child; Cook et al., 2003).
Integrated Cognitive Behavioral, Relational, and Family Treatment Treatment models that include some combination of cognitive behavioral therapy (CBT), psychodynamic/attachment therapy, and parent/family-based treatment models have the strongest and most consistent empirical support for treating CM (for reviews, see Cohen, 2005; Saywitz et al., 2000) along with nonbehavioral aspects such as the therapeutic alliance (see the Therapeutic Alliance section of this article). These models have been used with children of different ages and with children residing in either the parental home or in foster homes (see Cook et al., 2003). Although CBT with children only (individual or group modality) has been shown to be effective in reducing PTSD (Deblinger et al., 1996; Deblinger, Stauffer, & Steer, 2001), parent involvement in treatment improves child-reported depression and parent-reported child behavioral problems (Deblinger et al., 1996). The model that I present in this article is focused on child and parent involvement in treatment. In addition, the treatment model presented herein is based on research supporting the treatment of uncomplicated PTSD in children with a fairly circumscribed length of treatment (12 to 16 weeks). A limited number of studies have indicated initial success with chronically traumatized children (i.e., complex PTSD), using the integrated model that I present (Cohen, Deblinger, Mannarino, & Steer, 2004). It is likely that less severe and single incidences of CM require less intense and
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Understanding and Treating Children Who Experience Interpersonal Maltreatment less lengthy treatment than severe, multiple victimizations (i.e., complex PTSD; Perry, 2006). Treatment in phases is particularly effective with traumatized individuals (Cook et al., 2003). Attempting to move too quickly or to process the trauma before children are equipped to do so tends to overload their ability to process and learn new behaviors, thoughts, and relationship skills. For example, exposure interventions consistently provide greater reduction in PTSD symptoms than most other interventions. However, by itself, exposure intervention may trigger unmanageable emotional intensity for many children, hamper a good working relationship with the counselor, and result in high client dropout (Jaycox & Foa, 1996). Conversely, adding prior treatment phases that enhance safety and the therapeutic relationship and teach selfregulation skills, predicts successful exposure therapy (Cloitre et al., 2002; Cloitre et al., 2004). The following discussion enumerates a four- phase model of treatment: client stabilization, processing the traumatic experience, deriving new meanings, and consolidation of new learning.
Client Stabilization Under most circumstances the counselor will begin this treatment phase meeting with parents and child conjointly (Cohen, Mannarino, Murray, et al., 2006). If the family is lacking cohesion and has a history of instability, lack of parent support, or limited parenting skills, a series of conjoint sessions may precede individual sessions (Faust & Katchen, 2004). With higher functioning families, a single conjoint session may precede individual sessions followed by periodic conjoint sessions (Cohen, Mannarino, Murray, et al., 2006). Emotional dysregulation problems often accompany exposure to significant traumatic experiences. Emotional dysregulation is the sudden change in affective states and/or difficulty tolerating and coping with negative affect (Cohen, Mannarino, Murray, et al., 2006). This occurs because trauma undermines coping skills, triggering physiological changes that affect one’s ability to identify and process the traumatic experience. Fear and over-stimulation create a sense of confusion and being out of control. These children feel overwhelmed by emotions that continue long after they have been removed from the stressor. Thus, they are taught to de-escalate their trauma-related emotions by using anxiety management skills such as controlled breathing and progressive muscle relaxation. They are also taught the relationship between thoughts, feelings, and behavior and the use of thought stopping to interrupt distressing thoughts and to replace them with more accurate ones. They also learn to anticipate and manage distressing situations, how to evaluate their behavior, and how to engage in physical activities to increase a sense of control and mastery. Finally, they are taught to identify and rate the intensity of their emotions, and to express emotions that are congruent with the identified feelings (Cohen, Mannarino, Murray, et al., 2006).
Parents are taught skills that are similar to those taught to their children, because they also struggle with strong emotions about
the trauma. These feelings may compromise their parenting, therefore, they learn parenting skills as well as how to respond therapeutically to their child’s symptoms (Cook et al., 2003). Periodic conjoint sessions allow the children and parents to practice the skills together. During this process, the counselor needs to proceed at the child’s and parent’s pace and take time to address issues such as reluctance, mistrust, and feeling overwhelmed.
Processing the Traumatic Experience/ Trauma Integration If symptoms such as intense fear, intrusive trauma memories, and avoidance behaviors do not resolve on their own, it will be necessary to help children integrate their feelings, thoughts, and memories about the trauma into their autobiographical memory that has a beginning, middle, and end. Deblinger and Heflin (1996) maintained that trauma integration helps survivors (a) control intrusive and upsetting trauma-related imagery; (b) reduce avoidance of cues, situations, and feelings associated with trauma exposure; (c) identify unhelpful cognitions about traumatic events; and (d) recognize, anticipate, and prepare for reminders of the trauma. The primary focus of this phase of treatment involves exposure to the traumatic experience by either imaginal flooding or gradual exposure to increasingly more intense trauma images with accompanying emotions and thoughts over several sessions (Cohen, Mannarino, Murray, et al., 2006). Gradual exposure is arguably the most widely used of the two and is often less distressing for the child and his or her parents. The prospect of reexposure to the trauma material is often difficult for parents, children, and counselors. They often assume that talking about and reexperiencing the trauma only makes matters worse (Cohen, Mannarino, Murray, et al., 2006). However, avoidance prevents the processing of the trauma memory and prolongs the intense trauma symptoms. The anxiety management skills learned earlier can help manage symptoms during the re-experiencing process. There are steps that can be taken to integrate the trauma into the child’s life. The gradual exposure approach involves having children describe low to nondistressing aspects of the trauma and then gradually progress toward greater detailed descriptions of more intense and threatening aspects of the event along with emotional reactions. Briere and Scott (2006) emphasized the importance of maintaining a level of emotional intensity within the therapeutic window. This level of intensity is one that triggers the trauma memories and emotions that promote their processing without overwhelming the client and engaging avoidance responses. Cohen, Mannarino, Murray, et al. (2006) suggested constructing a trauma narrative in the form of a book, poem, or picture album. This technique should begin with a more pleasant, nondistressing event that is related to the child’s successes and then segue into low distress trauma events. Next, the child should be helped to chronicle the abuse events, going to the
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Lawson level of detail that can be tolerated at the time, describing a beginning, middle, and end to the story. New details can be added as the story is retold. The narrative may include related distressing events, such as telling parents, medical exams, and involvement of law enforcement. The emotionally engaged retelling of the traumatic event within a safe and therapeutic environment is the active ingredient in reducing affect dysregulation (Briere & Scott, 2006). This process is repeated until the child is able to relate the trauma narrative with manageable emotional responses. The child can use relaxation skills to maintain his or her distress level within the therapeutic window.
Cognitive Processing and Deriving New Meanings The focus during this phase of treatment is on challenging and replacing inaccurate and distorted thoughts resulting from processing the traumatic experience. Because they have a greater capacity for abstract thought, older children, more so than younger ones, tend to have more complex and distorted thinking about the traumatic event. They may search for something they did to cause the trauma in order to regain a sense of control, or they may view their world as unsafe. Particular problematic cognitions relate to shame, self-blame, survivor guilt, seeing the world as unsafe, being different, and thinking others do not believe their story (Deblinger & Runyon, 2005). These beliefs are predictive of psychological symptoms at both the time of the abuse disclosure and 12 months postabuse (Feiring, Taska, & Lewis, 1998). Most trauma models use standard cognitive techniques to process distorted cognitions: (a) identify inaccurate thoughts elicited from processing the trauma narrative, (b) interrupt the upsetting thought, (c) process the child’s reasoning and perspective, and (d) replace distorted beliefs with more accurate and reasonable ones. Counselors use Socratic questions, role play, creating alternative views, and perspective-taking exercises to challenge and replace distorted thoughts.
Consolidation and Relationship Enhancement This final phase of treatment helps the child and parents integrate the skills and the new beliefs and behaviors they have learned. They can now apply their new learning in low threat, real-world contexts, such as stores and malls, and with safe but unfamiliar people or places. Recovery is further enhanced as children reconnect with peers (Cohen, Mannarino, Murray, et al., 2006). More conjoint family work, including nonabused siblings, will likely be necessary with less cohesive and less supportive families. Issues related to believing the child; tolerating and managing reactions; establishing a safe and supportive environment; and establishing clear, functional, generational boundaries should be addressed (Faust & Katchen, 2004).
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Progress may be hampered until complementary family or caregiver dynamics have taken place. The experience of trauma and subsequent symptoms and life disruptions often dominate a person’s life (Cook et al., 2003). Few gratifying experiences are accrued during this time. Thus, both children and parents need to engage in activities that provide a sense of mastery, enjoyment, and spontaneity. This may involve solitary activities (e.g., hobbies, reading) as well as activities with others such as social activities, sports, hiking, playing games, and various physical activities. An important treatment approach is the use of psychopharmacological treatment. Some clinicians have suggested using medications only after counseling has proven ineffective (Donnelly & Amaya-Jackson, 2002). Others (Perry, 2006) have suggested that medications can restrict emotional dysregulation to make counseling possible, but that medications alone cannot create new, healthy neural connections without repetitive, interpersonal therapeutic activities. Research supports the effectiveness of medications in treating trauma symptoms such as nightmares, reexperiencing, hyperarousal, and comorbid depression (Brown, Albrecht, McQuaid, Munoz-Silva, & Silva, 2004).
Treatment Effectiveness Interventions that have been effective in treating abused adults have been adapted to treat CM (Cohen et al., 2000). However, treatment research on CM has developed at a much slower pace than research with adults. Early treatment effectiveness research on CM has produced conflicting results. Narrative reviews have examined study results and have drawn conclusions on the basis of nonstatistical methods analysis as opposed to a statistical method such as meta-analysis. These studies concluded that psychological treatment for CM victims (e.g., Cohn & Daro, 1987; Belsky, 1993) and offending parents (e.g., Cohn & Daro, 1987) was largely ineffective. Other reviews showed that CM victims improved following treatment (e.g., Azar & Wolfe, 1998; Finkelhor & Berlinger, 1995). These latter reviews found treatment to be effective with physically abused and neglected children (Oates & Bross, 1995) as well as sexually abused children (Finkelhor & Berliner, 1995). Reeker, Ensing, and Elliot (1997) conducted a meta-analysis of 15 studies that examined the effects of group treatment for children who were sexually abused and found that treated children improved in their functioning following treatment. These early studies have been criticized for weak methodologies such as the lack of comparison groups, nonrandomization of participants, use of one-group pretest/posttest designs, and failure to distinguish between types of maltreatment in comparisons (Skowron & Reinemann, 2005). In particular, a lack of control groups makes it difficult to confirm the effects of treatment because many abused children improve over time without treatment (Oates, O’Toole, Lynch, Stern, & Cooney, 1994).
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Understanding and Treating Children Who Experience Interpersonal Maltreatment To address these methodological concerns, Skowron and Reinemann (2005) conducted a meta-analysis that examined only controlled outcome studies of CM treatment. They identified 21 studies that examined treatment effectiveness that met the following criteria: (a) included victims of physical abuse, sexual abuse, neglect, or multiple types of abuse; (b) included a control group from the same population; (c) studies had sufficient detail to calculate effect sizes; and (d) studies were published in English-language journals. Because of the small number of well-conducted studies, the authors did not distinguish between types of CM. Twenty studies identified their treatment approach: 12 were cognitive behavioral, 3 were nonbehavioral (i.e., psychodynamic, humanistic, and developmental-ecological), and 5 used combination treatment approaches. Overall, children who received treatment were better off than 71% of those in the control groups. Nonbehavioral treatment approaches produced larger treatment effects (n = 3; d = .87) than did CBT (n = 12, d = .40). The authors urged caution in interpreting these differences because of the small number of nonbehavioral studies and the significant difference in length of treatment between the two types of approaches. The nonbehavioral approaches averaged 1 year compared with 3 months for CBT. Treatment effectiveness in these studies is most likely related to both type of treatment and length of treatment. This notion is important given that many CM studies have found CBT treatment to be superior to nondirective supportive or child-centered therapies with brief duration (12 to 16 weeks; Cohen, Mannarino, & Knudsen, 2005). Skowron and Reinemann’s (2005) meta-analysis provides strong support for the effectiveness of treatment with maltreated children and addressed many of the weaknesses in earlier reviews. However, it is difficult to draw conclusions about differences between treatment models because of confounding variables such as differences in treatment lengths, failure to consider severity of CM, or developmental differences between children. Although the Skowron and Reinemann meta-analysis indicated greater treatment effects for nonbehavioral over cognitive behavioral approaches, in general, comparison studies provided support for CBT over the nonbehavioral approaches for treating CM (Cohen, 2005; Saywitz et al., 2000).
Comparison Studies In a study with 67 sexually abused preschool children, the children and their parents were assigned to either CBT or nondirective supportive therapy (NST) for 12 individual sessions for both the child and the parent (Cohen & Mannarino, 1996). Results indicated no significant symptom change for the NST group but highly significant symptom change for the CBT group. A similar study by Cohen et al. (2005) with 82 sexually abused children (ages 8–15 years) and their parents indicated significantly greater improvement on symptoms among participants in the CBT group at 6- and
12-month follow-up than with an NST group. Other studies produced similar results, with the CBT groups showing superior treatment effectiveness compared with NST groups, for sexually abused children and their parents (Deblinger et al., 1996), in separate CBT groups for children and their parents (Deblinger et al., 2001), and with physically abused children and their families (Kolko, 1996). Kolko’s (1996) study is the only randomized clinical study conducted with physically abused children and their offending parents. Different from other studies, Kolko’s study compared CBT, family therapy, and case management. Results indicated that both CBT and family therapy were superior to case management in reducing internalizing and externalizing symptoms, child-to-parent aggression, parental distress, abuse risk, and conflict. The CBT group reported fewer peer-related problems and less drug use, whereas those in the family therapy group reported a greater reduction in parent-reported violent behavior toward children and family conflict from posttreatment to 1-year follow-up. This study provided strong support for the inclusion of parents in treatment. King et al. (2000) provided additional support for including family members in treatment. They randomly assigned 36 sexually abused children and adolescents to one of three treatment groups: child alone CBT, family CBT, or waiting-list condition. Children in both CBT treatment groups improved significantly more than the wait-list group. Including family members (family CBT) showed an additional benefit in decreasing fear at a 3-month follow-up. The most recent CBT study was conducted by Cohen et al. (2004) with a large (N = 229), multisite, randomized trial comparing trauma-focused CBT and child-centered therapy in treating sexually abused children with PTSD and their parents. Both abused children and their parents reported greater improvement in PTSD symptom reduction, depression, shame, and behavior problems and more effective parenting practices with the CBT than with childcentered therapy. These results were consistent at 6- and 12-month follow-up (Deblinger, Mannarino, Cohen, & Steer, 2006). Studies consistently demonstrate that CBT with a parent/family component is more effective than nonbehavioral treatment over 12 to 16 weeks. Beyond CBT and nonbehavioral therapies, recent studies have been conducted using Parent Child Interaction Therapy (PCIT) with CM. PCIT combines attachment based play therapy to enhance the parent–child attachment along with social learning-based parenting skills to provide appropriate, nonpunitive discipline. PCIT research results are promising, suggesting decreases in child behavior problems, decreases in parental stress, increases in positive parent–child interactions, and decreases in abuse risk with parent–child dyads with a history of physical abuse (Fricker-Elhai, Ruggiero, & Smith, 2005; Timmer, Urquiza, & Zebell, 2006).
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Implications Research Although this review provided strong support for intervention versus no intervention with CM and the superiority of CBT and parent-based treatment over nonbehavioral therapies, these results must be viewed within the context of initial research results. For example, CBT and parent treatment has been conducted almost exclusively with sexually abused children. There is only one randomized controlled trial with physically abused children (Kolko, 1996) and one with neglecting families (Gaudin, Wodarski, Arkinson, & Avery, 1990). Thus, it is difficult to draw conclusions about the effectiveness of CBT and parent treatment beyond sexually abused children without more research on other types of CM. A major hurdle is that often, the various types of maltreatment co-occur, making it difficult if not impossible to tease out the impact of treatment on the different types of maltreatment. Furthermore, existing studies have not distinguished between treatments for single incident versus chronic abuse cases, which is critical for selecting the most appropriate and effective treatment used. Similarly, developmental considerations for children and adolescents have seldom been addressed empirically even though most clinicians and researchers clearly realize adjustments in treatment must be made based on a child’s age. Moreover, although the therapeutic alliance is deemed to be critical, no CM studies have examined this variable. Although the majority of clinicians and researchers suggest integrative approaches (i.e., combining CBT, family therapy, parent training, attachment-based therapy), it is unclear which components are most helpful or in what way each component is helpful in bringing about change (Cohen et al., 2000). These areas must be addressed in future research. Practitioners Given the research to date, no single type of intervention is likely to be equally effective for all types of children or with all types of CM. Treating CM, especially chronic, severe cases, is complex and requires multiple levels of treatment and flexibility in treatment implementation. Close examination of current empirically supported CBT indicates an emphasis on the therapeutic alliance and attachment-related issues as a critical context for successfully implementing CBT (e.g., Cohen, Mannarino, Murray, et al., 2006; Kolko, 1996), thus providing support for the therapeutic relationship characteristic of nonbehavioral treatments. Additionally, many empirically supported CBT models also include a strong parent/family component (e.g., Cohen, Mannarino, Murray, et al., 2006; Faust & Katchen, 2004). Perhaps many of the current empirically supported CBT models should be considered integrative approaches that use cognitive behavioral and parent/family interventions but within a child-centered context that is informed by attachment theory. Yet even within this framework, practitioners must think developmentally in implementing the 212
various interventions based on both the child’s and the parent’s ability to respond to the treatment regime. This concept is reflected in the general acceptance of a phase-based model of treatment. Practitioners must also be flexible in the use of interventions within each phase, titrating the intensity, pace, and length of treatment for each client.
Conclusion CM is a wide ranging problem that can have adverse effects both immediately following the maltreatment and into adulthood in some cases. Although counselors have been treating CM for many years, only in recent years has research been conducted to study critical issues related to effective treatment. Although the specifics of treatment effectiveness have yet to be sorted out, research does indicate that treatment is superior to no treatment and that CBT and family/parent models have been shown to be the most effective type of treatment across a number of comparison studies. However, counselors must consider such issues as severity and frequency of the trauma, age of the victim, parent/family support, and dosage of treatment in implementing appropriate treatment for each case.
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