Developmental Problems of Maltreated Children and Early Intervention Options for Maltreated Children. Clinic-Based Mental Health Treatment

04/23/2007

As discussed previously (see Part 1), a substantial proportion of maltreated preschoolers exhibit disruptive behavior, anxiety, and relational problems. For these children with emotional and behavioral disorders (or heightened symptomatology), specialized treatment is warranted. At this time, many empirically supported treatments are available for older maltreated children, but treatments for children younger than age 3 are limited. A committee of scholars from a number of abuse-related programs, universities, and hospitals recently identified three psychotherapy interventions as best practices (Chadwick Center for Children and Families, 2004): trauma-focused cognitive behavioral therapy (TF-CBT), abuse-focused cognitive behavioral therapy (AF-CBT), and parent-child interaction therapy (PCIT) (although these interventions are yet to be tested for a variety of different ethnic populations and their efficacy is also unknown when these treatments are delivered by practitioners with less formal training and experience). The panel of scholars came to consensus that these interventions had empirical support from efficacy and effectiveness studies, had sound theory, were unlikely to do harm, had a manual, and could be used in an office setting (Saunders, Berliner, & Hanson, 2003). Of important note, the CBT treatments can be used for maltreated children who are age 3 years whereas the PCIT may be used for children ages 2 years and older. These treatments and others are discussed below.

TF-CBT and AF-CBT both use cognitive behavioral theory and principles as the foundation of treatment. Specifically, both of these treatments normalize the emotional and behavioral reactions of young maltreated children and their families as well as seek to change maladaptive behavior by providing or taking away reinforcements or punishments (behavioral theory) while altering distorted perceptions by stopping, challenging, correcting, and replacing beliefs that maintain dysfunction (cognitive therapy). TF-CBT, in particular, is designed for children who have posttraumatic symptoms as a result of sexual abuse. Maltreated children and their nonabusing family members learn various stress management skills (e.g., focused breathing, muscle relaxation, stopping disturbing thoughts, and replacing abuse-related thoughts with appropriate cognitions) and practice these techniques during graduated exposure to abuse-constructed trauma. Parents learn how to address their own emotional reactions and guilt in response to their child's sexual abuse and are taught how to help their children discuss or cope with abuse-related reactions (or both). Children who participate in TF-CBT show significant improvement in their fear reactions, depressive symptoms, inappropriate sexualized behaviors, and poor self-worth or self esteem compared with children receiving nondirective supportive therapy (Cohen, 2003, Cohen & Mannarino, 1997; Deblinger, Stauffer, & Steer, 2001).

AF-CBT treatment is designed to help physically abused children and their offending parents by targeting underlying contributors to maltreatment. Specifically, changing parental hostility, anger, maladaptive coercive family interactions, negative perceptions of children, and harsh parenting are the targets of treatment. The treatment protocol has individual child and caregiver components as well as dyadic work. Abused children are helped to view abuse as wrong and illegal and are taught emotional comprehension, expression, and regulation as well as needed social skills. Parents learn proper emotion regulation skills, how to avoid potentially abusive situations, and healthy child management and disciplinary techniques. Dyadic work, when offered, gives families an opportunity to measure progress, help identify and clarify family miscommunication, and establish a family no-violence agreement. The major outcome of this therapy is changing parental behavior that is associated with maltreatment. That is, parents decrease escalating behavior and harsh physical discipline. Benefits to children include a decrease in behavioral problems (e.g., defiant, oppositional, and aggressive behaviors), increased social skills, and improved peer relations (Chalk & King, 1998; Kolko, 2002).

PCIT was originally created for children with oppositional defiant disorder (ODD). However, because children with ODD and preschoolers who are physically maltreated are similar in the difficulty they experience when complying to parental commands, their engagement in frequent negative interaction with parents, and their exposure to coercive and harsh parenting practices, PCIT treatment has translated well for use with physically abused children (ages 2-8) and their families. The foundation of this treatment is to establish and strengthen the positive relationship between parent and child. From this healthy, enjoyable relationship, both parents and children are motivated to engage in behavior that maintains positive interactions. Through real-time coaching (i.e., a listening device in the parent's ear or in-the-room coaching), parents are trained to become more sensitive and child-focused. Parents are encouraged to praise, reflect, imitate, and describe their child's behaviors while being emotionally positive. Parents are also reminded to avoid over-initiation and to refrain from giving commands (e.g., No, don't, stop, quit, not) while interacting with the child. Only after a positive relationship is formed does the treatment focus on child compliance issues. In a later stage of treatment, parents learn how to give clear commands.

Parents practice newly learned skills while interacting with their child, both under the watchful eye of the therapist in session and independently at home. Results have shown that families who participate in this treatment increase positive interaction and reduce harsh, coercive interactions (Chaffin et al., 2004). Additionally, child benefits include improved compliance and reduced problem behaviors (Timmer, Urquiza, Zebell, & McGrath, 2005). It is important to note that the benefits of this treatment have been shown to generalize to other children in the family, indicating that parents use these effective strategies with their other children. Despite its usefulness, this treatment was designed for children between the ages of 2.5 and 8 years and is not indicated for sexually abusive parents; parents who have limited contact with the child; or parents who have hearing or language disorders, hallucinations, or delusions. However, PCIT has now been adapted for children between the ages of 12 and 30 months (Dombrowski, Timmer, Blacker, & Urquiza, 2005). Using this treatment for toddlers has promise; nevertheless, more research is needed.

There exist other treatments designed for maltreated toddlers and preschoolers, which  although not yet given the best practices seal  are gaining empirical support. For instance, resilient peer training intervention, using CBT principles, has been used to improve the social involvement of withdrawn maltreated preschoolers (Fantuzzo, Jurecic, Stovall, & Hightower, 1988; Fantuzzo, Manz, Atkins, & Meyers, 2005). This treatment involves allowing inhibited maltreated preschoolers to play with more socially skilled peers while getting verbal encouragement and praise from an adult. Results show that the inhibited and withdrawn preschoolers increase social overtures during the play session with the peer and show increased social interaction outside the session (compared with control group children who received play time without the prompting and encouragement of a socially skilled peer and adult). The second promising treatment for maltreated preschoolers is child-parent therapy. This treatment is designed for preschoolers suffering from PTSD symptoms after having witnessed domestic violence, and it has been found to be successful (Lieberman, Van Horn & Ippen, 2005). In particular, child behavior problems, traumatic stress symptoms, diagnostic status, and exacerbating maternal symptoms were significantly lower than for children and families who received regular case management plus community referrals for individual treatment. Finally, the Incredible Years Parenting Program  an efficacious parent training program for nonmaltreated children with conduct problems (Taylor, Schmidt, Pepler, & Hodgins, 1998)  is shown to prevent problem behavior in Head Start populations (Webster-Stratton, Reid, & Hammond, 2001) and in preschoolers with older siblings who exhibit conduct problems (Brotman et al., 2005; Brotman et al., 2003). It has been further tested with maltreating parents (Hughes & Gottlieb, 2004). Results of the study demonstrated that mothers who participated in the program increased their positive involvement with children, compared with waitlisted control group mothers, although child behavior did not change as a result of the intervention. Further research is needed to ascertain whether maltreated children and their parents may need a higher treatment dose of The Incredible Years program, whether opportunities for individualized attention are needed to alter maladaptive child behaviors, or both. The call for further research applies to this and other promising interventions. Specifically, more research is needed to determine whether and how these treatments will benefit maltreated children and how these treatments compare with other known efficacious treatments involving similar treatment outcomes.

Additionally, as the pressure increases to offer young maltreated children and their families empirically supported treatments, researchers have identified treatments that demonstrate efficacy and utility that is questionable or poor. For example, trauma-focused play therapy (Gil, 1991, 1998)  which has been used  has not been empirically tested and, therefore, has unknown clinical utility (Saunders et al., 2003). Some therapies designed to improve abnormal or pathological attachments (often seen in maltreated parent-child dyads) have been deemed potentially dangerous, as in the case of attachment or holding therapies (Hanson & Spratt, 2000; Lieberman & Zeanah, 1999; Saunders et al., 2003), or deemed less effective, as in the case of therapies that seek to change parental mental representations rather than increase parental sensitivity (Bakermans-Kranenburg, Van Ijzendoorn, & Juffer, 2005).

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