More support needed for trauma intervention

In the wake of the Penn State sexual abuse scandal, legislators are looking for ways to protect children from abuse. Less than two weeks after Penn State officials were charged with perjury and failing to report suspected child abuse, Sen. Robert Casey Jr. (D-Pa.) introduced legislation that would pressure states to have and enforce laws requiring all adults to report suspected child abuse and neglect.

Decades of research spell out the long-term consequences that abuse can have for children. The ongoing CDC “Study of Adverse Childhood Experiences,” for example, shows that children who are abused and neglected have an increased risk of severe mental and physical health problems, including post-traumatic stress disorder, depression, suicide, substance abuse, chronic obstructive pulmonary disease, ischemic heart disease and liver disease.

But just as important as identifying cases of abuse is supporting treatments that help victims recover. Psychologists have developed evidence-based interventions that can reduce the harmful effects of child abuse. The key is ensuring that all individuals who experience abuse have access to these evidence-based treatments, so they don’t become victims for life, says psychologist Anthony Mannarino, PhD, vice chair of the department of psychiatry, Allegheny General Hospital, Pittsburgh, and professor of psychiatry at Drexel University College of Medicine.

“With treatment, these kids can have the resilience to overcome their experience,” says Mannarino, who through APA submitted written testimony to a Dec. 13 hearing on child abuse held by the Senate Health, Education, Labor and Pensions Subcommittee on Children and Families. “Being a victim doesn’t have to become who they are or how they define themselves. But if they don’t get help and their families don’t participate, they can have long-standing difficulties.”

Scope of the problem

The Penn State case serves to remind the public that child abuse is all too common in the United States. Although estimates vary greatly depending on the source, the Fourth National Incidence Study of Child Abuse and Neglect, released in 2010, found that in 2005–06, one child in 25 in the United States, or 2.9 million children, experienced some kind of abuse or neglect. Most of those children — 77 percent — were neglected. Of the 29 percent of those children who were abused, 57 percent were physically abused, 36 percent were emotionally abused and 22 percent were sexually abused.

Estimates of the percentage of abused children who will suffer long-term consequences vary widely. One review of research on child maltreatment — including physical and sexual abuse as well as neglect — published in the 2004 “Posttraumatic Stress Disorder In Children and Adolescents: Handbook,” found that PTSD rates ranged from 20 percent to 63 percent. In her studies, psychologist Sheree Toth, PhD, director of the Mt. Hope Family Center in Rochester, N.Y., and associate professor at the University of Rochester, finds that as many as 90 percent of maltreated infants have insecure or disorganized attachment. “The bright side is that there are evidence-based treatments that can dramatically improve the prognosis for these kids,” says Toth. “We’ve shown that with intervention we can greatly decrease rates of insecure and disorganized attachment.”

Interventions that work

A study published in 2006 in Development and Psychopathology by Toth and her colleagues showed that before intervention, 90 percent of a group of 137 maltreated infants had disorganized attachment and only one infant had secure attachment. Of the 50 infants who subsequently received one of two evidence-based therapies — infant-parent psychotherapy or a psychoeducational parenting intervention — 58 percent had secure attachment a year later. In comparison, only one child among the 54 who received the standard treatment available in the community had secure attachment a year later.

Other researchers have shown positive results using evidence-based treatments to decrease the incidence of PTSD, depression, aggression and other behavioral problems seen in abused children. Mannarino, for example, has spent more than 25 years developing and testing an intervention called Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to treat children age 3 and older who have post-traumatic stress symptoms from abuse. In 12 to 16 sessions, children and their non-offending parents or caregivers learn about the specific effects trauma can have on emotions and behavior, and develop skills to manage their emotional distress, including relaxation techniques and how to use words to express their feelings.

In addition, the therapists help the children construct a narrative about their experience. “We talk about the idea of making the unspeakable speakable,” says Mannarino. “By showing them that it’s OK to talk about it, it makes the experience less overwhelming.”

Many child abuse experts agree that, to date, TF-CBT has a strong base of empirical support as an intervention to treat trauma in children, with 10 randomized controlled trials, all showing its effectiveness. The studies show that as many as 85 percent of children treated with TF-CBT get markedly better on measures of shame, PTSD and depression, says Mannarino. Parents improve as well, showing less depression and emotional distress, better parenting skills and having a better outlook for the future.

Another highly regarded intervention is Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT), whose senior developer is David Kolko, PhD, professor of psychiatry, psychology and pediatrics at the University of Pittsburgh School of Medicine. AFCBT is designed to address individual and family involvement in conflict, coercion and aggression, including hostility and anger, mild physical force and child physical abuse. Its focus on physical abuse includes joint and individual work involving the alleged perpetrator — in most cases abusing parents or caregivers — and the child at various times throughout treatment. Working with the adult offender makes treatment complicated clinically, says Kolko, and may require additional time, but his team sees good results from this integrated approach.

Kolko also directs a program that provides services to the adolescent sexual offender, called Services for Adolescent and Family Enrichment. His program — which is funded by the local court system — has kept data on more than 250 cases and finds a two-year recidivism rate of only 1.5 percent, he says.

Unfortunately, access to these evidence-based treatments for child abuse is “pitiful,” says Toth. Because researchers have developed them in university settings, they’re mostly available near big medical centers. In addition, only 45 percent of graduate programs and 51 percent of internships that train psychology students to treat abused or otherwise traumatized children use TFCBT, according to two studies published in December in Psychological Trauma: Theory, Research, Practice, and Policy and Training and Education in Professional Psychology.

That’s why Mannarino is putting much of his efforts these days into training and dissemination of TF-CBT around the country.

“Despite our ability to treat these kids, the real truth is that most kids who are abused are never properly treated,” says Mannarino. “They grow up bearing the scars of unfortunate victimizations and wind up having serious adult problems, including depression, psychiatric hospitalizations and a general overuse of health services because they didn’t get the help they needed.”

Beth Azar is a writer in Portland, Ore.