Expectations test: trauma scales for sexual abuse, physical abuse, exposure to family violence, and posttraumatic stress

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Sanctuary in a residential treatment center: creating a therapeutic community of hope countering violence

Purpose

– The purpose of this paper is to present insights into how and why the Sanctuary and SELF models are effective in decreasing trauma symptoms with a population of court-committed male adolescents in a residential treatment program. The Sanctuary model is a trauma-focussed, trauma-sensitive, organizational change model, and treatment protocol approach to working with clients who have experienced trauma, loss, and toxic stress to the degree that they interfere with social and personal functioning. The SELF model within Sanctuary is a treatment protocol that is an acronym for the organizing categories of safety, emotion management, loss, and the future. In essence, Sanctuary’s purpose is to create therapeutic community.

Design/methodology/approach

– Qualitative research methods of observation of groups and meetings, content analysis of existing quantitative data and agency documents, focus groups with staff and residents, and individual interviews with staff were utilized.

Findings

– Data show that the Sanctuary model ameliorates the symptoms of complex trauma. The substantive theory that emerges is that relational and neurological integration and recovery occur in the lives of residents as shaped first by the therapeutic community that supports the level of interpersonal relationships experienced with staff within a therapeutic milieu, along with shaping the organizational culture.

Research limitations/implications

– As a complex intervention, it is evident that reducing the Sanctuary model into its component parts cannot capture fully the essence of the intervention. A complex system can never be understood fully by observing it at single points in time.

Practical implications

– It is suggested that future research and programmatic planning within this therapeutic community need to demonstrate how to continue enhancing staff-resident relational integration vis-à-vis staff training and vehicles that offer residents more of a representative voice while in placement.

Social implications

– It is suggested that future research and programmatic planning within this agency need to demonstrate how to continue enhancing staff-resident trauma-informed therapeutic milieus and relational integration vis-à-vis staff training and vehicles that offer residents more of a representative voice while in placement.

Originality/value

– This is a unique study in that it employs qualitative methods to explore how and why the Sanctuary model contributes to its working in a residential treatment facility. The Sanctuary model is the only trauma-informed organizational intervention of its kind, with limited published evaluations in the current literature (Esaki et al., 2013). This study used focus groups with residents and staff that allowed them to influence the research and its processes. The residents expressed their views about the experience of being placed outside of their homes and of living in a therapeutic community within the Sanctuary Network. Staff spoke of aspects of working in a trauma-informed milieu and its effect on clients, colleagues, and the organization as a whole.

Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center

This paper examines the sustainability and outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as delivered by practitioners in a community-based child protection program who had received training in the model several years earlier. Formerly described as Abuse-Focused CBT, AF-CBT is an evidence-based treatment (EBT) for child physical abuse and family aggression/conflict that was included in the National Child Traumatic Stress Network's initial EBT dissemination efforts in 2002. Seven practitioners participated in a year-long learning collaborative in AF-CBT and in similar training programs for 4 other EBTs. The agency's routine data collection system was used to document the clinical and adjustment outcomes of 52 families presenting with a physically abused child who received their services between 2 and 5 years after the AF-CBT training had ended. Measures of the use of all 5 EBTs documented their frequency, internal consistency, and intercorrelations. Controlling for the unique content of the other four EBTs, the amount of AF-CBT Abuse-specific content delivered was related to improvements on standardized parent rating scales (i.e., child externalizing behavior, anger, anxiety, social competence) and both parent and clinician ratings of the child's adjustment at discharge (i.e., child more safe, less scared/sad, more appropriate with peers). The amount of AF-CBT General content was related to a few discharge ratings (better child prognosis, helpfulness to parents). These novel data provide suggestive evidence for the sustainability and clinical benefits of AF-CBT in an existing community clinic serving physically abused children and their families, and are discussed in the context of key developments in the treatment model and dissemination literature.

Runaway and pregnant: risk factors associated with pregnancy in a national sample of runaway/homeless female adolescents

PURPOSE

Homeless youth are at particularly high risk for teen pregnancy; research indicates as many as 20% of homeless young women become pregnant. These pregnant and homeless teens lack financial resources and adequate health care, resulting in increased risk for low-birth-weight babies and high infant mortality. This study investigated individual and family-level predictors of teen pregnancy among a national sample of runaway/homeless youth in order to better understand the needs of this vulnerable population.

METHODS

Data from the Runaway/Homeless Youth Management Information System (RHY MIS) provided a national sample of youth seeking services at crisis shelters. A sub-sample of pregnant females and a random sub-sample (matched by age) of nonpregnant females comprised the study sample (N = 951). Chi-square and t tests identified differences between pregnant and nonpregnant runaway females; maximum likelihood logistic regression identified individual and family-level predictors of teen pregnancy.

RESULTS

Teen pregnancy was associated with being an ethnic minority, dropping out of school, being away from home for longer periods of time, having a sexually transmitted disease, and feeling abandoned by one's family. Family factors, such as living in a single parent household and experiencing emotional abuse by one's mother, increased the odds of a teen being pregnant.

CONCLUSIONS

The complex problems associated with pregnant runaway/homeless teens create challenges for short-term shelter services. Suggestions are made for extending shelter services to include referrals and coordination with teen parenting programs and other systems of care.