Young people and their experiences of trauma focused therapy

There is so much research around that discusses the success of therapeutic approaches in terms of measuring changes and outcomes in individuals and the ease of which a therapist can utilise an approach, that it is really great to see research that looks at the experience of the individual during the therapy. This is especially the case when it is the experience of a child or young person. 

Engaging in a useful, helpful and supportive therapeutic relationship with children and young people who have experienced trauma is crucial to the success of therapy and to the ongoing wellbeing of the young person. We now know so much about the long term damaging impact that trauma can have, that effective therapy can be our chance to mitigate this impact and change the trajectory for the child. 

New research appearing in the Child Abuse & Neglect journal, has looked at the experience of receiving Trauma-Focused Cognitive Behavioural Therapy (TF - CBT) from the perspective of the young people involved in the therapy. There have been several studies that have demonstrated the efficacy of TF-CBT, both with adults and young people. The authors of this study state that they believe that this is the first to really examine the experience of TF-CBT from the a young persons perspective. 

"Because therapeutic work with traumatised children who struggle with posttraumatic stress symptoms may entail specific challenges, gaining greater knowledge from the children themselves about what is experienced as difficult or helpful in therapy may bring the field a step closer to helping the many children who suffer from traumatic experiences."

The authors of this study interviewed thirty 11-17 year olds in the weeks after they had completed their treatment. Their traumatic experiences included events such as bullying, sexual abuse and violence within and outside of the family. 

Results
Responses were grouped in to four main themes: 

• changing expectations (expectations of the therapist, expectations of the process)
• talking to the therapist and sharing information
• working through the trauma narrative
• change and change processes

The study reported that most young people found that engaging in therapy was initially anxiety provoking, but that working with a therapist who was kind, empathetic and knowledgable helped to reduce their anxiety. Primarily this experience of anxiety was around discussing their trauma history with a person they didn't know, which the authors believe may be closely related to the young person experiencing a prior breach of trust with adults and therefor experiencing an increased reluctance to place trust in the therapist. The young people in the study reported that they felt more willing to engage in work around the trauma narrative when the therapist had clearly explained why this was important, was able to work at the child's pace and not push them, and was also able to contain the strong emotions of the child that arose during the trauma narrative. 

Young people involved in the study also reported that confidentiality was particularly important for them, but that when issues around their trauma were discussed with their families (with the permission and prior planning of the young person) that this was helpful and appreciated. 

Most of the young people involved in the study reported that they experienced change as a result of the therapy and that it had assisted them by reducing the symptoms they experienced as well as to develop new skills to manage any trauma symptoms they may continue to experience. 

"Many therapists have found that working with traumatised youths is challenging, and talking about the traumatic events seems to be particularly demanding. However, the data from the present study suggests that youths view working with their trauma stories as one of the most helpful interventions."

Reference: 
Dittmann, I., & Jensen, T.K. Giving a voice to traumatized youth - Experiences with Trauma-Focused Cognitive Behavioral Therapy. Child Abuse & Neglect (2013). 

Better outcomes for vulnerable kids

Over the past few months we have had an increasing number of requests to present and provide training on what trauma informed care means. We have also noticed more and more training organisations are adding a trauma informed care course to their training packages. 

So, it was interesting to read more about what is being done to help organisations and systems that work with children, to work in a way that promotes the best interests of traumatised children. One of ways this is being done in the United States, is through Trauma Systems Therapy (TST).  TST has been developed by New York University and aims to enhance trauma informed systems in a way that they are able to work more effectively with children. It does not take the place of individual therapy for the child, but helps to change the systems that are involved in providing care and support for the child. A recent article in the Huffington Post talks about the application of TST with a young boy with a history of complex trauma. 

TST is based on the belief that traumatised children have a great deal of difficulty in regulating their emotional states and that the systems that support them is not able to assist the child to contain this dysregulation.

"the essence of TST is to help the child gain control over emotions and behaviour via enhancing the child's capacity to regulate emotion and diminishing the ongoing stresses and threats in the social environment. TST was also designed to build the capacity of significant others in the child's environment to help the child control his or her emotional and behavioural responses".  

TST is starting to be implemented in an increasing number of settings across the US. There has been some evaluation done that has shown positive outcomes, especially in working with children involved with child protection systems. 

Helping families, schools, child protection systems and other organisations that work with children, to understand more about how trauma impacts on children and to find the most effective ways to work with traumatised kids, can only lead to better outcomes for this vulnerable group. 

Treating kids affected by child sexual abuse: What's the evidence for psychoanalytic therapy?

Childhood sexual abuse has a devastating impact on many of the children and adolescents who are affected by it. It is a significant problem worldwide and has the potential to have serious negative impacts on mental health and physical health. 

Experiencing childhood sexual abuse often has negative impacts on the individual’s ability to function socially, emotionally and sexually in adulthood.  Childhood sexual abuse not only impacts on the child, but also on the family and the community more broadly.

It is difficult to conclusively state the estimated prevalence of childhood sexual abuse, often due to variations in the definition of sexual abuse. However, a recent meta-analysis of prevalence rates of child sexual abuse estimated a worldwide rate of self-reported sexual abuse of 18% for female participants and 7.6% of male participants (Stoltenborg et al 2011).

Not all children who have experienced childhood sexual abuse will require a therapeutic or mental health intervention. The impact of the sexual abuse can be mitigated by factors such as parental support and family functioning and can be worsened by the presence of other adversities, the severity and duration of the abuse and the lack of support from parents and other carers. Children and adolescents who do require therapeutic treatment following childhood sexual abuse obviously benefit from a treatment that is tailored to the developmental stage and needs of the individual.

This new Cochrane review aimed to:

"Assess the effectiveness of psychoanalytic / psychodynamic psychotherapeutic approaches in treating the effects of sexual abuse (psychologically and in terms of behaviour and social functioning) in children and adolescents."

Another commonly used approach, Cognitive Behavioural Therapy (CBT), was recently the subject of a separate Cochrane systematic review (Macdonald et al, 2012) that found that CBT was potentially able to address the adverse consequences of childhood sexual abuse. This review also concluded that there was a need for other therapeutic approaches, especially psychodynamic therapy, to be evaluated.

A simplistic definition of psychodynamic / psychoanalytic psychotherapy is that it:

"Attempts to explore, through talking, play (with younger children) and the formation of a therapeutic relationship, how earlier experiences influence and perhaps seriously distort current thoughts, feelings, behaviors (actions) and relationships."

You can read more about psychoanalytic / psychodynamic psychotherapy on the PsychCentral website.

Methods
The Cochrane reviewers searched for randomised trials, including quasi-randomised trials, that evaluated a psychoanalytic or psychodynamic psychotherapy versus treatment as usual or versus no treatment control or a waiting list control. Studies that compared psychoanalytic or psychodynamic therapy against an active comparison group (for example, CBT) were excluded. The reviewers also searched for studies that were limited to participants up to 18 years of age and who had experienced sexual abuse. The participants needed to be displaying some symptoms that required treatment. The reviewers were open to including interventions of any duration that were delivered to either individuals and/ or groups and were described as, or judged to be, psychoanalytic or psychodynamic in nature.
Out of the 2,982 studies that were initially identified through extensive database searching only 20 studies were assessed for eligibility against the inclusion criteria for the review. All 20 of these studies were found to be ineligible for the review for a number of reasons including the study type being ineligible, the participants were ineligible, the interventions were ineligible or the control group was ineligible. One of the studies was not able to be included as it discussed a planned trial, rather than one that had already commenced.

Results

The authors summarised their main results as:

"Our review did not find any randomized trials comparing psychoanalytic / psychodynamic psychotherapy with either treatment as usual or a no treatment / waiting list control for children or adolescents who have been sexually abused."

They found this surprising given that they believe that:

"many children and adolescents have been treated in this way and for many health professionals it would still be considered the psychotherapeutic treatment of choice."

Conclusions

There are many possible reasons that the reviewers were unable to identify any suitable studies. Typically there has not been much evidence based research in this area and case studies have been the favoured method for research and review in psychodynamic / psychoanalytic psychotherapy, with the belief that using case studies can richly elaborate the complexity of each case. There has also been reluctance in the field to engage in the scientific evidence base, though many would argue that it is important to bring more empirical evidence to this field in order to bring about a greater understanding of the intervention.

There are also many ethical considerations when it comes to researching children who have experienced sexual abuse. This is especially the case when it comes to developing randomised controlled trials that include no treatment as a comparator for children who have been sexually abused.

The authors highlighted one study that did not meet the criteria for the review. The study was a well designed RCT, but as it compared individual psychodynamic psychotherapy with psycho educational group therapy (rather than no treatment) for girls who had been sexually abused it was excluded. The study did find that the intervention appeared to be effective and therefore does provide limited evidence that the use of psychodynamic therapy be continued (Trowell, 2002).

Sexual abuse rarely occurs in isolation and children who experience sexual abuse are also often faced with many other potentially traumatic events, such as neglect, physical abuse, parental mental health or substance abuse and living in poverty as well as other adversities.  It is often difficult to separate out these children through one single traumatic event, and it may be more prudent to include a broader category of child maltreatment. However it seems that most therapies, including psychoanalytic / psychodynamic therapy have developed specific theoretical models and treatment approaches for different forms of abuse and therefore it may make sense for research to evaluate interventions of these specific forms of abuse, rather than grouping them together.

More research is needed and this should be in the form of carefully designed and well thought out studies that take into account the many ethical considerations that come with working with this already very vulnerable and damaged group of children and young people.

It is vital that children who have been affected by childhood sexual abuse receive the best therapeutic help that they can get. This will benefit them throughout their childhood and adolescence and into adulthood. The reviewers concluded that

"Further examination of the process of psychoanalytic / psychodynamic psychotherapy for this population and what aspects bring about change is also needed. This would greatly help therapists to increase the effectiveness of the intervention.

This article appeared first on the Mental Elf blog. 

Links

Parker B, Turner W. Psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD008162. DOI: 10.1002/14651858.CD008162.pub2.

Macdonald G, Higgins JPT, Ramchandani P, Valentine JC, Bronger LP, Klein P, O’Daniel R, Pickering M, Rademaker B, Richardson G, Taylor M. Cognitive-behavioural interventions for children who have been sexually abused. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD001930. DOI: 10.1002/14651858.CD001930.pub3.

Stoltenborg M, Van IJzendoorn M, Euser E. Bakermans-Kranenburg M. A Global Perspective on Child Sexual Abuse: Meta-Analysis of Prevalence Around the World. Child Maltreatment 2011; 16(2): 79 – 101. [Abstract]

Trowell J, Kolvin I, Weeramanthri T, Sadowski H, Berelowitz M, Glasser D, Leitch I. Psychotherapy for sexually abused girls: psychopathological outcome findings and patterns of change. British Journal of Psychiatry 2002; 180: 234 – 47.

Psychodynamic Therapy. Jim Haggerty, PsychCentral website. 

A tiered approach to addressing childhood trauma and adversity

The experience of childhood trauma and adversity remains a significant problem in Australia. Lots of kids will be exposed to potentially traumatic events and whilst many of them will be resilient, some will go on to develop difficulties with their physical health, mental health, relationships, self esteem and education. 

We talk alot about the impact that trauma and adversity has on kids. But what we really need to know is how to stop kids from being adversely affected from their exposure to trauma and adversity. How do you do this?? It can seem almost impossible. How can we stop children being exposed to abuse and neglect? We can't stop children from being exposed to other adversities, such as separation and divorce, car accidents, a death in the family.

This is why there needs to be a tiered approach to the way that we address the impact of trauma and adversity in children. A tiered approach means having a suite of interventions that are appropriate at different ages and stages and that work to prevent and intervene early in cases of trauma and adversity.

1. Early home visiting programs and parenting support programs for parents with children under 3 years.
Early home visiting programs that target vulnerable families and provide intensive support through regular home visits over an extended period have been shown to be a cost effective way for governments to address the issues of child abuse and neglect. These programs often target vulnerable parents and families, such as first time young parents and those that have a history of abuse themselves and work to form a consistent, supportive relationship between the visiting nurse and the mother with the aim of improving the health and wellbeing of both the parents and the child. The Nurse Family Partnership program in the US has been in operation for 30 years and has demonstrated many positive outcomes.  Outcomes from this program have shown improved parental health, fewer childhood injuries, increased maternal employment and improved school readiness. A similar program is now in Australia, working to support Indigenous mothers.

Another parenting program, with demonstrated outcomes, that has been available in Australia for many years now, is the Triple P program (Positive Parenting Program). This program aims to prevent severe behavioural, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents. This program has been offers support in many different forms - from DVD's that can watched at home, through to group programs and home visiting. There have been several studies that have shown that Triple P works to improve children's behaviour, improve parent child interactions and reduce child maltreatment, out of home care placements and hospital visits.

2. Programs that target kids and families and help to build resilience
Adversity is unavoidable, so helping kids and families have the skills necessary to get through tough times is essential. There are many programs for kids that help to support and build resilience. Kids Matter is an early childhood and primary school initiative that has been successful in reaching out to a great number of children and improving mental health and wellbeing. 

3. Increasing the knowledge and information that is available to families and the community
Families and the community need to know more about the impact that trauma and adversity has on kids. This includes more information about how kids of different ages and stages respond to trauma and adversity, what factors may make children more vulnerable in the face of adversity and what families can do to protect and support children. The Trauma and Grief Network: Supporting Families website has worked to develop tip sheets and resources that increase family knowledge of these impacts and their ability to respond to them. 

4. Increasing professionals knowledge and information about the impacts of trauma and adversity and how this contributes to other mental health difficulties
We know from the large body of research that is now available, that trauma and adversity has the potential to impact on a childs mental health, physical health, behaviour and education. The diverse range of professionals who work with children need more knowledge and information about how trauma impact on children. Mental health professionals need more information and knowledge about how trauma and adversity impacts on a child's mental health. School professionals need more information and knowledge about how trauma and adversity may impact on the child's ability to learn and their ability to function in the classroom. Early childhood professionals and those working with vulnerable families need more informaiton and knowledge on the impacts on behaviour and parent child relationships. Our (the Australian Child & Adolescent Trauma, Loss & Grief Network) website has been working to develop resources, hold webinars and is currently developing an e-learning module to increase knowledge and information for a diverse range of professionals working with children. 

5. Trauma informed systems and incorporating knowledge about and response to trauma within services
The practice of considering trauma needs to be incorporated into the systems and practices of agencies working with children affected by trauma and adversity. Recently, at the Journey 2 Recovery conference, there were some great stories of services that had successfully incorporated trauma informed care into their programs for kids, and with great success for both the staff and the children they worked with. A presentation by Burnside on incorporating a trauma informed system into their residential care was particularly inspiring. 

6. Trauma specific systems - with evidence based interventions for kids that directly target the impact that the trauma has had on the child.
Trauma specific services are those that treat kids that we already know have experienced a significant trauma. Judy Atkinson recently wrote a great paper on trauma informed services and trauma specific care. Once children are recognised as experiencing difficulties as a result of trauma or adversity, they then needed to be treated with approaches that we know are going to help them. In our last blog, we discussed the treatment guidelines for Post Traumatic Stress Disorder (PTSD) from the Australian Centre for Post Traumatic Mental Health. There are a number of interventions that are used to treat children who have PTSD or other mental health or emotional difficulties as a result of trauma, however, many of these need further research to ensure that they are actually effective in their approach. 

In the end, we all need to be keeping trauma and adversity in mind in our work with children. And we need to continue to make these issues part of the national agenda. Intervening early for kids who have experienced trauma and adversity means preventing the onset of many mental health, social, emotional and educational difficulties. 

Australian guidelines on treating trauma

This week, the Australian Centre for Posttraumatic Mental Health (ACPMH) released their latest Guidelines on the treatment of Posttraumatic Stresss Disorder (PTSD) and Acute Stress Disorder (ASD). The ACPMH are to be congratulated on the development of such a comprehensive resource. 

Of course, we were particularly interested to read what they had to say about the treatment of trauma in kids. The guidelines highlight that around two third of kids in the US will experience a traumatic event by the time that they are 16 years old, and we can say that similar statistics have been found in Australia as well. Whilst most of these events will be potentially traumatic events (ie most kids will be resilient but some will experience negative outcomes as a result of the trauma), it really show us the need to pay more attention to kids and trauma. 

The guidelines provide great guidance for clinicians on the important considerations around family: such as the impact that the family functioning will have on the child's response to the traumatic event; the importance and need to engage with the family, especially in the treatment of younger children; and the differences that can sometimes be present in the child and parents understanding of the impact of the traumatic event. 

The ACPMH has included a good summary of the literature around the pre and post trauma risk factors for the development of trauma in children. The identification of these risk factors being so important in the prevention and early intervention of trauma. 

These guidelines provide us with some interesting insights around the treatment of PTSD in children and adolescents. First of all, it is worth noting that the guidelines remind us that when a child is exposed to trauma, it is not only PTSD that they may develop. Children and young people exposed to trauma often present for treatment for depression or anxiety and increasingly difficulties with behaviour and education. Trauma focussed cognitive behavioural therapy (TF CBT) is featured as the treatment with the greatest evidence base for children. The guidelines also feature information on the success of TF CBT in school environments, especially post disaster, with these interventions reaching greater numbers of kids who stay engaged with the intervention for longer periods of time. The role that school professionals play in these interventions needs to be recognised and supported. 

What we can also gain from reading these guidelines is that there remains so much important work to be done in the area of childhood trauma. There needs to a lot more work done in the area of complex trauma, which we know has the potential to be so damaging for children and young people. We also need to be looking more closely at the needs of infants who experience trauma. After a disaster, or other mass trauma, infants are often overlooked when providing assistance and interventions and they often miss out on the benefits of school based interventions. And, of course, we need to keep finding out more about what works to help kids who are traumatised.

Children seeking asylum: trauma and adversity

Children seeking asylum: trauma and adversity

In the images of asylum seekers that are in the media at the moment, we are seeing many faces of adolescents, children and babies. It is a reminder that we need to be thinking more about what these children are experiencing. Some of them are travelling with their parents, some with other family members and some are alone. All of them have been on a journey that most of us can not begin to imagine. 

Children who are refugees or asylum seekers face huge adversities and traumatic experiences. Recently, the Network released this resource that discusses the refugee experience and how it impacts on children. Some of the adversities that are outlined in the resource include the impact of parental stress on children, children's exposure to violence and the potential exploitation of vulnerable children. 

What adversities are these children facing?

Children generally tend to follow a healthy pattern of development when they are in a safe, protective environment with adults who nurture them. Children need parents to respond appropriately and consistently to them, something that can be particularly difficult to do when they are under constant stress, living in uncertainty and finding it difficult to cope themselves. The nature of the refugee experience is one that places extreme stress on children and their families. The journey is usually arduous and may involve the loss or death of others making the same journey. The process for asylum seekers leads to further stress of prolonged detention and the uncertainty of the length of that detention and what the outcome will be at the end of this time. All of these contributing to the poor mental health of the parents and in turn the mental health of the child. 

Many children who are refugees or seeking asylum will also be exposed to violence. Often, their parents will have limited opportunities to protect their children from this violence. We already know from the research that exposure to violence can be particularly damaging to children. When this exposure is extreme or repeated, these traumatic experiences are likely to leave an indelible impression on the child. 

Children who are alone, or without a parent, become particularly vulnerable to exploitation at all stages of the refugee journey and whilst seeking asylum. They may experience physical or sexual abuse or witness violence or other inappropriate acts of others that their parents would otherwise shield them from. 

Long term impact of trauma

We know that many children can be resilient in the face of adversity, but we also know that the greater the number of adversities that a child faces, the more chance there is that there will be a detrimental impact on their outcomes. Trauma impacts on the physical and mental health of children, as well as their development, social functioning and their academic achievement. We know that the impact of trauma can last for a lifetime. 

It is everyone's role to make sure that children are protected from the harmful impact of trauma and adversity. We need to be thinking more about what can be done to protect this particularly vulnerable group of children. 

The ongoing impact of childhood trauma

We are now seeing a steady flow of research that is telling us more about the connections between childhood trauma and mental and physical health difficulties later in life. But, what is really great to see, is more research from here in Australia, talking about this.

New research that has just been published, has used an Australian community based survey (the 2007 National Survey of Mental Health and Wellbeing) to look at the relationship between child abuse and the long-term health care costs and impact on wellbeing.

This is what they have found:

".... that adults with a history of childhood abuse suffer from significantly more health conditions, incur higher annual health care costs and are more likely to harm themselves. Our results suggest that child abuse has long-lasting economic and welfare costs. These costs are greatest for those who experienced both physical and sexual abuse."

There have been many studies that have linked childhood trauma and child abuse to poor long term mental and physical health outcomes. The Adverse Childhood Experience (ACE) study in America has identified that childhood trauma contributes towards substance abuse, heart disease, smoking, suicide attempts, depression and many other illnesses in adulthood.

This new Australian research has not only shown a correlation between poor mental and physical health outcomes, but has also provided an estimate of the increased cost each year that childhood trauma is having. This research has found that for adults who were both physically and sexually abused as a child, the annual healthcare cost per person is approximately $1856 higher than for those in the general population. This means that childhood trauma has huge implications for the health care system and for the cost to the community as a whole.

What impact does childhood trauma have? 
The paper describes the many ways that childhood trauma can lead to poor adult health outcomes and increased health care costs. There is the immediate harm that is done to the child and the impact of the prolonged stress that the child lives under. This prolonged stress causes damaging, long term negative effects on the body, which become particularly apparent in the damage done to the heart and circulatory system. Prolonged stress also damages the immune system and leaves the child more vulnerable to a range of physical health problems that can last into adulthood.

Childhood trauma is also strongly associated with a range of mental health difficulties such as depression, anxiety and psychosis. Childhood trauma has negative impacts on self esteem and the child's ability to interact with others and develop appropriate interpersonal skills that are needed to develop and maintain the protective relationships of family and loved ones.

Adults who have experienced childhood trauma are also more likely to engage in more risk taking such as excessive drinking and drug taking, all of which we already know play a major role in contributing to poor health outcomes. They are also more likely to engage in self harming or suicide.

Another major area that childhood trauma impacts on, that is not mentioned in this current study, is the impact on educational engagement and success. Children who experience trauma or adversity are more likely to experience educational difficulties and poor academic achievement. This then impacts on their ability to be successful at school and go on to be a productive working member of the community.

What next? 
With the expanding body of research continuing to demonstrate that childhood trauma has such negative long term impacts, it is essential that more is done now to intervene early; to increase the knowledge around and awareness of these impacts; and to be more effective in treating children who have experienced trauma.