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Thursday, 26 September 2013

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.
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.


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."
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. 


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. 

Wednesday, 18 September 2013

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.