What Helps Children and Young People Move Forward Following Child Maltreatment?

Abstract

Since Kempe et al. (1962) first defined and identified ‘the battered child syndrome’, researchers and practitioners have, in turn, highlighted other forms of child maltreatment, such as child sexual abuse/exploitation, physical neglect, and emotional abuse and neglect. Unsurprisingly, the focus of much of that research has been to explore the negative effects that can occur as a result of child abuse and neglect, either in isolation or combination (Herrenkohl and Herrenkohl, 2007; Hillberg et al., 2011; Mersky and Topitzes, 2010). It is known that some young people show remarkable resilience to very negative experiences (Layne et al., 2009). For others, however, alongside a broad range of multiagency interventions (e.g. family support, removal of the child), appropriate individual/family psychological support and therapeutic approaches are desirable and/or necessary to facilitate recovery and prevent a severe impact on the function and quality of victims’ lives. Thus, while knowledge about outcome is both necessary and useful, one of the key benefits has been in enabling the development of models of therapeutic practice and informing practitioners about the most effective means of intervening following child maltreatment. ‘Appropriate individual/family psychological support and therapeutic approaches are desirable and/or necessary to facilitate recovery’ This themed issue of Child Abuse Review is therefore focusing on different forms of intervention following child maltreatment. To reflect the broad spectrum of work that is available within the field, the papers included in this themed issue include both a review and empirical papers, different methodological approaches (qualitative and quantitative; individual and group) and focus on child neglect, child sexual abuse/exploitation and witnessing domestic violence. One notable theme throughout several of the papers has been the role of parents, including communication style, warmth, sensitivity and responsiveness. Negative parental behaviours, attributions and interactions have long been seen as risk factors for child abuse and neglect (Crittenden, 2002; Sagy and Doton, 2001), so it is encouraging to review interventions that have explicitly addressed these in their work, such as by having simultaneous parental components. In addition, hearing the voices of young people who have experienced child sexual exploitation (CSE) (Gilligan, 2016) also highlights the importance for us, as professionals, to listen more closely to these ‘experts by experience’, who have very clear ideas about what they want and need. ‘Focusing on different forms of intervention following child maltreatment’ To start the issue, the first paper by Tristan Milot and colleagues (2016) summarises the literature on the traumatic stress perspective, with a focus on child neglect. (For other interventions following neglect, see the Child Abuse Review special issue on ‘Interventions in chronic and severe neglect: What works?’, guest edited by Danielle Turney and Julie Taylor in 2014). In trauma-focused theories of child maltreatment, trauma is seen as affecting normal developmental processes (i.e. behavioural, emotional and psychophysiological). Early work considered outcomes mainly in the form of post-traumatic stress disorder (Sullivan et al., 2006; Widom, 1999), but the authors emphasise the need for practitioners to include other outcomes such as behavioural difficulties, emotional dysregulation and insecure or disorganised attachment. It is argued that accounting for these wider outcomes (‘complex trauma’; Briere, 2002; D'Andrea et al., 2012; Ford and Courtois, 2009) allows for better understanding of an individual's difficulties and needs for intervention. Interestingly, when asked about their perspectives of ‘success’, children and families go even further (Howarth et al., 2015). Alongside those factors considered in research studies (e.g. reductions in behaviour problems, better understanding and effective emotional regulation, adaptive coping, improving parent–child relationships), families listed broader outcomes, such as increased understanding of and ability to talk about violence, having fun, happiness and empowerment. ‘Summarises the literature on the traumatic stress perspective, with a focus on child neglect’ Milot et al. (2016) then move on to consider different forms of trauma-focused interventions that cover a range of aims and treatment modalities (group, individual, parent–child). Commonalities between these different interventions included: assessment of trauma experiences, providing a safe environment, building a feeling of emotional security, improving parental sensitivity, developing child emotional self-regulation and offering emotional therapeutic support to the parent. Within the paper, parent–child relationships are a key feature. It is notable, however, that despite being referred to as parent–child, the focus of research is almost always on mothers’ behaviour and the subsequent impact on child attachment and emotional self-regulation. Overall, maternal sensitivity and communication seem to play an important role in child neglect and its outcomes, whereby appropriate, sensitive and supportive caregivers can (in turn) enable more positive psychological adjustment in their children. More research is required into the role of fathers. ‘Maternal sensitivity and communication seem to play an important role in child neglect and its outcomes’ The second paper in this issue has also taken, in part, a trauma-focused approach. Atara Hiller and colleagues (2016) investigated factors that might moderate the effect of game-based cognitive-behavioural therapy (GB-CBT). GB-CBT is an integrative treatment approach based on trauma-focused therapy, play therapy and group therapy (Misurell et al., 2011). Importantly, GB-CBT was devised for children in urban, low socio-economic and culturally diverse communities, using play and developmentally appropriate techniques; it also has a simultaneous component for working with parents, drawing on the evidence base that parental reaction and support are crucial to outcome. One of the key components of this empirical paper, however, was to move beyond showing that an intervention worked, to consider the important question of why interventions may work better for some children than others: specifically, whether some factors moderate the effects of interventions for symptomatology associated with child sexual abuse. Thus, Hiller et al. report on 166 economically diverse and socially disadvantaged six to ten year olds, considering whether demographic characteristics and abuse-related factors predict outcome from this GB-CBT programme. It was a reassuring outcome that internalising/externalising symptoms, sexually inappropriate behaviours and personal safety skills all improved, irrespective of demographic or abuse-related factors. However, since GB-CBT was devised for children from these demographic backgrounds, whether the findings reflect the successful development of this intervention or that such factors do not impact on outcome remains to be fully understood. Thus, the authors note that GB-CBT is a possible alternative to more traditional forms of CBT for children who have experienced sexual abuse, but this would benefit from additional evaluation. ‘The important question of why interventions may work better for some children than others’ ‘GB-CBT is a possible alternative to more traditional forms of CBT for children who have experienced sexual abuse’ In contrast to Hiller et al. (2016), Philip Gilligan (2016) adopts a qualitative approach to investigate CSE. Sponsored by a grant from BASPCAN, one of the key aims was to enable young people in Bradford who had experienced CSE to voice their needs, thoughts about interventions and ideas how to improve services and help others in their position. Gilligan highlights the lack of research with young people themselves. This really talks to an ongoing difficulty – namely, persuading professionals that children and young people (CYP) should be given the choice, rather than have that decision made for them by not being informed about the research studies. While this is inevitably done with the best of intentions (and, undoubtedly, there are some occasions when it is not appropriate to raise research studies with CYP), the extent to which professionals ‘protect’ the young people with whom they work means that the voices of young people are not heard. Assuming that a study has received appropriate ethical scrutiny and that researchers ‘own’ their responsibility for ethical practice, as professionals, we need to begin to question why we are refusing young people their voice. Indeed, research with young people has shown that most are able to make an informed decision, raise their fears or concerns, ask questions and (if they decide to take part) usually report feeling empowered by the experience. (See Houghton, 2015, for a wider discussion on young people's views on the ethics of participating in research following domestic abuse.) Gilligan's research and the quotes from 25 young people also highlight this. The participants are very clear in their thoughts and it is notable that the themes they highlighted fit so well with research from other sources. For example, ongoing contact during the day and night via phones (Whittle et al., 2014) and that therapeutic alliance is key for the work to be successful: ‘if you don't have a bond then there is no point’ (Gilligan, 2016, p. 121). Finally, in terms of interventions, allowing that some young people may still see their perpetrator as their ‘boyfriend’ creates a different dynamic to account for in therapy, and one that is crucial not to overlook. ‘We need to begin to question why we are refusing young people their voice’ Moving on to look at child maltreatment across the spectrum, Kyunghee Lee (2016) reports on specific outcomes for young children in foster care who have often had a wide range of negative experiences, including maltreatment, removal from the family home and repeated moves. The US federal Head Start programme began in 1965, taking a ‘whole child’ perspective. The aim was to improve outcomes for children aged from birth to five years in low-income families (i.e. health, social skills and learning). Overall, 25 million children have been enrolled on the programme and much evaluation has taken place. However, little has been done to consider if some of the most vulnerable young children (i.e. those in foster care) really benefit. Lee cites work showing that half of children in foster care have been shown to be developmentally delayed, often perform less well academically and are five times more likely to have specialist education provision (e.g. Pears et al., 2012). This paper reports the very crucial finding that, unfortunately, the Head Start programme is not improving cognitive outcomes for five to six year olds in foster care (particularly boys), although a variety of background factors related to the child and the carer did impact on outcomes. A commentary on the paper by Adam Zolotor (2016), however, notes that the study is underpowered due to the small sample size, making it very difficult to identify change. Thus, Zolotor cautions against disregarding the programme, highlighting other research showing the long-term impact of good-quality nursery care, as well as some very interesting findings from Head Start. Most importantly, this work has highlighted the need for specialist work to help these most vulnerable children in society. ‘Reports on specific outcomes for young children in foster care’ ‘Little has been done to consider if some of the most vulnerable young children… really benefit’ The final paper by Keri Pinna (2016) reports on one of the most widely discussed aspects of child maltreatment: the intergenerational cycle of maltreatment. Although research demonstrates that, in fact, the majority of maltreated individuals do not go on to maltreat their own children (Dixon et al., 2005; 2009), it cannot be disputed that there is an increased risk. Some have argued that it is the accumulation of risk factors that is most important in the intergenerational cycle of maltreatment (Thornberry et al., 2014). However, Pinna has focused on the intergenerational transmission of violence following the witnessing of domestic violence, showing that parental warmth and positive attributions of children's behaviours mitigate the risk of developing conduct disorder and/or violent acts. This, then, can inform future interventions. While parental negative attributions are more commonly targeted, parental warmth is often a by-product of other progress rather than seen as an aim in its own right. Perhaps this balance needs to be redressed. ‘Parental warmth and positive attributions of children's behaviours mitigate the risk of developing conduct disorder and/or violent acts’ To conclude, two training updates and two book reviews are reported. A training programme for working with parents who have difficulties with alcohol and substance misuse receives very positive reviews from Joanna Manning (2016), while Dushyanthan Mahadevan (2016) comments that Attaching through Love is a very useful book for parenting strategies or for use with a parenting group. For work with victims, Sara's Story outlines interventions aimed at helping young women cope and recover from female genital mutilation, as well as signposting to other resources (Rymer, 2016). To draw everything together, Akhtar Kapasi (2016) reviews Treatment of Child Abuse – evidence-based treatments including trauma-focused CBT and parent–child interaction therapy. Although focused for an American audience, Kapasi notes that it is useful for anyone working with maltreated children. Overall, in families where abuse/neglect has occurred or there are multiple challenges, there are multiple risks to be addressed and different levels of intervention to be considered (Cicchetti and Valentino, 2006). This themed issue highlights useful intervention approaches across a variety of topics, but with some commonalities for us to reflect upon. ‘In families where abuse/neglect has occurred… there are multiple risks to be addressed and different levels of intervention to be considered’