This review will focus on the therapeutic interventions for children who have experienced traumatic experience of abuse and neglect. Furthermore, it will explore the link between the effective interventions and the projects in Peopleknowhow People Know How’s(PKH) provided for the childrenPositive Transitions Service supporting children and young people.
Child maltreatment is a vital public health concern. Abuse and neglect include physical, emotional sexual abuse, as well as physical, emotional neglect such a Child maltreatment including all types of abuse and neglect is predominantly common lead to children traumatic experience. Child maltreatment address the act of commission or omission by parents or any caregivers, which may cause potential harm or threat to a child (Leeb et al., 2008). Also, apart from maltreatment from family, abuse and neglect also exist in the community, in school, in public place from other adults and from peers (bully victimization) (Radford et al, 2011).
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Exposure to maltreatment in childhood through abuse and neglect are more common than we thought. The prevalence rate across countries for sexual abuse (12.7%, girls 18% and boys 7.6%), for physical abuse (22.6%), for emotional abuse (36.3%), for physical neglect 16.3 and for emotional neglect (18.4%) (Stoltenborgh et al., 2014). In population survey in the UK regarding the rate of children maltreatment and other victimization, 2.5% of children (under 11 yrs) and 6% of young people (aged 11-17) reported experienced one or more times of maltreatment in the past year (Radford et al., 2013). Though the responding rate of children protection has increased in UK, the situation evaluation of 0.5% children has been recognized as vulnerability for maltreatment each year. By 2016, there is an substantial increasing trend for physical neglect and emotional abuse in the child protection registration, whereas a slightly decrease in physical abuse and sexual abuse (DeIngli Esposti et al., 2019).
These experiences have been linked to trauma-related symptoms across domains in childhood and later life. Symptoms of mental health problems can appear soon f traumatic following traumatic event, but in some cases symptoms will not show until years later (Buss, Warren & Horton,, 2015). Children exposure to trauma has been proven to be linked with depression, attention deficit/hyperactivity disorder, and developmental crisis in psychosocial functioning (American Psychiatric Association, 2013). Emotion maltreatments, specifically, are strongly associated with internalizing problems (Moylan et al., 2010; Vanmeter et al., 2020) such as depression (Humphreys et al., 2020), social anxiety, trait anxiety and self-esteem and self-concept formation in children (Berzenski & Yates, 2011), while physical abuse and neglect is more related to externalizing problem such as aggressive behavior. In fact, children who experienced abuse or neglect showed substantial rate of PTSD, with which up to 50% (????). Therefore, therapeutic interventions for children with experience of abuse or neglect must be effective on reducing post-traumatic stress disorder (PTSD) symptoms. As the devastating and long-lasting impact on emotion and psychosocial development and interpersonal relationship, interventions applicable in the setting of clinical situation, school and community are all warranted for children at risk of abuse or neglect or with exposure to abuse or neglect who need to seek help.
This article reviews the existing evidence and evaluate the three more popular therapies, including Trauma Focused-Cognitive Behavioral Therapy (TF-CBT), Eye movement desensitization and reprocessing (EMDR) and art therapy. In addition, it will also evaluate the link between the popular and effective interventions within the current project in Peopleknowhow People Know How’s current projects including such as aArts therapyTherapies, befriendingBefriending, social work support Family Support, and art Art befriendingBefriending.
TF-CBT conducted in the ways as group intervention and individual intervention with or without the involvement of parents are regarded as well-established interventions (Dorsey et al., 2017). TF-CBT consists psychoeducation about trauma, stress coping skills, emotion regulation strategies, relaxation to manage the anxiety and fear. In addition, it includes exposure via creative techniques in a gradual manner to correct the maladaptive cognitions. TF-CBT is developed based on the theory of social learning and cognition, and can be addressed the (symptoms from conditioned and learned behavioral responses (Berwin, 1989, (ART c CBT). TF-CBT for children with comorbid aggressive behavior will also address delivery of positive interpersonal behavior.
The exposure session can be conducted in a graduated manner utilizing a series of creative techniques will be utilized such as imagining of the trauma. To be specific, distressing disclosure regarding trauma related memory will be avoided at the beginning, as the session gradually progressed children will encouraged to convey the detail of traumatic experience with a series of creative techniques.
As to the narrative component, for example, for children with exposure to intimate partner violence (IPV), the goal of the narrative component is to enable their recognition of maladaptive cognitive process via expression trauma related feelings and experience (Cohen, Mannarino & Iyengar, 2011). Furthermore, it aims to develop their ability to differentiate between real threat and their emotions of anxiety and fear.
Cohen and his colleague (2011) conducted a randomized control study to examine the effect of TF-CBT in the community setting for children aged 7-14 with experience of intimate partner violence. The finding indicated that brief community TF-CBT has largely lower the level of PTSD related symptoms (i.e. hyperarousal and avoidance) and anxiety compared to Child Centered Therapy. The great improvement may due to the focus of TF-CBT model, as it focused on developing children ability of discrimination of the real danger and relaxation strategies to make them feel safer when confronted violent experience.
A study examined the potential impact of Trauma Narrative (TR) in TF-CBT for children with experience of child sexual abuse. The study demonstrated that the eight session programme with TN component is not only effective in improving behavioral functioning and PTSD- related symptoms but also most efficient to ameliorate the trauma-related emotional distress for both children and parents (Deblinger et al., 2011). Maintained impacts of the TF-CBT were observed in follow-up assessment 6 or 12 months after the intervention for all conditions, with no difference between conditions (Mannarino et al., 2012).
The external validity has been demonstrated in the community setting, while the internal validity is relatively low attributed to the high dropout rate (39.5%) of the project in community (Cohen et al., 2011). As to the generalizability of TF-CBT, two study examining the effectiveness of interventions on youth experienced multiple types of trauma extended the effecacy of TF-CBT beyond the sexual abuse (Hensen et al., 2014; Murray et al., 2013).
EMDR mainly aims to restore stressful and painful memories but also can applied as a technique for age-specific modification. In two studies, the group using EMDR with a focus on emotion and cognition as well as distressful memories and externalizing problems show a significant decrease on post traumatic symptoms than waitlist group (Soberman et al. 2002; Ahmad et al. 2007). As EMDR is incorporated with the CBT simply as a component of the whole intervention in some research, the effect of EMDR failed to be evaluated separately (De Roos et al., 2011; Farkas et al., 2010). Besides, the intervention with EMDR component is limited by the small sample size (Silverman et al., 2008). Therefore, large sample size study is needed to provide further evidence to the effect of EMDR.
Although the practice of art therapy has been in existence for many years, until very recently, the efficacy of art therapy has not been empirically addressed. Art therapy intended to address the cognitive and emotional issues via art activity through which the young children can express their thought and feeling. There is limited research to date to validate the effect of art therapy. The study conducted by Lyshak-Stelzer et al. (2007) utilizing the arts-and craft-making activity in art treatment compared to treatment as usual. The finding provided supporting evidence to take art as an effective tool for traumatized children. Overall, The lack of evidence might due to unmeasureable outcomes, unstandardized procedure, the unspecific methods in most research as well as the methodological limitations (Eaton, Doherty & Widrick., 2007). Besides, although numerous case studies in art therapy can give more insight of the theory, more group study is warranted due to the limited generalizability of case study.
Pifalo and T (2007) proposed to combined TF-CBT with art therapy. Art therapy facilitates the children affective processing when children recalling the painful and stressful situation of trauma, and also improve their coping skills. However, two study examine a classroom-based intervention combined Creative expressive component and CBT utilizing the techniques such as music, drama to express and drawing for exposure among children with experience of war. The findings indicated the reduction of PTSS at the completion and follow-up, but in one study no significant was found between intervention group and waitlist group. However, some research proposed that the art as a method facilitate the client and therapist to form safe relationship, which is very critical to the intervention outcomes. A meta-analysis provided support to the notion (Asay & Lambert, 1999)
In terms of treatment across all types of interventions, the component of parent involvement exhibited a rather mixed effect. There is little difference between groups with or without parent involvement for depression, and post trauma stress symptoms and externalizing problems, whereas it produced large effect for the anxiety ((Dorsey et al., 2017). In the review of Silverman et al. (2008) parent session conducted along with the child session in the TF-CBT, the finding indicated that the parent involvement component does not account for most outcomes of the treatment. Whether parents should be involved in the treatment remain unclear and debated (Leenarts et al., 2013).
The art therapy project in PKH People Know How’s Arts Therapies project aims to provide children the chance to communicate their emotions and explore the support they need in a supportive environment. Though verbal skills developed fast during early childhood, children are limited by their communication abilities to express their feelings and thoughts (Cohen, 2010). Many art therapists noted that young children are the population can benefit a lot from the art therapy, as they more willing to articulate themselves in an imaginative way (Clements, 1996).
While trauma narrative has been proven to be effective in reducing children trauma-related painful feeling, children in the 16-session programme without NT also show a reduce in the trauma-related painful feelings. Although the children are not encouraged in the programme, coping strategies and body skills also help for the processing of trauma. Despite the befriending project do not address the expression of the experience of trauma event or feeling, it provide a safe and trustful environment which can allow the children and the volunteers to share their feelings and discuss about the coping strategies rather than direct discussion of the trauma.
Art befriending is intended to carried out to utilized the art as the tool to create a safe environment for the volunteers and the children as well as facilitate them to form a trustful relationship.
As six common components have been identified in the majority of effective treatments for children with exposure to trauma, some of this could be considered to be incorporated the project of People knowhowKnow How. For example, psychoeducation about trauma prevalence, impact and intervention; training in emotion regulation strategies such as relaxation, emotion differentiation, and coping skills) can be incorporated in social work support project the or be delivered in the befriending project.
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