Children and Trauma - What works · • The “Dibs in Search of Self” scenario might sound very inving – but how possible is this for our average child and family? • Yesterday

ChildrenandTrauma–Whatworks?

JoanvanNiekerkChildlineSouthAfrica

ManagerAdvocacyandTraining

ChildrenandTrauma–Aspecialisedfield?

•  Thisisnowbeingseenasaspecialisedfieldofwork

•  ThereisincreasingevidenceofthehighlynegaCveimpactoftraumaandabuseonchildren

•  Largernumbersofchildrenwhohaveexperiencedtraumaand/orabusearebeingreferredfortherapy

•  InternaConallythereisalackofresearchoneffecCvetreatmentprogrammes(Bonner2008)

ChildrenandTrauma–Aspecialisedfield?

•  HoweverinSAtherearesCllmanymisunderstandingsabouttheconceptoftherapy‐(case)

•  Wealsoneedtorecognise,acknowledgethevalueof,andintegratethemanyculturalbeliefsandpracCcesthatexistinourcountryintotraumamanagement–parCcularlyinthemoreruralprovinces

•  Thisisanareaofresearchinitself.

Evidence‐basedpracCce

•  InacountryinwhichthereisahugeneedandscarceresourcesevidencebasedpracCcebecomescriCcallyimportant

•  HoweverfewofusresearchourworksystemaCcally,documentacCviCesandresponsesindetails

•  Researchinitselftakesupresources–sothereisthetensionbetweenCmeforworkwithchildrenandCmetogatherandinterpretevidence

EvidencebasedpracCce

•  Wealsoneedresearchthatislongitudinaloverachild’slifeCme,

•  takingintoaccountthatcertaintransiConalstagesinachild’slifemayrequirefurtherintervenConsthatsomeCmesindicatethesuccessratherthanthefailureofprevioustherapy

•  WealsoneedtodevelopsomecommonunderstandingsoftheindicatorsusedtoassesstherapeuCcintervenCons

HowdoweunderstandtheconceptoftraumainrelaContochildren?

•  Howdochildrenunderstandandprocesstrauma?•  Thismayberelatedtothechild’slevelofcogniCveand

socio‐emoConaldevelopment•  ThisunderstandingisoWenlinkedtotheunderstandingand

processingofthattraumabythosewhoareclosesttothem•  SomeCmeswefocusalloureffortsinthewrongspace•  AndsomeCmesweassumetraumawithoutaproper

assessmentofthechildbecausetheparentistraumaCsed–orbecausewearehorrifiedbythestory.(CaseHistory)

•  Carefulassessmentofthechild,theparents/caretakersandthe“traumaCc”eventsiscriCcallyimportanttodeterminewhoandwhatintervenCon–andresearchintoeffecCveintervenCon‐shouldtarget.

PrevenCon–thebesttraumamanagementstrategy

•  ResearchintothebraindevelopmentofchildrenindicatesthattraumaCcevents(especiallywhenrepeated)mayimpactonthebraindevelopmentandfuncConing

•  Thesechangesimpactoneveryaspectofthechild’sdevelopment

•  Repeatedresearchoverthepastdecadehasconfirmedthesefindings

•  Theyoungerthechild,themoreprofoundtheimpact

•  Numerousresearchersconcludethatthesechangesarepermanent

PrevenCon–thestrategythatworks

“Theeffectsofearlymaltreatmentonachild’sdevelopmentareprofoundandlonglasCng.Itistheimpactofmaltreatmentonachild’sdevelopingbrainthatcauseseffectsseeninawidevarietyofdomainsincludingsocial,psychological,andcogniCvedevelopment.TheabilitytoregulateemoConsandbecomeemoConallya[unedwithanotherdependsonearlyexperiencesandthedevelopmentofspecificregionsofthebrain.Earlymaltreatmentcausesdeficitsinthedevelopmentofthesebrainregions,primarilytheorbito‐frontalcortexandcorpuscallosum,becauseofthetoxiceffectsofstresshormonesonthedevelopingbrain.”ArthurBecker‐Weiderman(www.arCclesbase.com)2009

PrevenCon

•  Permanentdamagecannotbechanged,itcanonlybeprevented.RecognizingthattraumamayleadtosuchpermanentchangesdemandsearlyintervenContolimittheactualdamagethatoccurs.

PrevenCon–How?

•  TheimportanceofearlyintervenConanda[enContothechronicityofenvironmentaladversitymayindicatetheneedforpermanentalternaCvecaregivers,inordertopreservethedevelopmentofthemostvulnerablechildren.(DanyaGlaser–JournalofChildPsychiatryandPsychology2000)

•  InSouthAfricachildrenareoWenleWinsituaConsinwhichtheyarerepeatedlyexposedtoconCnuoustrauma/abuseinthehome

•  ourlawsupportsgivingparentsasecondchance–andpossiblyathird,fourth……..

PrevenCon–how?

•  Theyoungerthechild,themoreimportanttheintervenCon–researchindicatesthatallformsofbio‐psycho‐socialintervenConshavediminishingreturnstheolderthechildbecomes.(Doyle,Harmon,Heckman,andTremblay)

PrevenCon‐How

•  Whose“bestinterests”doweactin?•  ThelawconCnuouslyemphasisesthatthebestinterestsofchildrenshouldbeconsideredofparamountimportance–andyetremovalisseenasalastresort.

•  HowdowebalancethisimperaCve,knowingwhatweknowabouttrauma/exposuretotraumaanditsimpactonbraindevelopment,andulCmatelyachild’sholisCcdevelopment?

PrevenCon–How?

•  ObviouslymanytraumaCceventsexperiencedbychildrenaredifficulttoanCcipateandpreventbutwherechildrenareexposedtorepeatedandpotenCallytraumaCceventsintheirhomeandcommunityenvironment,protecCveintervenConshouldoccurasearlyaspossible.

bigmistakesinprevenCon?

•  Teachingchildrentosay“no”•  Teachingchildrenselfdefence•  AssumingthatteachingchildrentheirrightsgivesTHEMthepowertoenforcethese

•  TeachingchildrenthatsexualtouchingisBADtouching

DoesplacingtheresponsibilityforavoidingabuseandtraumaonchildrenthemselvescompoundtheimpactofatraumaCceventwhenithappens?

EvidencebasedPrevenConStrategies

•  Li[legoodresearchinthisarea•  Mostofitrelatestoclassroomteachingof“protecCve”skillsandbehaviourstochildren

•  Goodresultsintheclassroom

•  EffecCveoutsidetheclassroomintherealsituaCon?

MinimisesecondarytraumaCsaCon

•  Whereverpossibletrackthechild’sprogressthroughtheCriminalJusCcesystemandmediatecontactsandprocessestoensurecompetentmanagement

•  AdilemmaistheimperaCvetoreporttothissystem–allhelpingprofessionalsincludingpsychologistsandsocialworkersareall“mandatedreporters”intermsofthe

‐  Children’sActasAmendedno38of2005‐  CriminalLaw(SexualOffencesandRelatedMa[ers)AmendmentActno32of2007

‐  FilmsandPublicaConsActasAmended

PreparingchildrentoentertheCJSsystem

•  ThereisbroadrecogniConofthenegaCveimpactofchildrenmovingthroughthesystemwithoutassistanceandpreparaCon

•  TherearenumerouscourtpreparaConprogrammesinternaConallyandinSouthAfrica.

•  Mosthavenotbeenrigorouslytested•  Someareofdubiousquality

•  ThereisanenormousneedforresearchinthisareaandforevidencebasedprogrammedevelopmentwheresuccessfuloutcomedoesnotfocusonconvicConsbutratherontheexperienceofandoutcomesforthechildandthechild’sfamily

Therapy–Thelimitedresources

•  Fewfamilies/caregiverscanaffordopen‐endedconCnuoustherapyfortheirchildren

•  OurfocusthereforeneedstobeoneffecCvebutCmelimitedintervenCons

•  The“DibsinSearchofSelf”scenariomightsoundveryinviCng–buthowpossibleisthisforouraveragechildandfamily?

•  Yesterdayweheardthatforcertainformsofa[achmentdisorderchildrenneedtobeseen3Cmesperweek

•  GiventhenumberoftraumaCsedchildreninSAandtheshortageoftherapists–thisisnotrealisCc.

WhereCmeandresourcesarelimited

•  AssessthesituaConandcondiConofthechildandcaretakerand

•  Wherepossibleinvestinthechild’scaretaker‐  Dealwiththeirsenseoftrauma

‐  Enhancetheirabilitytocareforthechildandprovidesomehealingexperiences

•  Atherapistmayspendanhouraweekwithachild–thecaretaker–numeroushours

•  HelpthemrestorerouCneforthechild–rouCnesbringasenseofsecurityandpredictabilityintoachild’slife

•  Forexample–ifonelooksatsomeoftheimpactsoftraumaCcexperiencesforchildren(andadults),caretakersofchildrencanusenumerousacCviCesandinteracConswithchildrentoreducethese–egdealingwith

‐  Powerlessness‐  Highlevelsofarousal‐  Re‐experiencingsymptoms

EvidenceBasedTreatmentApproaches

•  OnceagainthereisalackofgoodresearchinthisareaespeciallyinSA.

•  Studiesarebasedonsmallsamples

•  StudiesareoWenCmelimited–longitudinalstudiesarescarce

•  InterveningvariablesaresomeCmesunpredictableanddifficulttocontrol

•  Therapistvariablesaredifficulttoassessandcontrol–differenttherapistsmayusetheoryandpracCceindifferentways

EvidenceBasedTherapy

•  Bonner(2008)reviewedresearchintooutcomesofvarioustrauma/abusedfocussedtherapies

•  Conclusions–‐  ThetherapeuCcapproachesthatshowedmostpromisewere

1. TraumaFocussedCogniCveBehaviourTherapy

2. Parent‐ChildInteracConTherapy

TraumaFocussedCogniCveBehaviourTherapy

•  IsmosteffecCvewhenitacknowledgesthediversityofsymptomsinchildren

•  Specificallyfocussesonthetraumaitself

•  FocussesonimprovementsinposttraumaCcStresssymptomsinbothchildrenandtheirparents

ParentChildInteracConTherapies

•  WeremosteffecCvewhenthefocus

‐  includedafocusonparentsymptomsoftraumaandstress

‐  Includedafocusonthechild’ssymptoms

‐  includedafocusonpre‐exisCngissues/challengesexperiencedbythechildorcaretakerorbothortheinteracConbetweenchild(ren)andcaretaker

BonnernotedthathomevisitaConcontributedtothesuccessofPCIT.

FurthernotesfromBonner’sreviewofresearch

•  ParentalbeliefsandsupporttothechildissignificantlyrelatedtoposiCveoutcomesforthechild.

•  Thereshouldbeaclearfocusonparent/childrelaConships,healthcareandhomesafetyinthemanagementoftrauma

•  ThereissomeevidencetosupporttheuseexposurebasedtherapiesandcogniCvetherapyparCcularlywhenthesearelinkedtospecificneeds

SomethoughtprovokingquesCons

•  Istherapyanartform?

•  HowimportantisrelaConshipversustheory,skillandtechnique?

•  Matchbetweenchildandtherapist?•  Whenshouldtherapystop–whatarethedisablingconsequencesofconCnuingtherapywhenachildis“well”?AspecificissueforchildrenseeninprivatepracCce?

•  Howdowemeasure“Wellness”?

THANKYOU

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