The greatest change in the development of treatment programs to address child abuse and neglect has been an emphasis on evidence-based practices rather than new theories that might suggest radically different treatment areas. Two primary advances have occurred. The first is the development of therapies that specifically target the impact of trauma or abuse on children. These approaches deal mainly with posttraumatic stress, depression, and anxiety—the primary emotional impacts of abuse. There is a robust literature on interventions addressing these outcomes, but it is not exclusive to child abuse. This research base acknowledges the importance of screening for trauma (including abuse) and validating its occurrence, but encompasses strategies that operate within the traditional framework of mental health interventions. Treatment clinically targets the outcomes or the mental health condition, not the event or cause per se. This focus is consistent with the evidence showing that not all children exposed to child abuse, various forms of trauma, or even terrible lives in general develop mental health disorders. The emphasis also is on modular approaches that address multiple clinical outcomes rather than a single presenting problem.
The second main advance in treatment interventions is in approaches to problematic parenting and behavior problems in children. Child abuse and neglect represent extreme forms of problematic parenting, and parenting interventions are the most common service recommendation in child welfare. It has long been known that parenting approaches, parental behaviors, and their interaction with child behaviors are primary determinants of behavioral problems in children. In child abuse and neglect situations, behavioral problems are both a consequence of abuse or neglect and a potential risk factor for triggering physical abuse. It is not only physical or sexual abuse that may produce behavioral problems in children; the inconsistent or coercive parenting that often characterizes neglect is also implicated (Gardner, 1989; Patterson et al., 1990; Stormshak et al., 2000). Neglecting parents may be inattentive, unresponsive, or inconsistent. Therefore, effective parenting interventions are the first-line treatments both for dealing with behavior problems in child victims and for reducing the risk for subsequent child abuse and neglect.
The empirical literature is unanimous that behavioral problems are addressed most effectively through interventions that target parents as the primary change agents. In many cases, especially those involving younger children, the interventions are fully parent mediated (Carlson et al., 1989); the children need not be the recipients of individual treatment. This targeting of parents is particularly apt in the context of child abuse and neglect as compared with the typical nonabusive scenario in which children have behavioral problems. Wolfe and others (Graziano and Diament, 1992; Wolf et al., 1987; Wolfe et al., 1988) demonstrated early on that a behavioral parent training program was effective with abusive parents. However, the idea of applying this well-established approach to child abuse and neglect situations did not fully take hold until Urquiza and McNeil (1996) published a paper in Child Maltreatment advancing the application of parent-child interaction therapy (PCIT) in these cases (Urquiza and McNeil, 1996) (PCIT is further discussed below). The emphasis on promoting positive parent-child relationships to address behavioral problems in abused or neglected children resonated with the child abuse and neglect community because behavioral problems in these cases are the result of abusive or neglectful parenting. In other words, applying a proven parent-mediated intervention would simultaneously address the child’s behavior problems and the deficits in the parent-child relationship. Ideally, enhancing the parent-child relationship promotes more secure attachment and stronger bonding, which in turn not only improves child behavior but also lowers the risk for future abuse or neglect.
The focus on parenting interventions is not new; they have always been a primary service for child abuse and neglect cases. What changed was the recognition that parenting practices and child behavior problems are inextricably interrelated and are best addressed through a single parenting-focused intervention, as opposed to sending parents to parent education classes and children to individual therapy when abuse or neglect results in behavior problems. Moreover, the parenting interventions typically offered were didactic classes or peer support, neither of which involve learning and using new skills in difficult parenting interactions. While parenting classes are still common, it is increasingly appreciated that they are unlikely to produce behavior change in abusive or neglectful parents.
Evidence for Effectiveness
The standard, well-established parent management training or behavioral parent training programs have now been applied extensively to child abuse and neglect situations, and in some cases subjected to specific clinical trials. Findings on parent management training suggest robust effects across cultural groups (Lau, 2006; Martinez and Eddy, 2005). PCIT is effective with abusive or neglectful parents (Timmer et al., 2005), as well as with foster parents (Timmer et al., 2006), when children have behavioral problems. For example, the Incredible Years (Herman et al., 2011; Webster-Stratton et al., 2011a,b) has been tested extensively with low-income Head Start families, many of which are at high risk for abuse or neglect or have been involved in the child welfare system.
The Parent Management Training Oregon (PMTO) model is one of the earliest and most well-established interventions for behavior problems. It is the basis for two interventions that have been used in child welfare populations. The first, Multi-dimensional Treatment Foster Care (Chamberlain et al., 2008), is a treatment foster care model for severely behaviorally disturbed children that teaches foster parents to deliver the PMTO model with the active consultation and support of a consultant. Under the model, youth can be transitioned to regular foster care or their family home in less than 6 months. The second intervention is Keeping Foster and Kin Parents Supported and Trained, a less intensive version of the model for foster parents and kinship caretakers that has been found to be effective in reducing behavior problems and promoting placement stability (Chamberlain et al., 2008). As discussed later in this chapter, another well-established parent management training program—the Positive Parenting Program, commonly known as Triple P (Sanders et al., 2002)—also is increasingly being used in child welfare cases.
A number of these parenting interventions have been shown to improve child welfare outcomes in addition to improving behavior problems in abused and neglected children. PCIT with a motivational enhancement component significantly reduces referrals to the child welfare system compared with services as usual (Chaffin, 2004; Chaffin et al., 2004). In fact, PCIT by itself outperforms PCIT combined with other services (Chaffin, 2004). Alternatives for Families-Cognitive-Behavioral Therapy (AF-CBT) entails parent-child cognitive-behavioral therapy for physically abusive families. It incorporates standard parent management training; coping skills for children and parents; and a process for parents to make amends for the abuse, which reduces behavior problems and violence in both children and parents. Parent-Child CBT (PC-CBT), a similar approach for abusing families in which the intervention is delivered in child and parent groups, also has been shown to improve behavior problems and reduce future aggression (Runyon et al., 2009). And Triple P delivered as a population-based intervention has been shown to offset increases in child abuse referrals and placement rates (Prinz et al., 2009).
Infant mental health interventions have been developed for the very youngest victims of abuse and neglect. These programs are fully parent mediated and focus on enhancing parents’ sensitivity and responsiveness to their children, as well as basic protective parenting. Parents learn to recognize child cues, especially for distress, and to respond in ways that are consistently comforting. Several programs have been tested in clinical trials involving abusive or neglectful situations and been found to be effective in improving parent sensitivity and child adjustment (Bernard et al., 2012; Spieker et al., 2012).
SafeCare is a parenting-focused intervention for neglect situations involving young children. It is a brief structured home-based program, delivered by trained professionals or paraprofessionals, consisting of three components: safety proofing the home, teaching parents how to monitor and manage child health, and coaching in parenting. The parenting coaching component is not intended for cases in which the children have significant behavioral problems, but teaches basic positive parenting skills. In a recent statewide randomized trial taking the intervention to scale, families receiving SafeCare in addition to the usual array of home-based services had significantly lower rates of rereferral to child protective services (Chaffin et al., 2012a). Implemented in a trial with American Indian families, SafeCare not only was effective but also was highly acceptable to these families (Chaffin et al., 2012b).
Not infrequently, children show more than one internalizing impact of abuse and neglect, including posttraumatic stress, anxiety, and depression. The literature is robust for the effectiveness of Trauma-Focused CBT (TF-CBT) (Mannarino et al., 2012), a structured intervention for children and caregivers that directly targets the impact of traumatic experiences, including physical and sexual abuse. It reduces not only posttraumatic stress, but also depression and moderate behavior problems when present. The intervention consists of standard CBT elements such as psychoeducation, relaxation and emotion regulation skills, and positive parenting. The trauma-specific CBT component is the trauma narrative, which entails gradual exposure to trauma memories and cognitive processing to correct maladaptive trauma-related beliefs. TF-CBT has been tested extensively with children involved with the child welfare system, including those in foster care placement. It has also been widely disseminated in a variety of public mental health settings through the National Child Traumatic Stress Network. CBT is well established for children with depression or anxiety (Walkup et al., 2008), although research has not specifically addressed whether the proven interventions are equally effective with abused and neglected children.
Child and Family Posttraumatic Stress Intervention (Berkowitz, 2011), a brief trauma-focused intervention, has been shown to be effective in preventing chronic posttraumatic stress disorder when delivered shortly after a trauma. It consists of assessing trauma impact with feedback to families, providing psychoeducation and normalizing about traumatic stress, and teaching coping skills. Although not yet specifically tested in child abuse or neglect cases, this intervention has been shown to be effective in domestic violence cases and is potentially applicable as an early intervention in cases of child abuse and neglect.
There are also well-established interventions for anxiety and depression in children. CBT is the first-line treatment and may be combined with medication in some cases (Walkup et al., 2008). Children are given information about anxiety or depression; are taught relaxation and coping skills; undergo cognitive restructuring designed to change maladaptive and unhelpful thoughts; and in the case of depression, are taught exposure to unrealistic fears and behavioral activation. Parents may or may not be actively involved in this therapy. The literature has not established that these models work specifically with abused and neglected children, but there is no reason to believe that they would not.
TF-CBT and many parent management training programs have been found to be equally effective for minority youth and their families among the samples included in clinical trials. For example, equivalent outcomes for TF-CBT have been observed for African Americans (Scheeringa et al., 2010). A school-based group version of TF-CBT (Cognitive-Behavioral Intervention for Trauma in Schools [CBITS]) was initially tested and found effective in the highly diverse Los Angeles school district, where a majority of children are immigrants (Jaycox et al., 2002). Culturally adapted versions of CBITS for Latinos and American Indians have been developed (Chaffin et al., 2012b; Workgroup on Adapting Latino Services, 2008). Another trauma-focused intervention (Resilient Peer Treatment) has been identified as probably efficacious for abused African American youth. Several interventions for anxiety have shown some efficacy with ethnic minority youth (Huey and Polo, 2008). Group cognitive-behavioral therapy (GCBT) has been identified as possibly efficacious for African American and Latino youth (see Huey and Polo, 2008). In addition, anxiety management training and CBT have been identified as possibly efficacious for African American youth. For conduct problems, a variety of approaches show some degree of efficacy; specific approaches tend to differ for African American and Hispanic/Latino youth. Consistent efficacy has been found for Multisystemic Therapy (MST) and Coping Power with African American youth, and for Brief Strategic Family Therapy (BSFT) with Latino youth. In addition, MST has been effective with Native Hawaiian youth (Rowland et al., 2005), and in a small randomized controlled trial, The Incredible Years was found to be effective for maladjusted Chinese American youth (Lau et al., 2011). While these interventions have not been tested specifically with abused and neglected youth, there is no reason to believe they would not be effective with this population.
In 2013 a comparative effectiveness review of parenting interventions, trauma-focused treatments, and enhanced foster care approaches that address child abuse and neglect was conducted under the auspices of the Agency for Healthcare Research and Quality (Forman-Hoffman et al., 2013). While the authors note the support for a number of promising treatment strategies, the review found that methodological gaps in the evidence limit the ability to compare results across studies adequately.
The Bottom Line
There are two big success stories in interventions for children affected by abuse and neglect. The first is TF-CBT. Tested extensively, it has been found effective for children and families from diverse backgrounds and circumstances and has been adapted specifically for foster children and children in residential care (Mannarino et al., 2012). TF-CBT has been widely disseminated throughout the United States, and there are well-established training models for the program.
The second big success story is the application of well-established parent management training programs to child welfare populations. Many of these programs have been found not only to improve behavior problems caused by child abuse and neglect but also to impact child welfare outcomes such as reabuse and rereferral.
The most pressing remaining questions relate to how these interventions can be taken to scale in the mental health and service settings where abused and neglected children receive their care. These questions about implementation and sustainability are not specific to interventions in child abuse and neglect. Questions specific to child welfare relate more to service planning and to how many of what types of interventions should be readily available or ordered for families in the child welfare system. The current approach is to order a single, limited intervention for each problem, which often results in a long list of services that families must complete as part of their child welfare case plan (Society for Prevention Research, 2004). As demonstrated by Chaffin and colleagues (2004), a single evidence-based intervention may actually be more effective for both child and system outcomes than multiple services designed to address the many different problems families may have.
Finding: Significant advances have been achieved in the development of therapies that specifically target the impact of trauma or abuse on children. These advances include the extensive testing of TF-CBT models that have been shown to be effective.
Finding: The application of well-established parent management training programs with proven success to children and families involved in the child welfare system has been highly successful with regard to improved outcomes across behavioral problems caused by child abuse and neglect, as well as a reduced need for further involvement in the child welfare system across metrics such as reabuse and rereferral.
Finding: More research is needed to explore how better to deploy effective treatment intervention programs in the mental health and service settings where abused and neglected children receive care. Questions to be addressed relate to the types and breadth of services to provide for children and families, as well as how to sustain the impact of effective programs over the long term.