Therapy eases PTSD in kids facing family violence

Trauma-focused therapy can help reduce anxiety and treat post-traumatic stress disorder (PTSD) in children who have been exposed to intimate partner violence (IPV), a new community-based study shows.

But despite the positive findings, one of the study's authors said, the focus must go beyond treatment to finding ways to keep these children-who "almost always" continue to have a relationship with the perpetrator-safe.

"We can lower their anxiety, we can lower their fear, (but) if we can't protect them, if we can't make them safe, that's of limited value really," Dr Judith A. Cohen of Allegheny General Hospital in Pittsburgh, the study's first author, said.

Women will often return to an abusive partner, and most jurisdictions don't consider exposure to intimate partner violence to be a form of child abuse, Dr Cohen and her team note in an issue of the Archives of Paediatrics and Adolescent Medicine.

"Thus," they write, "treating IPV-related PTSD must be tailored to address the potential of ongoing violence from an IPV perpetrator to whom the child is ambivalently attached in the context of incomplete protection by a victimised mother."

The study

Dr Cohen and her colleagues enrolled 124 children, ages 7 to 14, whose mothers had sought services from the Women's Centre and Shelter of Greater Pittsburgh.

All had at least five PTSD symptoms related to intimate partner violence, with at least one symptom in each of the three PTSD symptom clusters in the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-PL).

The children were randomly assigned to trauma-focused cognitive behavioural therapy (TF-CBT) or client-centred therapy (CCT). Each child and parent received a 45-minute individual therapy session once a week for eight weeks.

In the TF-CBT group, parts of each weekly session included the parent and child together.

In CCT, which is intended to build empowerment and trust, the patient can choose what they wish to talk about. Children who have experienced intimate partner violence, Dr Cohen noted, will typically avoid talking about it in this form of therapy.

Talking about violence

TF-CBT, in contrast, focuses on having children talk about at least one episode of domestic violence, and teaching the child skills that will help them to cope with continuing episodes of violence.

While children exposed to domestic violence often have "over-generalised fears" and are frightened by any type of conflict, according to Dr Cohen, TF-CBT is intended to help them learn how to deal with normal everyday conflicts while giving them the skills to be safe in the face of real danger.

Another goal of the treatment was to have children share their experiences with their mothers, and address "maladaptive cognitions," such as blaming themselves or blaming their mother.

Most of the children experienced continuing trauma during treatment, and just 75 completed the study.

On the main outcome measures, scores on the K-SADS-PL and the University of California-Los Angeles PTSD Reaction Index (RI), children in the TF-CBT group showed significantly greater improvement (mean difference of 1.63 and 5.5, respectively).

K-SADS-PL symptom clusters for hyperarousal and avoidance improved to a greater extent in the TF-CBT group, as did scores on the Screen for Child Anxiety Related Emotional Disorders (SCARED).

Among the 43 children in the TF-CBT group who completed the study, the number of children who met the K-SADS-PL PTSD diagnosis fell from 32 to 8 (75% remission), compared to 18 to 10 (44% remission) in the CCT group.

Adverse affects

There were two serious adverse events, such as child self-injury, child abuse or problems requiring psychological hospitalisation, in the TF-CBT group, compared to 10 in the CCT group.

Children in the TF-CBT group showed clear improvements in hyper-arousability, "jumpiness," and their ability to distinguish between real and generalised danger, Dr Cohen said. "The skills really did help them and talking through what happened really did give them a way to make sense of their experiences," she explained.

While children in the client-centred group also improved, she added, they did not improve as much.

"This is a very important and at-risk population," said Dr Christopher M. Layne of the UCLA/Duke University National Centre for Child Traumatic Stress in Los Angeles. He said, "Clearly, working in a domestic violence shelter has many types of challenges, barriers to being able to seek treatment that may place an upper limit on the number of treatment sessions that you can provide."

The findings, he added, suggest "that perhaps even six to eight sessions ... may be effective in reducing kids below the diagnostic threshold."

Dr Cohen said, "I was actually surprised that we had a significant finding, given that it was a very short-term study and it was done in a community setting by community therapists. Mental health treatment, however good it might be, doesn't take the place of protecting children from family violence, and I think that's a really important message."

(Reuters Health, Anne Harding, January 2011)

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