Children Exposed to Violence: Children Exposed to Violence: Impact Identification and Impact Identification and Children Exposed to Violence: Children Exposed to Violence: Impact Identification and Impact Identification and Impact, Identification and Impact, Identification and Interventions Interventions Impact, Identification and Impact, Identification and Interventions Interventions Benjamin E. Saunders, Ph.D. Professor and Associate Director National Crime Victims Research and Treatment Center D t t fP hi t dBh i lSi Department of Psychiatry and Behavioral Sciences Medical University of South Carolina Charleston, South Carolina Presentation at the Defending Childhood Conference, September 23, 2011, Cleveland, OH.
Transcript
Children Exposed to Violence: Children Exposed to Violence: Impact Identification andImpact Identification and
Children Exposed to Violence: Children Exposed to Violence: Impact Identification andImpact Identification andImpact, Identification and Impact, Identification and
InterventionsInterventionsImpact, Identification and Impact, Identification and
InterventionsInterventions
Benjamin E. Saunders, Ph.D.Professor and Associate Director
National Crime Victims Research and Treatment CenterD t t f P hi t d B h i l S iDepartment of Psychiatry and Behavioral Sciences
Medical University of South CarolinaCharleston, South Carolina
Presentation at the Defending Childhood Conference, September 23, 2011, Cleveland, OH.
Conventional Wisdom: Ab d Vi l B dAbuse and Violence are Bad
BadBadOutcomeOutcomeAbuse 100%100%
A Question…A Question…
Is exposure to violence Is exposure to violence really really a serious risk a serious risk factor for mental health problems factor for mental health problems for for Is exposure to violence Is exposure to violence really really a serious risk a serious risk factor for mental health problems factor for mental health problems for for children children and adolescents?and adolescents?children children and adolescents?and adolescents?
National Survey of Adolescents St diStudies
1995 2003 2005 2006 2008
NSA-FFollow up
NSA-RW1
NSA-RW2
NSA-RW3
NSAW1 Follow-up
N=1756W1
N=3614W2 W3W1
N=4023
NSA:P l ti E ti t f Vi lPopulation Estimates of Violence
Violence TypeViolence Type nn PrevalencePrevalencePopulation Population Estimate*Estimate*
Sexual AssaultSexual Assault 326326 8.1%8.1% 1.8 million1.8 million
Physical AssaultPhysical Assault 701701 17.4%17.4% 3.9 million3.9 million
Physically Abusive Physically Abusive 376376 9 4%9 4% 2 1 million2 1 millionPunishment by ParentPunishment by Parent 376376 9.4%9.4% 2.1 million2.1 million
Any Direct AssaultAny Direct Assault 1,0501,050 26.1%26.1% 5.8 million5.8 million
Witnessed ViolenceWitnessed Violence 1,5861,586 39.4%39.4% 8.8 million8.8 million
Any Violence ExposureAny Violence Exposure 1,9111,911 47.5%47.5% 10.6 million10.6 million
*Based on US Census Bureau Estimate that there were 22.3 million adolescents in the U.S. in 1995. Rounded to nearest 100,000.
NSA:Lifetime PTSD Prevalence by
Victimization History and Gender
30 28 3027
MalesMalesFemalesFemales
2015
20
erce
nt
105
11
7 64
Pe
0Y N Y N Y N
3 24
Yes No Yes No Yes NoSexual Assault Physical As./Ab. Witnessed Violence
NSA:Past Year Substance Abuse by y
Victimization History and Gender
30 27
19 2021 20
MalesMalesFemalesFemales
2019 20
14
21 20
12 13rcen
t
10 75
734 4
52
Per
0Yes No Yes No Yes No Yes No
2
Yes No Yes No Yes No Yes NoSexual Assault Physical Assault Physical Abuse Witness Violence
NSA:Past Year Delinquency by Victimization q y y
History and Gender
40
50 47 47 Males
Females
30
40 32
20
29
rcen
t
Females
10
20 17
107
20
5
17Per
0
10
Yes No Yes No Yes No
73 1
Sexual Assault Physical As./Ab Witness Violence
NSA-R:
Risk of Mental Disorders by yNumber of Violence Types
Psychological and Behavioral I t f Childh d Vi ti i tiImpact of Childhood VictimizationAbuse and victimization in childhood correlated with:Abuse and victimization in childhood correlated with:
Anxiety disordersAnxiety disorders (PTSD, social phobia, generalized anxiety disorder)
Affective disordersAffective disorders (major depression)Affective disordersAffective disorders (major depression)Sexual disordersSexual disorders (dysparunia, vaginismus, inhibited sexual desire)Substance use/abuse/dependenceSubstance use/abuse/dependence (drug, alcohol, tobacco)Delinquency and criminal behaviorDelinquency and criminal behaviorViolent behaviorViolent behavior (peer aggression, dating violence, spouse/partner
A characteristic that increases the A characteristic that increases the likelihood of an outcome occurring.likelihood of an outcome occurring.
1.1. Not Not everyone everyone with the characteristic with the characteristic will have thewill have the outcomeoutcomewill have the will have the outcome.outcome.
2.2. Not everyone with the outcome will Not everyone with the outcome will have the characteristichave the characteristichave the characteristichave the characteristic..
3.3. The characteristic may have nothing The characteristic may have nothing to do with causing the outcome.to do with causing the outcome.to do with causing the outcome.to do with causing the outcome.
Responses to TraumaResponses to Trauma
Resilience
Bad ThingsBad ThingsHappenHappen
Child Copes,Few Problems
Resilience
HappenHappen
Recovery
Bad ThingsBad ThingsHappenHappen
Child Has Problems
Child RecoversNaturally
I t tiChild H
Intervention Required
Bad ThingsBad ThingsHappenHappen
InterventionNeeded
Child Has Problems
Trauma Response PathwaysTrauma Response Pathways
Problems NaturalRecoveryAbuse
Intervention
Manage
InterventionRequired
ManageImpact
Resolution PersistenceResolution Persistence
Pathway factors?Pathway factors?
How do we explain these arrows?How do we explain these arrows?
National Women’s Study:
Risk Factors for PTSDRisk Factors for PTSD
Saunders, B. E., Kilpatrick, D. G., Hanson, R. F., Resnick, H. S., & Walker, M. E. (1999). Prevalence, case characteristics, and long-term psychological correlates of child rape among women: A national survey. Child Maltreatment, 4(3), 187-200.
NSA Model of Childhood Victimization and Adult Outcomes
Child
ChildSexualAssault
Tobacco
Alcohol
AdultSubstance
Use
ChildPhysicalAssault
ChildPh i l
AdultDepression
Adult
ChildhoodDepression
Adverse
DelinquentPeers
PhysicalAbuse
ChildWitness
Community
Marijuana
PTSD
ChildhoodPTSD
IPV
FamilyEnvironment
CommunityViolence
ChildWitnessParental
Hard Drugs
Delinquent
Sub. Assist.Sexual Assault
ForcibleViolence Behavior
Suicidal Ideationand Attempts
ForcibleSexual Assault
Moderators: Gender, Race, Family Income
p
A Question…A Question…
Is exposure to violence Is exposure to violence really really a serious risk a serious risk factor for mental health problems factor for mental health problems for for children children and adolescents?and adolescents?
Yes. But it’s a little more complicated than we thoughtcomplicated than we thought.
**Wanted**Effective Treatments
Eff ti i t ti d d f i tEffective interventions are needed for common proximate victimization-related mental health problems.
PTSD, fear, anxietyDepressionDepressionBehavioral difficultiesAggressionGuilt, shame, stigmatization, difficulty with trust, , g , y
Effective treatments are needed to prevent the development of future problems.
Substance use/abuse/dependencePhysically or sexually aggressive behaviorDelinquency, criminal behaviorSexual disordersR l ti hi diffi ltiRelationship difficulties
ProblemProblem::All sorts ofAll sorts ofAll sorts of All sorts of “treatments” “treatments” are availableare availableare available are available out there.out there.
A Good Question...
H t t th d fH t t th d f
A Good Question...
How can we sort out the good from How can we sort out the good from the benign, poor or even harmful the benign, poor or even harmful interventions and programs?interventions and programs?
Common Errors When Deciding About T t t P Eff tiTreatment or Program EffectivenessReliance solely on individual anecdotes and remembered cases.
“That child made such amazing changes during treatment.”Confusing client satisfaction with clinical improvement.
“The family just loved coming to see me. Never missed a session during their 3 years of therapy. Amazing. Too bad they had to move away.”y py g y y
Assuming more is always better or an untested something is better than nothing.
“The family is receiving medical and mental health services, 24/7 on call, and wrap around care We should add parenting classes and job counseling ”around care. We should add parenting classes and job counseling.
Misattribution of the cause of change.“That anger management class really seemed to help after he was arrested.”
Failure to appreciate resilience and natural recovery.“With treatment her PTSD resolved in about 3 months after the rape.”
Guru effect in training and treatment adoption.“I heard Dr. McDreamy is doing a level II training. And, it’s in San Diego in January!”y“Those videos were just so amazing! I have got to try that.”
What is an “Evidence Supported Intervention”?
MeetsMeets a defined threshold ofa defined threshold ofMeets Meets a defined threshold of a defined threshold of research evidence for its efficacy.research evidence for its efficacy.
Quality, quantity, variety, and results of empirical support build our confidence.
Systematic review (e.g. Cochrane Collaborative, Campbell Collaborative) results.results.Meta-analysis results.Number of RCT’s conducted with positive results. Quality of the research methods.Effect size.Effect size.Replication by researchers other than the treatment developers.Dismantling studies.Other supporting research
Controlled studies without randomizationOpen trials, pre- post-, or uncontrolled studiesMultiple baseline, single case designs
25 years of Clinical Research
Evidence Supported Treatments Developed Tested and Ready forDeveloped, Tested, and Ready for
ImplementationTrauma-Focused Cognitive-Behavioral Therapy – TF-CBTParent Child Interaction Therapy – PCITAbuse-Focused Cognitive Behavioral Therapy – AF-CBTCognitive Processing Therapy – CPTg g pyChild-Parent Psychotherapy – CPPProject SafeCareThe Incredible Years (TIY) seriesThe Incredible Years (TIY) seriesOther Parent Management Training (PMT) modelsCBT for Children with Sexual Behavior ProblemsFunctional Family TherapyDialectic Behavior Therapy (DBT)Multi-Dimensional Treatment Foster CareMultisystemic Therapy (MST)Triple P
Why Should We Use ESTs?Why Should We Use ESTs?
Meta-analysis of 32 randomized trials of ESTs for youth
Meta-analysis of 32 randomized trials of ESTs for youth.
Weisz et al., 2006 (abstract)Weisz et al., 2006 (abstract)
Superiority not reduced by:Superiority not reduced by:•High levels of severity• Inclusion of minority youth
Weisz, J.R., Jensen-Doss, A., & Hawley, K.M. (2006). Evidence-Based Youth Psychotherapies Versus Usual Clinical Care: A Meta-Analysis of Direct Comparisons. American Psychologist, 61(7) 671-689.
Why Use E id S t d T t t ?Evidence Supported Treatments?
“The race is not always won by the swift, nor the contest by the strong, but the smart man bets that way.”
Damon Runyon
Why should we worry Why should we worry about usingabout using ESTsESTs??about using about using ESTsESTs??
Candace Newmaker Connell WatkinsKilled by therapistsApril 19, 1999
Connell WatkinsJulie Ponder
Retrieved August 21, 2009:http://www.rockymountainnews.com/drmn/local/article/0,1299,DRMN_15_691211,00.htmlhttp://www.rockymountainnews.com/news/2001/jun/19/therapists-get-16-years/http://www.rockymountainnews.com/news/2008/aug/01/therapist-convicted-rebirthing-death-living-workin/
Large Gap Between Scientific Knowledge and Front-line Practice
Reasons we don’t useReasons we don’t useEvidence SupportedEvidence Supported
I t tiI t tiInterventionsInterventions
I don’t need no stinkin’ evidence!
Top 10Reasons We Don’t Use ESTs?
10.We view therapy as primarily an art rather than a sciencea science.
Top 10Reasons We Don’t Use ESTs?
9. Therapists often don’t like the idea of following a treatment protocol, a specific phased approach, or
i t d di d dusing standardized procedures.Seems impersonal, structured, or “cookbook.”Seems to ignore the importance of the therapeutic relationship.g p p pLimits my “creativity” in therapy.Can’t respond to current crises.I like doing whatever seems best to me at the timeI like doing whatever seems best to me at the time.You actually have to know something.
Top 10Reasons We Don’t Use ESTs?
8. Research findings don’t apply to the real world of clinical practice. Researchers talk in gibberish.
Findings are always so over-qualified they seem uselessFindings are always so over qualified they seem useless.They never look at things I see in my practice.Research studies just are not like front-line practice.Cli t i h t di t lik li t M li tClients in research studies are not like my clients. My clients are different from anywhere else.
Top 10Reasons We Don’t Use ESTs?
7. Old habits are hard to7. Old habits are hard to change.
Research support rarely a criteria for intervention orcriteria for intervention or program selection.Rely on prior training consultation withtraining, consultation with peers, continuing education events.Frequently unaware of theFrequently unaware of the ongoing science.
Top 10Reasons We Don’t Use ESTs?
6 Unconvinced ESTs really are more effective than6. Unconvinced ESTs really are more effective than our current approach.
Don’t work with everyone, even in clinical trials.Don’t work with complicated cases.Not an EST for all problems.My clients are special and different.Won’t work in my community.
Are Usual Services Effective?Are Usual Services Effective?
Analysis of 9 clinic studies of child mental healthAnalysis of 9 clinic studies of child mental health services.Treatment effect sizes ranged from -0.40 to 0.29.gMean effect size was 0.01.In general, the services delivered had no discernable impact on the usual course of presenting problems.
Weisz, J.R., Donenberg, G.R., Weiss, B., & Han, S.S. (1995). Bridging the gap between laboratory and clinic in child and adolescent psychotherapy. Journal of Consulting and Clinical Psychology, 63(5), 688-701.
Stewart & Chambless, 2009Stewart & Chambless, 2009
Review of 56 effectiveness studies of CBT for adultReview of 56 effectiveness studies of CBT for adult anxiety disorders.Effect sizes were large and comparable to efficacy studies.CBT is effective in clinically representative situations.The most clinically representative studies had onlyThe most clinically representative studies had only slightly smaller effect sizes.CBT is an effective treatment in front-line clinical settings.
Stewart, R.E., & Chambless, D.L. (2009). Cognitive-Behavioral Therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4),595-606.
Project BEST Training CasesUCLA RI Treatment Outcome ResultsUCLA RI Treatment Outcome Results
ChildChild C l tC l t (N 114)(N 114) PP tt P tP t tt ddChildChild CompleterCompleters s (N=114)(N=114) PrePre--txtx PostPost--txtx ddMeanMean 30.1 16.1 0.940.94
Cohen et al. (2011) pre-post child UCLA RI d = 0.64Deblinger et al. (2011) mean pre-post across child outcomes d = 0.94 g ( )
Top 10Reasons We Don’t Use ESTs?
5 ESTs do not work with patients from racial or5. ESTs do not work with patients from racial or cultural minority groups.
Huey & Polo, 2008Huey & Polo, 2008
Systematic analysis and classification of the efficacy of evidence y y ysupported treatments with ethnic minority youth. Conclusions
“EBTs do exist for ethnic minority youth” (p. 282)Treatment effects in the “medium” rangeNo treatment met criteria for “Well-established”13 treatments met criteria for “probably efficacious” (TF-CBT)17 treatments met criteria for “possibly efficacious”17 treatments met criteria for “possibly efficacious”Of 13 studies that examined ethnicity as a treatment effect moderator, 8 showed no effect. Of the 5 finding a moderator effect, 3 found that the treatments had g ,stronger effects among ethnic minorities. Only 2 of 13 studies found a poorer treatment impact with ethnic minorities.
4 Practitioners were not trained in the principles of4. Practitioners were not trained in the principles of evidence-based practice or the use of evidence supported interventions in primary training programs.
Top 10Reasons We Don’t Use ESTs?
3. We have an inadequate continuing education system3. We have an inadequate continuing education system for disseminating scientific information and providing effective training to clinical competence in ESTsESTs.
Conference presentations are often as much about entertainment as content.Effective clinical training in ESTs often is not readily available.Training is often too expensive and time consuming.
TF-CBTWebd /tf bt
TFTF CBTCBTWebWeb is a webis a web
www.musc.edu/tfcbt
TFTF--CBTCBTWebWeb is a webis a web--based, multibased, multi--media, media, distance education distance education course for learningcourse for learningcourse for learning course for learning TraumaTrauma--Focused Focused CognitiveCognitive--Behavioral Behavioral TherapyTherapy (TF(TF--CBT).CBT).TherapyTherapy (TF(TF CBT).CBT).
TFTF--CBTCBTWebWeb is is offeredoffered freefreeoffered offered freefreeof charge.of charge.
10 hours of CE
TFTF--CBTCBTWebWeb now has over now has over 100,000 100,000 registered learners worldwide.registered learners worldwide.
CTGWebd / t
CTGCTGWeb Web is a followis a follow
www.musc.edu/ctg
CTGCTGWeb Web is a followis a follow--up course that up course that teaches how to teaches how to apply TFapply TF--CBT to CBT to cases of child cases of child traumatic grieftraumatic griefau a c g eau a c g e
CTGCTGWebWeb is is offeredoffered freefreeoffered offered freefreeof charge.of charge.
6 hours of CE
CTGCTGWebWeb was launched on September 1, 2008was launched on September 1, 2008..
TF-CBTConsultwww.musc.edu/tfcbtconsult
Automated caseAutomated case consultation for
TF-CBT
Bringing Evidence Supported TreatmentsBringing Evidence Supported Treatments to South Carolina Children and Families
Coordinating CentersThe Dee Norton Lowcountry Children’s Center
Charleston, SCNational Crime Victims Research and
Treatment CenterMedical University of South Carolina
2 Lack of demand for use of ESTs by2. Lack of demand for use of ESTs by employers, consumers, brokers, and payers of mental health services.
Administrators mainly concerned about billing productivity and• Administrators mainly concerned about billing, productivity, and compliance rather than treatment outcome.
• Consumers poorly positioned or equipped to demand quality treatmenttreatment.
• Brokers of mental health services (those who identify, refer, and monitor children) do not know about ESTs, rarely include ESTs in treatment plans, cannot identify providers trained in ESTs, and do not know how to case manage to promote successful completion of EST.
• Payers only concerned about cost.
Top 10Reasons We Don’t Use ESTs?
1 Lack of accountability for clinical outcomes1. Lack of accountability for clinical outcomes.Usually, we are paid for time spent with clients regardless of outcomes achieved.Program evaluation is usually some version of “number of customers served” and patient satisfaction with services. Rarely assess client outcomes as part of our program evaluation.
“Junk Science” orS i i J k?Science is Junk?
Will we develop a community t th t illresponse system that will…
U th id bl il bl i t idUse the considerable available science to guide our response to youth violence and victimization.Discern who needs what interventions, when.Enable reasonable access to those interventions.Provide Evidence Supported Interventions that work as the standard responsethe standard response.Discourage the use of ineffective, unproven, or possibly harmful interventions.
ChallengesChallenges
Continue to discover what interventions are effectiveeffective for what problems with what children in what settings?Determine the best ways to disseminate and implementdisseminate and implementevidence supported interventions and programs?evidence supported interventions and programs?Determine how front-line practitioners can best be trainedtrained in their use?How to motivatemotivatepractitioners, supervisors, administrators, and intervention systems to use evidence supported interventions as standard practice?How can we identify and overcome barriersidentify and overcome barriers that inhibit the use of evidence supported practices?use o e de ce suppo ted p act ces
Great ThoughtsGreat Thoughts
“New ideas pass through three periods: 1) It can't be done 2) It probably can be done but it's not worth2) It probably can be done, but it s not worth
