Trauma, Violence, & Abuse
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An Overview of Child Physical Abuse : Developing an Integrated Parent-Child Cognitive-Behavioral Treatment Approach
Melissa K. Runyon, Esther Deblinger, Erika E. Ryan and Reena Thakkar-Kolar Trauma Violence Abuse 2004 5: 65 DOI: 10.1177/1524838003259323 The online version of this article can be found at: http://tva.sagepub.com/content/5/1/65
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Runyon et VIOLENCE, TRAUMA, al. / TREA & 10.1177/1524838003259323ABUSE / January 2004 TMENT OF CHILD PHYSICALABUSE
ARTICLE
AN OVERVIEW OF CHILD PHYSICAL ABUSE
Developing an Integrated Parent-Child Cognitive-Behavioral Treatment Approach
MELISSA K. RUNYON ESTHER DEBLINGER ERIKA E. RYAN REENA THAKKAR-KOLAR
University of Medicine and Dentistry of New Jersey—School of Osteopathic Medicine
This article reviews and summarizes the extant literature regarding child physical abuse (CPA).
Literature is summarized that describes the wide range of short- and long-term effects of CPA on children as well as the documented characteristics of parents/caregivers who engage in physically abusive parenting practices. Although the reviewed research documents that interventions geared only toward the parent have been found to produce significant improvements with respect to parenting abilities, parent-child interactions, and children’s behavior problems, there is a paucity of research examining the efficacy of interventions developed specifically to target the child’s emotional and behavioral difficulties. Based on the few studies that have shown emotional and behavioral gains for children who have participated in treatment, an integrated parent-child cognitive- behavioral therapy (CBT) approach is proposed here to address the complex issues presented by both parent and child in CPA cases. The direct participation of the child in treatment also may improve our ability to target posttraumatic stress disorder (PTSD), depressive symptoms as well as anger control and dysfunctional abuse attributions in the children themselves. Implications for practice, public policy, and research are also addressed.
The Essay on Critique Of confronting Child Sexual Abuse
I believe the film "Confronting Child Sexual Abuse" enlightened myself on the service of CPS. To be a social worker you need to be able to deal with stress and to be able to leave the job at work when you go home. The case manager is responsible to assure that all the medical and educational needs of the child is meet. The case worker spends 40-50% of their time out in the field. The top priority ...
Key words:
child physical abuse, cognitive-behavioral treatment, parent-child relationships port the urgent need to develop and evaluate the efficacy of cost-effective treatment strategies that target this population in an effort to reduce children’s difficulties as well as the recurrence of child physical abuse (CPA) within families. Empirical and clinical literature demonstrates that child victims of physical abuse may suffer a wide array of psychological, behavioral, and interpersonal difficulties as a result of their
IN 2000 ALONE, 879,000 substantiated cases of child abuse and neglect were reported across 50 states; according to the National Child Abuse and Neglect Data System, approximately 84% of these cases involved abuse and neglect by a parent (U.S. Department of Health and Human Services [USDHHS], 2002).
Of these cases, 19% (approximately 167,000 children) were related to physical abuse. These alarming statistics supTRAUMA, VIOLENCE, & ABUSE, Vol. 5, No. 1, January 2004 65-85 DOI: 10.1177/1524838003259323 © 2004 Sage Publications
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The Essay on Child Abuse 19
"Trust unto Jehovah with all thy heart, And unto thine own understanding lean not. And He doth make straight thy paths." The statistics on physical child abuse are alarming. Of the estimated hundreds of thousands of children battered each year by a parent or close relative, thousands die. For those who survive, the emotional trauma remains long after the external bruises have healed. Communities ...
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KEY POINTS OF THE RESEARCH REVIEW
• Child physical abuse (CPA) is associated with a wide range of debilitating emotional and behavior problems that may persist into adulthood and generalize to future relationships, including parent-child relationships. • Parent-only cognitive-behavioral treatment (CBT) interventions have demonstrated significant improvements with respect to parenting abilities, parent-child interactions, and children’s behavior problems. • Although there is a paucity of research examining the efficacy of CBT interventions in reducing children’s emotional and behavioral difficulties, the few extant studies report promising results for CBT models for children who have suffered CPA. • There is a consensus among researchers and mental health professionals that an integrated parentchild approach to CPA may be warranted, when clinically appropriate, because providing treatment to the parent alone may inadvertently neglect the child’s mental health needs as well as the parent-child relationships. • Although there is some support for an integrated approach, empirical research should examine the added benefit of including the child in the parent’s treatment as well as how to best include the child.
victimization. Anger, hostility, guilt, shame, anxiety, and depression are common emotional reactions reported for victims of CPA (e.g., Beitchman et al., 1992; Pelcovitz et al., 1994; Sternberg et al., 1993).
Support for the association between posttraumatic stress disorder (PTSD) and CPA has also been provided by several studies (Ackerman, Newton, McPherson, Jones, & Dykman, 1998; Falmularo, Fenton, Kinscherff, & Augustyn, 1996; Feldman et al., 1995).
Specifically, these children may experience nightmares, intrusive thoughts, recurrent memories, hypersensitivity, anxiety, angry outbursts, and other posttrauma symptoms. Some of the most prominent difficulties exhibited by children who experience CPA are aggressive behavior, poor social problem-solving skills and communication skills, and lower levels of empathy and sensitivity toward others (e.g., Azar, Barnes, & Twentyman, 1988; Dodge, Pettit, & Bates, 1994; Fantuzzo, 1990; Klimes-Dougan &
Kistner, 1990; Salzinger, Feldman, Hammer, & Rosario, 1993).
Victims of CPA are also more likely than nonabused children to interpret interactions with peers as hostile (Dodge, Pettit, & Bates, 1990) and experience greater levels of fear when exposed to any form of anger (nonverbal, verbal, physical) between adults (Hennessey, Rabideau, Cicchetti, & Cummings, 1994).
The Essay on Child/ parent relationship in the Little Boy Crying?
The poem, Little Boy Crying, written by Mervyn Morris is mainly about father and sons relationship. Poet shows the two main themes through this relationship; fathers love towards his child and his effort to lead his child into a right world in life. Mervyn Morris explores the child and parents relationship by using second person narration and language techniques such as allusion and emotive words. ...
For school-aged children, engaging in aggressive behavior serves to alienate them from social groups (Salzinger et al., 1993) and increases the likelihood that the child will be perceived by others as to blame for the abuse (Muller, Caldwell, & Hunter, 1993).
Without treatment, these behaviors may also escalate as evidenced by studies demonstrating that CPA has been associated with violent, criminal behavior in adolescents (Herrenkohl, Egolf, & Herrenkohl, 1997) and adults (Widom, 1989a), abusive or coercive behaviors in dating relationships (Wolfe, Wekerle, Reitzel-Jaffe, & Lefebvre, 1998), and an increased risk for victimization during adulthood (see Kaner, Bulik, & Sullivan, 1993; Root & Fallon, 1988).
Other studies have documented an increased risk for adults abused as children to abuse their children (Crouch, Milner, & Thomsen, 2001), with one study indicating that as high as 70% of abusive parents report their own history of CPA (Kaufman & Zigler, 1984).
Based on these studies, CPA not only appears to have an immediate negative psychological impact on children but also may lead to psychosocial difficulties that, without intervention, persist into adulthood and potentially impact the next generation of children. Although children who have suffered physical abuse exhibit a wide range of emotional and behavioral difficulties, a majority of parents at risk for committing CPA do not meet criteria for full-blown psychiatric disorders. In fact, only 10% to 15% of offending parents are diagnosed with a specific disorder (Ammerman, 1990).
These parents demonstrate deficits in parenting skills, stress-related difficulties, and break downs in their relationships with their children. For example, they may be more likely, when compared to nonabusive parents, to report symptoms of depression and anxiety as well as substance abuse (Milner & Chilamkurti, 1991).
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The Essay on Parenting Skills
1. What are the job responsibilities of a parent? – The job responsibilities of a parent include being financially able to provide for a child. This includes food, shelter, clothing, health care, as well as other luxuries such as extra-curricular activities and electronics. 2. What are the differences between being a biological parent, an adoptive parent, and a foster parent? – The ...
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Parents who engage in extreme punitive practices have also been characterized as immature, easily annoyed, and lacking in general knowledge of child development and appropriate child management skills (Wolfe, 1985).
These parents are also prone to engage in inconsistent, negative, and aggressive child-rearing practices (e.g., Whipple & Webster-Stratton, 1991).
In general, families in which CPAoccurs have been characterized by lower levels of overall parentchild interactions, particularly positive parentchild interactions (Loeber, Felton, & Reid, 1984).
Parents in families of CPA have been found to lack problem-solving skills related to childrearing situations, to judge their child’s misbeh a vio r m o re h a rs h ly ( Az a r, Ro bin s o n , Hekimian, & Twentyman, 1984; Chilamkurti & Milner, 1993), and to have unrealistic expectations of their children (Azar, 1997).
Caregivers who engage in punitive practices are more reactive to their child’s negative behavior, more likely to interpret their children’s behavior as intentional, and have more negative general perceptions of their child (Peterson & Gable, 1998).
REVIEW OF TREATMENT LITERATURE
Interventions for Parents at Risk for CPA
To address this myriad of complex issues experienced by children and parents at risk for CPA, the most common intervention for these families typically involves only parents being referred for parenting skills training, which may inadvertently neglect the individual needs of the traumatized child, and the quality of the parentchild relationship. A variety of cognitivebehavioral therapy (CBT) approaches, including child management skills training (Egan, 1983), stress management skills training (e.g., Gaudin, Wodarski, Arkinson, & Avery, 1990; Schinke et al., 1986; Whiteman, Fanshel, & Grundy, 1987), or a combination of these interventions (e.g., Kolko, 1996a; Wolfe & Wekerle, 1993), have been efficacious in treating punitive parents. Other studies used cognitive restructuring to target punitive parents’ misinterpretation of children’s behavior, negative attributional biases in assigning causality to child
behavior, and unrealistic expectations of the child (see Azar, 1989; Kolko, 1996a).
The Essay on Child Abuse Children Parents Society
Screaming violently and giving meaningless threats toward a child may make him / her feel uncomfortable; it is a form of abuse. How do we discipline a child In our society, parents don t comprehend the difference between disciplinary and abusive actions. They are not aware of where to draw the line. The difference between child abuse and discipline is like the difference between night and day. The ...
Anger management techniques (Kolko, 1996a) appear to have value in teaching nonviolent alternatives to conflict resolution, although some will argue that this is not sufficient (Azar, 1997).
Problem-solving approaches are also effective in correcting problem-solving deficits in punitive parents (Jacobson, 1977; Wolfe, Sandler, & Kaufman, 1981).
Other studies have documented the utility of comprehensive treatment packages for assisting punitive parents. For example, Whiteman et al. (1987) randomly assigned parents (those at risk and those who engaged in abusive parenting practices) to one of four treatment groups: cognitive restructuring (n = 8), relaxation training (n = 12), problem-solving skills (n = 11), and a combined approach (n = 11).
Although parents across all groups reported a decrease in anger, the combined group demonstrated the greatest reduction. Another investigation (Wolfe, Sandler, et al., 1981) demonstrated significant gains in all targeted skills, which were maintained at 1-year follow-up for parents receiving treatment (child behavior management training, stress management, anger control, and developmental education) compared to a no-treatment control. These studies demonstrate that punitive parents benefit from skills training. However, there was no follow-up of recurrence of abuse (Whiteman et al., To address this myriad 1987; Wolfe et al., 1981).
In of complex issues some cases, parents were experienced by not taught specific skills children and parents to improve their interacat risk for CPA, the tions with their children most common (Whiteman et al., 1987).
intervention for these However, a study by Azar families typically (1985) involving abusive involves only parents and neglectful parents being referred for demonstrated no recurparenting skills training, which may rent episodes of maltreatment at 1-year follow-up inadvertently neglect the individual needs for the CBT treatment of the traumatized group as compared to those parents who were child, and the quality of the parent-child in insight-oriented or relationship. waiting-list conditions.
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Child Interventions
Although a variety of interventions have shown promise for teaching skills to parents at risk for physically abusing their children, only 13% of children who have been victimized receive any treatment following their disclosures (Kolko, Selelyo, & Brown, 1999).
The Essay on Parenting Skills 4
1. What role do you think discipline plays in developing a child’s self-esteem? What forms of discipline best serve the self-esteem of the child or adolescent? 2. List and discuss how activities, clubs, or sports, impact the self-esteem of children and parents. Provide at least two activities, clubs, or sports in your answer. Discussion Answers 1. I think that discipline done correctly could help ...
Likewise, there is a paucity of research that has examined the efficacy of such treatments aimed at ameliorating the abuse-related symptoms exhibited by children who have suffered CPA (see Kolko, 1996a/ 1996b; Wolfe & Wekerle, 1993).
Although CBT strategies involving both the child and nonoffending parent have been documented as effective for reducing symptomatology in children who have suffered child sexual abuse (CSA) (Deblinger, Lippmann, & Steer, 1996; Stauffer & Deblinger, 1999), a review by Oates and Bross (1995) reported that only 13 studies have addressed the needs of children who were at risk for physical abuse and neglect. Of these 13 studies, only 2 studies involved children with a documented physical abuse history (Parish, Meyers, Brandner, & Templin, 1985; Timmons-Mitchell, 1986).
Only 1 of these 13 studies randomly assigned children to treatment groups (Fantuzzo, Jurecic, Stovall, Hightower, & Goins, 1988).
Reviews of treatment outcome literature report that therapeutic daycare has been integrated into programs serving neglectful or physically abusive parents of preschoolers (Oates & Bross, 1995; Wolfe & Wekerle, 1993) and has been associated with developmental gains in young children (Culp, Little, Letts, & Lawrence, 1991).
Other empirical and case studies have focused entirely on behavioral strategies aimed at improving children’s interpersonal and self-control skills, increasing positive peer interactions, and decreasing behavior problems exhibited by maltreated preschool children (Davis & Fantuzzo, 1989; Fantuzzo et al., 1988; Fantuzzo, Stovall, Schachtel, Goins, & Hall, 1987; Fantuzzo, Sutton-Smith, Atkins, & Meyers, 1996).
With respect to school-aged children, a recent pilot study conducted by Swenson and Brown (1999) demonstrated that children reported significant reductions in posttraumatic stress, gen-
eral anxiety, dissociation, and anger following their participation in a 16-week CBT group program for children who suffered CPA. This program included relaxation training, exposure therapy, anger management, and social skills building. Although these children experienced significant improvements in the areas reported above, there was no reduction in externalizing behavior problems or depression. The failure to decrease externalizing difficulties and depression is consistent with prior research, indicating the need for parental involvement and the use of child behavior management skills to decrease externalizing behavior problems and depression among children who suffered CSA (Deblinger et al., 1996).
Although addressing the needs of the child, a majority of these studies reviewed did not examine the recurrence of future physical abuse, posttraumatic stress symptoms, or parent-child interactions and parenting skills, all of which have been associated with better outcomes for children (see Azar, 1989; Azar & Siegel, 1990).
Integrated Parent-Child Interventions
Recognition that excluding the child from treatment may neglect the child’s emotional needs as well as parent-child interactions has prompted many professionals to suggest that an integrated parent-child approach for intervening with families may produce increased positive outcomes for parents and children. According to Urquiza and McNeil (1996),
effective treatments must incorporate both the parent and child, alter the pattern of interactions within the abusive relationship, and provide a means to directly decrease negative affect and control while promoting (i.e., teaching, coaching) greater positive affect and disciplining strategies. (p. 140)
Despite this proposition, research has just begun to examine the use of comprehensive parent-child approaches in the treatment of children and families at risk for physical abuse. A representative investigation (Wolfe, Edwards, Manion, & Koverola, 1988) involved randomly assigning 30 mother-child dyads to an information group or a behavioral parent training group that included a direct coaching component similar to
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models proposed by Patterson and his colleagues (Patterson, 1982; Patterson, DeBaryshe, & Ramsey, 1989).
Results indicated that behavioral training was superior in reducing child abuse potential, parental depression, and child behavior problems, all areas that are important to address in maltreating families. A similar approach, parent-child interaction therapy (Eyberg & Robinson, 1982), uses coaching to change the dysfunctional relationship between parent and child. Some success was demonstrated in a single case study of a mother-child dyad at risk for physical abuse, evidenced by a reduction of child behavior problems and maternal distress and an increase in positive parentchild interactions (Borrego, Urquiza, Rasmussen, & Zebell, 1999; Urquiza & McNeil, 1996).
Multisystemic treatment, which involves both the parent and child, was found to be superior to parent education (involving no behavioral rehearsal) for reducing family problems and restructuring parent-child interactions (Brunk, Henggeler, & Whelan, 1987).
Although these approaches support the use of coaching and joint parent-child interventions to improve interactions and reduce behavior problems, they do not directly address the dysfunctional abuserelated thoughts and feelings that children experience, which may underlie chronic PTSD and the intergenerational transmission of violence. To date, only one study conducted by Kolko (1996a) involved random assignment and a controlled comparison of two treatment interventions designed specifically for school-aged child victims and their parents in families who had experienced severe physical punishment/ physical abuse. In this important study, samples were randomly assigned to one of three conditions: individual CBT, family therapy, or standard community care. Compared to those receiving standard community care, both the CBT and family therapy conditions were associated with improvements on measures of child externalizing behavior problems, parental distress, abuse risk, and family conflict and cohesion. Children in both treatment conditions also exhibited relative improvements in internalizing symptoms such as depression and anxiety. CBT was most effective relative to the other two
conditions for reducing parental anger and the use of physical punishment (Kolko, 1996a).
These gains were maintained at follow-up. Although these results are promising, further research is necessary before definitive conclusions can be drawn about the effectiveness of CBT involving both the child and offending parent and how to best integrate treatment for the child and the offender (Kolko, 1996a).
CONCEPTUAL MODEL OF AN INTEGRATED PARENT-CHILD CBT TREATMENT APPROACH Although parent-only interventions have been found to produce significant improvements with respect to parenting abilities, parent-child relationships, and children’s behavior problems, it seems that an integrated CBT approach, such as the one proposed below, will assist professionals and researchers in examining whether the inclusion of the child as well as the parent in treatment would lead to greater gains in these areas. Perhaps as important, the direct participation of the child in treatment also may improve our ability to target PTSD, depressive symptoms, anger control, and dysfunctional abuse-related attributions in the children themselves. This may improve the child victim’s ability to cope with the trauma of CPA which, in turn, may reduce the child’s risk of victimizing others or being revictimized themselves.
Conceptualization for Parent Interventions
First, it is critical to stop the ongoing physical abuse, to teach parents effective, nonviolent disciplining strategies, and to teach parents a variety of adaptive coping skills that assist them in managing their own emotions and successfully implementing behavior management techniques. Urquiza and McNeil (1996) suggested that Patterson’s (1982) social learning model can be used to conceptualize parent-child dyads in CPA. According to this model, parents resort to familiar strategies, such as coercive/violent disciplining techniques in an effort to control their children’s behavior. When children initially comply, the parent’s behavior is reinforced. However, when the child begins to ha-
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It is necessary to teach parents adaptive coping skills and nonviolent disciplining strategies as well as to provide developmentallyappropriate education and challenge parents’ misattributions about their child’s behavior.
bituate over time, parents resort to higher levels of coercion to gain their child’s compliance (see Urquiza & McNeil, 1996).
This cycle can result in a chronic and escalating pattern of parent-child conflict that results in increasing harm to the child over time (see Knutson & Bower, 1994).
This illustrates the need to teach parents alternative skills to gain their children’s compliance. According to Azar (1997), cognitive processes may mediate the relationship between children’s behavior problems and the use of coercive parenting strategies. These parents frequently have unrealistic expectations for their children (Azar et al., 1984).
When the child fails to meet these unattainable standards, the parent may interpret the child’s behavior as intentional noncompliance or a personal parental failure. These attributions of negative intent have been associated with an increase in parental anger and frustration (Averill, 1978; Bandura, 1973) as well as the use of punishment in parent-child situations (Grusec, Dix, & Mills, 1982).
Thus, as the parent’s anger increases, the child is blamed for the misbehavior or for the parents’ feelings of inadequacy, which makes them a likely target of anger. Because parents who engage in abusive practices tend to lack anger regulation skills (see Ammerman, 1990; Hansen & MacMillan, 1990), general parenting knowledge, and parental problem-solving abilities (see Azar, 1989), the physically abusive behavior is maintained via operant conditioning when the anger subsides after the child complies. However, this cycle may continue if the child reacts negatively (e.g., PTSD-related hypervigilance and fearfulness, aggressive behavior) to the abusive behavior, which the parent may interpret as defiance and may only serve to further frustrate the parent. In turn, the parent’s frustration may further alienate the parent and child, resulting in a lack of parent-
child interactions until the parent’s anger escalates and he or she reabuses the child which, in turn, increases the likelihood of negative outcomes for the child. Hence, it is necessary to teach parents adaptive coping skills and nonviolent disciplining strategies as well as to provide developmentally-appropriate education and challenge parents’ misattributions about their child’s behavior. These strategies are aimed at improving parent-child relationships to promote optimal outcomes for children. To assist parents in examining attributions about their children’s behavior that contribute to anger arousal and violent disciplining strategies in child-rearing situations, cognitive coping (e.g., Deblinger & Heflin, 1996; Kolko & Swenson, 2002) and child development education is incorporated. First, parents are taught cognitive coping skills in general to assist them in mastering the skill of examining dysfunctional/inaccurate beliefs that are perpetuating negative emotional states. After parents have learned cognitive coping skills, they will integrate this skill into anger management and self-control skills training to assist them in identifying beliefs about their children’s behavior that exacerbate anger and punitive behavior toward their children. By learning how to dispute these beliefs and understanding developmentally appropriate expectations of their children, parents can begin to manage their anger and implement effective parenting strategies in a calm manner. To facilitate the acquisition and generalization of cognitive coping, anger management, and selfcontrol skills, therapists initially model the skills for parents. Then parents rehearse the skills and are provided praise and performance feedback to refine skills. Parents are reinforced in session by therapists and later by improvements in their children’s behavior. With respect to children’s behavior problems, children’s interactions with their parents are a factor that contributes to the acquisition and maintenance of these negative behaviors which, in turn, may increase the likelihood of recurrent physical abuse episodes. Modeling (Bandura, 1973) is a learning mechanism that may explain the repeated finding that children who suffer
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physical abuse have a tendency to use aggressive conflict resolution strategies and to display poorer social problem-solving skills than children who have not experienced physical abuse. It is likely that children learn these aggressive behaviors by observing their parents’ aggressive behavior. Children are likely to use aggressive/abusive parenting strategies during adulthood that were modeled for them by their parents. An integrated approach employs modeling to teach parents skills (e.g., anger management, contingency management, cognitive coping, etc.).
For all skills, the therapist initially models the respective skill for parents. Next, parents rehearse the skill and are offered praise and corrective feedback to shape behavior and facilitate acquisition of skills. After parents assimilate these skills into their behavioral repertoire, they serve as models of emotional regulation and nonaggressive interactions for their children. Environmental contingencies also come into play in the development and maintenance of abuse-related and general behavior problems (cf. Wilson & O’Leary, 1980).
For example, parents may inadvertently reinforce internalizing and externalizing behaviors, including aggression, in their children. The findings of a recent investigation (Deblinger, Steer, & Lippmann, 1999), in fact, demonstrated that sexually abused children exhibited higher levels of PTSD symptoms and acting out behaviors when children perceived their parents as using psychologically controlling and/or anxiety-/guiltprovoking parenting appeals to influence their children’s behaviors (e.g., “Some day you’ll be sorry you didn’t behave better.”).
This type of negative parental attention, which is often associated with physically abusive behavior, is well known to increase behavioral difficulties. As proposed in the integrated CBT approach described, it is necessary to teach parents communication skills and behavior management skills to assist them in enhancing their interactions with their children which, in turn, decreases their children’s behavior problems. Consistent with CBT (cf. Wilson & O’Leary, 1980), this approach employs modeling, behavioral rehearsal, praise, and corrective feedback to teach
behavior management skills and facilitate positive parent-child interactions.
Conceptualization of Child Interventions
Furthermore, it may be important to include the child in treatment to maximize symptom improvements and facilitate optimal long-term outcomes for children who have suffered CPA. As noted above, the treatment of parents involving behavior management techniques is beneficial for reducing aggressive and noncompliant behavior as well as depression in victims of CSA (Deblinger et al., 1996) and other child clinical populations (Kazdin, Siegel, & Bass, 1992; Webster-Stratton & Hammond, 1997).
However, the benefit of combined parent-child approaches has been demonstrated for other child clinical populations. For example, WebsterStratton and Hammond (1997) found that a combined parent-child treatment for children with conduct problems was superior to parenttraining and child treatment alone for producing significant improvements in parent-reported child behavior problems, positive parent-child interactions, and child social problem-solving skills and conflict management strategies with peers. With respect to aggressive children, a combined child-parent intervention program (Kazdin et al., 1992) has been found to produce the greatest and most long-lasting effects in children’s behavior compared to child problemsolving skills training or parental behavior management training alone. With respect to PTSD, there is evidence that parents alone may not be the most therapeutic agents in helping their children overcome PTSD (Deblinger et al., 1996).
This may be due to the fact that parents alone may be too emotionally involved to effectively conduct exposure and processing exercises with their children. These studies suggest that there may be added benefit to working directly with the child in the treatment although it is an empirical question that has not yet been addressed with this population (Kolko, 1996a).
Gradual exposure (GE), involving prolonged exposure and systematic desensitization, is the CBT component designed to target PTSD symp-
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toms in children who have suffered CSA and CPA (Deblinger & Heflin, 1996; Kolko & Swenson, 2002; Swenson & Brown, 1999).
It involves gradual imaginal and in vivo exposure to anxiety-provoking stimuli (e.g., talking, drawing, or writing about abuse) in the context of a supportive, therapeutic environment. With repeated exposure to abuse-related cues, the intensity of children’s conditioned emotional responses are expected to diminish. GE may free children to reveal and process dysfunctional abuse-related thoughts that have been associated with abuse-related symptoms, such as PTSD, anxiety, and abuse-specific fears (i.e., removal from the home) in children who suffer CPA (Brown & Kolko, 1999).
Cognitive distortions have been identified and corrected in children who have suffered CSA (Deblinger et al., 1996) and have been included in CBT models for CPA (Kolko, 1996a).
The integrated CBT approach uses modeling, behavioral rehearsal, praise, and corrective feedback to teach children relaxation, emotional expression, and cognitive coping skills to prepare them for the GE and processing component whereby dysfunctional abuse-related thoughts can be identified and corrected. Without treatment, children’s emotional problems may escalate, thereby increasing their likelihood of victimizing others or being revictimized themselves. Steiner, Garcia, and Matthews (1997) reported a high prevalence rate of externalizing disorders among victimized juvenile delinquents that they attributed to the loss of impulse control and diminished anger control, which may be associated with PTSD. Specific to ongoing stressors such as physical abuse, Pelcovitz et al. (1994) hypothesized that externalizing symptoms may initially emerge followed by PTSD symptoms in youth. Thus, those children who do not receive treatment that addresses their anger and PTSD may exhibit an ongoing and escalating pattern of aggressive behavior. There is an immediate concern that the parent will then revert to coercive/ violent disciplining techniques when the child, who has not received treatment, demonstrates ongoing emotional and behavioral problems (e.g., PTSD-related hyperarousal, fearfulness,
and/or aggressive behavior) that the parent interprets as noncompliance. This pattern of hostile behavior may also continue into adulthood. According to the intergenerational transmission of violence (see Widom, 1989b), a social learning model (Bandura, 1973), children who have observed violence in their homes may learn violent strategies for resolving conflict, which may generalize to their adult relationships and parenting style. For example, studies have documented an increased risk for adult survivors of CPA to abuse their children (Crouch et al., 2001) and their partners (Downs, Smyth, & Miller, 1996).
Thus, the cycle of violence may be perpetuated if the child does not receive treatment, even though the abusive parent receives treatment and the ongoing CPA is stopped. An integrated approach provides children with education about abuse/violence and nonviolent relationships and uses modeling, behavioral rehearsal, praise, and corrective feedback to teach a variety of skills (e.g., anger management, role perspective taking, social problem solving, safety skills, and nonviolent conflict resolution skills) to enhance positive, nonviolent interactions with others and reduce the likelihood of future revictimization.
Conceptualization of Integrated Parent-Child Interventions
Based on the results of Webster-Stratton’s study (1997) as well as Patterson’s (1982) social learning conceptualization, including the child in the treatment process may also facilitate the parent’s acquisition and use of positive disciplining strategies as well as the development and maintenance of positive parent-child interactions (Milner & Chilamkurti, 1991).
To address these issues, the proposed integrated parent-child CBT model teaches parents a variety of nonviolent parenting strategies to gain their children’s compliance. By using coaching during joint parent-child sessions to provide parents with appropriate models, praise, and performance feedback, parental skills (e.g., active listening, anger management, cognitive coping, contingency management, etc.) are shaped similarly to the way parents are shaping their children’s behavior when they implement
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effective parenting strategies. Effective parenting responses are also reinforced by their children’s compliant behavior. This further reduces the likelihood of future coercive/punitive parent-child interactions. With regard to joint parent-child sessions, parents are given an opportunity across treatment to practice learned parenting skills with their children while receiving coaching, praise, and performance feedback from therapists. It is important to note that children and parents should be carefully prepared for all joint meetings to minimize the possibility of parents having negative interactions with their child. If either parent or child is not ready for a particular interaction, the activity should be postponed to later sessions. In addition to practicing skills, the clarification process is introduced during the later treatment sessions (Kolko & Swenson, 2002; Lipovsky, Swenson, Ralston, & Saunders, 1998).
This is a powerful process that requires significant preparation separately before parents and children can attempt the process jointly. It involves having parents prepare a letter that demonstrates that they take responsibility for their abusive behavior and alleviate children’s responsibility/self-blame. Over the course of several parent group sessions, the therapist offers educational information, assistance in processing abuse-related thoughts and feelings, and constructive feedback as each parent formulates and revises the letter for their child. This is a process by which parents and children communicate openly regarding the abusive experiences. Based on CBT principles, behavioral rehearsal, praise, and corrective feedback are used to shape parents’ behavior so they respond in a supportive and appropriate manner to children’s questions about the abuse.
Description of Proposed Model
The proposed model is an adaptation of the empirically validated CBT model for sexually abused children outlined by Deblinger and Heflin (1996).
Additional CBT components, particularly those specific to the needs of parents at risk for physically abusing their children, are adapted from treatment models targeting families in which physical abuse (Donohue,
Miller, Van Hasselt, & Hersen, 1998; Kolko, 1996a; Kolko & Swenson, 2002) or domestic violence (Runyon, Basilio, Van Hasselt, & Hersen, 1998) occurs. Although the proposed model in its entirety has not been evaluated with children and families at risk for CPA, the individual CBT components have been effective in addressing many of the psychological and behavioral difficulties exhibited by physically abused children and their parents. For instance, components of the proposed child management program (positive reinforcement, extinction, time-out, and behavioral contracting) have been empirically validated as effective treatment approaches with punitive families (Forehand & McMahon, 1981; Kelly, 1983; Trickett & Kuczynski, 1986; Wolfe, Edwards, Manion, & Koverola, 1988; Wolfe, Kaufman, Aragona, & Sandler, 1981), and cognitive restructuring has been effective in changing parents’ misperceptions of their children’s behavior (Azar et al., 1984; Kolko, 1996a).
As is typical of a CBT approach, we will use methods that directly address the behaviors, cognitions, and affective processes of children and parents. The treatment techniques build on one another and flow from session to session. To facilitate the acquisition and generalization of skills, the proposed CBT approach uses modeling, role-plays, behavioral rehearsal, praise, and corrective feedback. The proposed CBT approach consists of three components: (a) child intervention, (b) parent intervention, and (c) parent-child intervention, and has been modified based on client feedback collected during ongoing pilot groups at the Center for Children’s Support (University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine).
Parents and children attend weekly 2-hour group sessions over a 16week period. Parent and child interventions are conducted concurrently for the first hour and 15 minutes of the session by four group therapists and the second 45 minutes involves the integrated joint parent-child sessions. The latter portion of each parent and child group is spent preparing children and parents for the joint parent-child activity, similar to the process described by Deblinger and Heflin (1996).
Over the course of group sessions, more and more time is devoted to the joint sessions, during
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which families receive individual attention from a consistent coach given that groups are limited to four families. Thus, families receive the benefit of receiving feedback from their peers as well as individualized attention during joint parent-child sessions. Although some of the joint parent-child activities are conducted as a group, families and therapists break into dyads in the group room, where families can obtain more individualized attention when discussing critical issues (e.g., safety plan and clarification of abusive behavior).
Parent interventions. The parent component involves providing offending parents with information concerning emotional and behavioral effects of severe corporal punishment/ CPA, reviewing unpleasant internal and external consequences of CPA for the parent to increase their motivation to comply with treatment, cognitive restructuring to assist the parent in accurately interpreting their child’s behavior, and teaching parents child behavior management strategies, and alternative methods of conflict resolution (e.g., angermanagement strategies).
In addition, treatment focuses on identifying and increasing parental social support resources in an effort to reduce stress that may be associated with negative parent-child interactions as well as parental distress. Sessions 1 and 2 of the parent group focus on familiarizing parents with the purpose of the group, discussing group confidentiality and other guidelines, conducting a consequence review as a method for increasing treatment compliance (as described by Donohue et al., 1998), discussing alternate forms of disciplining children to spanking, a method of disciplining children that has significant side effects and is generally ineffective in changing children’s longterm behavior. The consequence review (Donohue et al., 1998) will be used to motivate parents to comply with treatment. Parents are provided with praise and corrective feedback for their participation and efforts. Sessions 3 and 4 provide parents with education regarding effects of severe corporal punishment/CPA on children and attending and reinforcing positive behavior. During the
third session, parents are assisted in identifying types of abuse/violence and are given an opportunity to discuss the emotional and behavioral impact on children of CPA as well as the impact of their own personal history of violence/abuse. This provides parents an opportunity to process their own abusive experiences, which can also allow for empathy training in helping them understand how their behavior may have impacted their children. Parents learn to identify positive behaviors, recognize reinforcers and punishers, and attend to and reinforce desired behavior (session 4).
Although practice of attending and reinforcing children’s positive behaviors is continued, sessions 5 through 7 teach parents a variety of skills, cognitive coping, anger management, and relaxation to assist parents in regulating their emotions and implementing child behavior management strategies in a calm manner. Parents are assisted in learning to identify personal anger triggers and cues (i.e., raised voice, red face, slamming door), to identify multiple explanations for their children’s misbehavior in an effort to challenge beliefs that contribute to anger arousal, and to learn skills to modulate their level of anxiety and anger during problematic parent-child situations. The relationship between thoughts, feelings, and behavior is introduced to parents and they are asked to identify beliefs related to their child’s behavior that perpetuate their anger which, in turn, can result in abusive behavior. Other coping strategies are also introduced to parents. Progressive muscle relaxation is used to decrease anxiety. Anger management strategies involve identifying personal anger cues, antecedents, behaviors, and consequences of anger-evoking situations. For example, thinking aloud is introduced as the use of self-instructions before engaging in a behavior that is likely to produce negative consequences (e.g., “If I hit my child, then he or she will learn aggressive ways of handling conflict,” or “If my child is hurt while I am disciplining him/her, my child may be taken away”).
These sessions integrate cognitive coping and anger management skills similar to other treatment packages (see Donohue et al., 1998; Kolko, 1996a).
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Children’s personal safety is highlighted during session 8 or 9 (depending on parent’s progress), and parents are included in the development of self-protection plans that their children will be rehearsing to minimize the risk of the situation escalating. Parents continue to practice anger management skills and are presented with new skills such as active listening to facilitate the joint safety planning process. Additional skills for resolving parent-child conflict are problem-solving strategies. Problemsolving strategies consist of five steps (i.e., identify problem, identify goal, generate possible solutions, choose the best solution, and give self-reinforcement).
During sessions 10 and 11, parents practice integrating and using skills to effectively solve potential child conflicts. This may involve diffusing anger initially by challenging faulty beliefs about the causality of the child’s behavior, then using five steps to resolve conflict they have experienced at home with their child (i.e., child refuses to comply with bedtime) and implementing an appropriate parenting strategy. Additional child management strategies will be introduced. Additional child management techniques are introduced during sessions 12 through 16. For example, for parents of young children, the use of effective commands will be revisited and the time-out procedure will be presented. Other effective parenting strategies may include reward charts, behavioral contracts, and work chores depending on the child’s age. Sessions 11 through 14 also involve working with the parents on the abuse clarification process (Lipovsky et al., 1998), which involves (a) clarification of abusive behavior, (b) offender assuming responsibility of abusive behavior, (c) offender acknowledging impact of abuse on child and family, and (d) initiation of a safety plan. Although these components have been addressed over the course of treatment, the parent prepares a letter to address these issues with their child during one of the integrated sessions. Therapists closely supervise letter preparation to ensure that parents are ready to participate in the process. The process is put in writing to ensure that parents say what they initially practice. The purpose of the clarification process is to
alter any misconceptions or inaccurate attributions that the child victim or offending parent may have related to the abuse. Session 16 is used to review parent and child progress, celebrate their graduation, and address termination issues with parents. Child interventions. Sessions 1 through 5 consist of (a) an introduction, (b) psychoeducation, (c) affective expression, and (d) anxiety management and cognitive coping skills training. During session 1, group participants are oriented to the group process, with the primary goal to build cohesiveness/rapport among group members and to establish ground rules to ensure members’ safety. Sessions 2 and 3 have Sessions 2 and 3 have four primary goals: four primary goals: (a) to (a) to define abuse define abuse and vioand violence, (b) to lence, (b) to provide an provide an understanding that viounderstanding that lence is not appropriate, violence is not (c) to provide education appropriate, (c) to regarding the effects of provide education CPA, and (d) to normalize ambivalent feelings that regarding the effects of CPA, and (d) to may be experienced by children who have suf- normalize ambivalent fered abuse. Children par- feelings that may be experienced by ticipate in exercises to enchildren who have hance their ability to suffered abuse. identify and express their feelings. This is particularly important given that children who suffer abuse typically have difficulty labeling personal emotions and identifying feelings that others are experiencing. Children are also encouraged to learn to express their feelings in words and request clarification of others’ feelings as well. Children also begin identifying abuse-related feelings. During sessions 4 and 5, children are introduced to the cognitive triad to assist them in using cognitive coping skills to cope with core beliefs (e.g., self-blame and worthlessness) and misperceptions that may be disclosed during the exposure process. They discuss their families, violence in their families, and feelings and beliefs related to violent episodes. If necessary, relaxation training is introduced to reduce anxi-
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ety associated with addressing violence in their homes. Sessions 6 and 7 involve developing a personal safety plan to reduce the child’s risk for physical harm as well as introducing assertiveness training. Sessions 8 through 10 focus on rehearsal of self-protection behaviors and learning esteembuilding and assertion skills. Verbal praise and performance feedback is provided to enhance skill acquisition. During these sessions, children learn to identify anger cues that alert them to implement safety procedures (i.e., engaging in agreed-on behaviors that deescalate the conflict, going to a safe room in the house).
Children also identify helpers to contact after an abusive episode occurs. Safety plans are rehearsed until children can perform them with relative ease. It is important to ensure that parents are in agreement with all aspects of the child’s safety plan so the child’s actions do not escalate the situation with the parent. Selfprotection skills are continually rehearsed over the course of treatment as client safety is a fundamental goal of the program. The third skills component, esteem building, teaches children to use positive self-statements and to accept compliments from others. In conjunction with accepting compliments, children receive training in assertion and anger management skills, including (a) giving compliments, (b) making requests, (c) increasing assertive responses, and (d) decreasing aggressive behavior. Anger management strategies, including physical exercise, relaxation exercises, and calming self-talk, provide children with skills to diffuse anger, which enables them to act assertively. These skills also serve to improve children’s social interactions with peers. Positive reinforcement and feedback is provided to ensure mastery of skills. Sessions 11 through 16 teach anger management skills, social problem-solving skills, and role-taking skills. Participants continue to employ relaxation and calming self-statements as anger reduction strategies. Furthermore, children learn problem-solving skills and roletaking skills. During this phase of treatment, children begin the process of GE and affective processing that has been demonstrated as effective in reducing trauma symptoms in children
who have suffered CSA (Deblinger et al., 1996).
This treatment component is introduced later in the treatment process in CPAcases, compared to CSA. Given that children who suffer CPA are generally residing with the parent who abused them, the first goal is to create a safe environment and increase positive interactions and communication between parent and child before attempting to have the child process past abusive experiences. Children may express abuse-related thoughts and feelings through a variety of mediums, such as drawing, writing, talking, and so forth. Children will also compile a book about their abuse-related experiences and feelings that they may share with their parents during joint sessions if clinically appropriate. Cognitive coping is used to assist children in changing dysfunctional thoughts related to the abuse which, in turn, alters their mood. Modeling, rehearsal, praise, and corrective feedback are provided to aid children in learning skills. These skills will be revisited throughout treatment as necessary. Session 16 addresses termination issues. Joint parent-child interventions. The initial joint parent-child sessions will involve parents and children exchanging praise. In general, integrated parent-child sessions will provide parents and children with opportunities to use child behavior management skills (i.e., attending and reinforcing, time-out) during session. A primary goal will be to provide group facilitators with an opportunity to observe caregiver/ parent-child interactions, to coach parents in the appropriate implementation of skills, and to provide positive reinforcement and performance feedback to parents. During integrated sessions, parents assist children in identifying anger cues and rehearsing safety protection plans. Parents pair off with their children during play activities and practice attending to appropriate behavior and ignoring undesired responses by removing all attention from the child. Scenarios will be roleplayed when time-out is implemented by the parent when the child refuses to comply with a command or engages in inappropriate behavior (i.e., aggression toward peer or sibling).
Furthermore, parents provide children with re-
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wards for compliance during group activities. Joint sessions will also involve having children share with parents what they have learned during their sessions. Children and parents will also communicate about the abusive experiences and will participate in the abuse clarification process as described above. During this process, children may share their abuse-related thoughts and feelings with the parent (including information revealed during the gradual exposure process) if the child is comfortable with doing so. Each joint session will end with parents and children exchanging praise. There is some controversy about whether GE is as applicable to children who have suffered CPA and remain with their offending parents. Indeed, this is an empirical question that is yet to be answered. Interestingly, parents in the pilot groups reported that the most helpful aspects of therapy were learning to control their anger and handle problem situations with their child as well as to talk openly with their children about the CPA incident(s).
Children also identified talking about the abuse as the most helpful aspect of their therapy. It is notable that the above is a summary of the interventions that will be conducted. However, the model provides flexibility so if a particular family needs additional work in a specific area, more time can be devoted to the respective problem. It is expected that many interventions, such as the parent motivational procedure, selfprotection plans, anger management skills, and cognitive coping related to abusive experiences, will be repeatedly reviewed over the course of treatment. IMPLICATIONS The literature reviewed above demonstrates that although a variety of treatment models for child physical abuse exist, few of the models have been empirically tested and the majority of them are not based on an integrated approach that includes both the parent and the child. In fact, despite a growing consensus among child abuse professionals that treatment should optimally involve parents and children (see Kolko, 1996a; Urquiza & McNeil, 1996), community treatment with respect to child physical abuse
continues to focus on the parent alone. Routine community care in our region consists of a 6week parenting class that does not involve the child. Given the complex, multifaceted issues presented by families in which physical abuse occurs, an integrated approach that includes both parents and children seems warranted. It is critical to provide treatment to parents and stop any ongoing physical abuse; however, there may be important benefits in providing treatment to children to help reduce short-term symptomatology, long-term negative effects, and the likelihood of adult revictimization. Furthermore, interventions with children may reduce the generalization of violent behavior to adult relationships and/or future parent-child interactions.
Practice
Although it is an empirical question that has not yet been directly and adequately addressed, there is some support that Although it is an including the child in empirical question t re a t m e n t m a y h a ve added benefit for reduc- that has not yet been directly and ing psychological sympadequately toms and facilitating optiaddressed, there is mal long-term outcomes some support that for children who have including the child in suffered CPA (see Kolko, 1996a; Kolko & Swenson, treatment may have added benefit for 2002; Swenson & Brown, reducing 1999).
Indeed, CBT treatpsychological ment models, which insymptoms and clude both children and facilitating optimal parents, have been empirically supported for chil- long-term outcomes dren who have been sexu- for children who have suffered CPA (see ally abused (Deblinger & Kolko, 1996a; Kolko & Heflin, 1996).
Researchers Swenson, 2002; and mental health profesSwenson & Brown, sionals have just begun to 1999).
adapt comprehensive parent-child CBT models to address the needs of children and families in which CPA has occurred (Donohue et al., 1998; Kolko, 1996a; Kolko & Swenson, 2002).
Furthermore, compared to cases of CSA, children who have suffered CPA are much more likely to re-
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main in the home where they continue to interact with the offending parent on a daily basis. Consequently, it is reasonable to offer treatment to both the offending and nonoffending parent as well as the child to address their individual needs and parent-child relationships. An integrated approach may also allow for improvements in monitoring safety in the home as multiple informants (e.g., both parents, child, and siblings)—if deemed clinically appropriate— will be providing information about parentchild interactions and potential recurrent abusive incidents on a weekly basis. Other family members may be more likely than the offending or at-risk parent to report recurrent incidents of abuse. Obviously, an integrated parent-child CBT approach, such as the one proposed, would not benefit all families who have suffered CPA. It is imperative that mental health professionals take significant precautions to safely incorporate the child into the parent’s treatment as the safety of all family members is paramount. Prior to initiating treatment, a comprehensive detailed assessment should be conducted with all family members to identify not only treatment targets but also the readiness of the family to participate in an integrated treatment process. If possible, information should be obtained from collateral contacts, child protective services, reporting source (if possible), other treatment providers, and school personnel to assist in assessing potential risks to family members. Particular attention should be given to the parent’s readiness to participate and to alter parenting behavior as well as the child’s level of trauma and anxiety related to having joint sessions with his or her parents. In cases in which a parent or child is not ready to proceed with joint parent-child work, both may benefit from individual treatment focused on addressing emotional and behavioral issues that may interfere with their readiness in an effort to prepare them for the joint work. Furthermore, in situations in which a child has been removed from the home and the court has instituted a nocontact order due to safety issues, an integrated parent-child approach would not be appropri-
ate. Other issues, such as parental mental illness, parental substance abuse, and child’s fears/anxiety may also need to be addressed in intensive individual therapy before an integrated approach is initiated. Last, if a parent and child are separated due to safety issues and reunification is not a goal for a particular family, an integrated approach would not be warranted. Whether the parent is participating in individual treatment or an integrated parent-child approach, it is important for clinicians to avoid judging parents and provide them with empathy and support by acknowledging the monumental task of being a parent while holding the parent accountable for his or her abusive behavior. Even though a child’s behaviors may be difficult and/or inappropriate, the clinician should not engage in or allow the parent to blame the child for the abusive incident. When holding a parent accountable for his or her behavior and assisting them in acknowledging and learning alternative parenting strategies, a clinician must support a parent in progressing at his or her own pace and be respectful of cultural and religious beliefs. One of the benefits of using a collaborative, structured, time-limited CBT approach is that it allows flexibility and ongoing feedback between therapist and client to ensure that the cultural needs of the client are being respected and addressed. Whether treatment has differential effects depending on the child’s age is an empirical question that has just begun to be addressed with child victims. It is notable, however, that the proposed model employs CBT treatment strategies based on CBT principles that can be individually tailored and applied to families with children of all ages. For example, many of the principles and skills we will be teaching cut across all age groups (e.g., active listening, contingency management, praising/rewarding appropriate behavior, giving choices), but parents are provided with education on appropriate developmental expectations and given guidance concerning appropriate types of discipline practices depending on the child’s age (e.g., time-out for younger children, work chores for older chil-
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dren).
All strategies are based on CBT principles but can be tailored to the child’s developmental level. An integrated parent-child CBT approach may be offered in either the individual or group format. Several studies examining individual (Deblinger et al., 1996) and group (Deblinger, Stauffer, & Steer, 2001; Stauffer & Deblinger, 1999) CBT approaches designed for victims of CSA as well as their nonoffending parents also have been demonstrated as promising. As mentioned above, there is less empirical evidence available to support individual (Kolko, 1996a) and group approaches (Swenson & Brown, 1999) for CPA cases. Obviously, an individual approach has the benefit of offering children and families intensive, individualized attention that may be warranted based on the clinician’s comprehensive assessment. However, group treatment is cost-effective and has specific therapeutic benefits. It provides both children and parents with unique opportunities from both a therapeutic and socialization standpoint. In fact, many professionals generally concur that support by peers who have had similar experiences expedites posttrauma recovery in children (Galante & Foa, 1986; Terr, 1989).
Moreover, group treatment provides children and parents with opportunities for socialization, feedback regarding socially appropriate behavior, and role-playing of desired peer and parentchild interactions. Group treatment is useful for increasing parental social supports, decreasing the social isolation frequently reported by maltreating parents (Wodarski, 1981).
These opportunities are of primary importance, given the research reporting that at-risk and physically abused children have poor peer interactions, lack social skills, and use aggressive conflict resolution strategies (Dodge et al., 1994; Kolko, 1992/1996b; Malinosky-Rummell & Hansen, 1993).
Group treatment may also help parents develop a social support network, parenting skills, and more positive interactions with their children. Group treatment may be a viable approach if limited to a small number of families who can receive individualized coaching and parent-child interventions during the joint parent-child meetings.
Policy
The needs of families in which physical abuse occurs necessitate a variety of professionals and agencies collaborating with each other to ensure successful intervention that requires systemic changes at many different levels. The first step in working toward more successful intervention is improving the identification and assessment of families at risk for physical violence. It is crucial for pediatricians and family care physicians to be aware of the possible indicators, including behavioral, medical, and somatic concerns, related to physical abuse. This requires medical professionals to have knowledge of accidental and nonaccidental injuries and to consistently report reasonable suspicions to child protection agencies. Furthermore, workers at child protection agencies should be well trained in understanding and recognizing the dynamics of families in which physical abuse occurs. Sensitivity to these issues should enhance interviewing and assessment techniques, ensuring that families receive intervention and that physical abuse is not overlooked. More effective intervention with families also requires a shift in the process of referral to mental health professionals. Rather than focusing on crisis management after parenting practices have already reached a level of seriousness necessary to meet the criteria for substantiation of child physical abuse, professionals need to focus on providing parents with nonjudgmental support and assisting them in obtaining mental health services in an effort to prevent future incidents that meet the legal definition of physical abuse. This would require that child protection agencies offer support, guidance, and/or appropriate referrals to families following incidents that may not meet full criteria for the current standards of substantiation of physical abuse. The consequences of failing to recognize the needs of at-risk families may result in more serious trauma for children. To best serve the needs of children and families, increased resources need to be available for prevention, intervention, and research. For child protection agencies to shift their referral procedures, they will require increased funding for training and expansion to allow for a greater
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focus on prevention. In addition, mental health agencies may require financial assistance to service clients who might not be covered by insurance or other sources of funding. Increased resources might also be allotted to child maltreatment professionals to ensure adequate communication and collaboration among disciplines. Furthermore, the Victims of Crime Act (VOCA) could offer funding for treatment for not only the child but the parent as well. Although the child is the identified victim, providing services to the offending parent has an indirect positive impact on the child victim. It is also notable that many offending parents are violent crime victims who did not receive adequate mental health services, perhaps due to a lack of Continued assessment research resources, during their o w n ch i l d h o o d . Reusing sources should be allopsychometrically cated to programs that sound measures, not only address physicarefully developed cally abusive behavior conceptual models, but also assist parents and rigorous from coping with past longitudinal and/or traumas, which in turn matched control may contribute to their designs will current parenting praccontribute greatly to tices. Although these our ability to design policy changes may initreatments that tially require a significant effectively target a m o un t o f e xt ra rethose factors that lead to more positive sources, these resources would serve as a longoutcomes for these children and parents. term investment that may substantially reduce social service and mental health care costs associated with interventions provided. In addition to making resources available to families in which CPA has occurred, child protective service agencies and legal representatives need to improve their ability to motivate parents to follow through with treatment programs. In our community, only a few parents are court-ordered for treatment, and this may not be the best approach. Regardless, families are frequently referred for treatment with little or no follow-up. Thus, when a family does not follow through with the referral and child protective services is notified, there seems to be a
lack of strategies for motivating and/or engaging the families to participate in treatment. With regard to our agency, there are few dropouts after the family has actually become engaged in the treatment process. The difficulty lies with motivating parents to follow through with referrals.
Directions for Future Research
Research in the field of CPA is critical but highly complex to undertake given the myriad of legal, ethical, and clinical issues that must be carefully considered when initiating and implementing an investigation with this population. Although important assessment studies have clearly documented the significant short- and long-term consequences of suffering physical abuse in childhood, we are only beginning to fully appreciate and understand the mechanisms by which these abusive experiences impact on children’s physiological, emotional, intellectual, and social development. Similarly, research has begun to shed light on parental characteristics that seem to be associated with CPA, but there are still many gaps in our understanding of parents who impulsively and/or systematically use abusive discipline strategies. C o n t in ue d a s s e s s m e n t re s e a rch us in g psychometrically sound measures, carefully developed conceptual models, and rigorous longitudinal and/or matched control designs will contribute greatly to our ability to design treatments that effectively target those factors that lead to more positive outcomes for these children and parents. Research with respect to treatment for this population is clearly in its infancy, perhaps because it presents many challenges. Still, given the enormous psychosocial and financial costs associated with the impact of CPA on individuals, families, and society as a whole, it behooves us to confront and overcome these challenges in an effort to design, evaluate, and disseminate therapies that will effectively break the cycle of violence. To overcome the inherent challenges posed by the field, researchers are encouraged to work collaboratively with child protection, law enforcement, and medical professionals as they play a critical role in the identification, re-
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cruitment, and responsiveness of families. In addition, given the diversity of definitions and means of determining whether physical abuse has occurred, it is important for researchers to establish objective inclusion/exclusion criteria in an effort to clearly define and describe their subject samples. Moreover, the identification and measurement of individual and family factors may help us to determine which children and families profit most from which interventions. Gender, developmental age, cultural factors, and coping styles are all variables that may be important moderating influences on treatment outcome. Research findings suggest that treatments for this population should address the therapeutic needs of the parents as well as the children on a variety of levels (e.g. cognitive, behavioral, affective, social, and familial).
The limited treatment research to date has focused primarily on high-risk parents, with much less attention given to the examination of treatments for the children themselves. Thus, there may be value in not only designing and testing treatments for children but evaluating the benefits of integrating such treatment into programs designed for abusive parents. In general, given the resource limitations and the community settings in which these families are seen, treat-
ments designed should be practical, consumerfriendly, cost-effective, and manualized to allow for replicability in the field. Treatment outcome investigations should also be based on theory-driven models and should incorporate psychometrically sound measures that tap multiple domains and assess treatment targets as well as potential mechanisms of change. Although ethical considerations may preclude the use of no-treatment control conditions with this population, random assignment to alternative treatment conditions that reflect models used in the field is not only justifiable but critical to the development of effective treatments. Millions of dollars are spent each year on this population for mental health services that have not been empirically evaluated. It should be noted, however, that comparative outcome studies, in which two or more active treatments are expected to produce positive change, require larger sample sizes to detect differences. In addition, it is important to incorporate significant follow-up assessments in treatment outcome designs whenever possible. Treatments should be evaluated not only for their effectiveness in achieving significant improvements but also for their success in producing lasting change.
IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH
• Existing research supports the use of CBT treatment strategies with both the child and offending parent in families in which physical abuse occur. Research has documented posttreatment improvements on measures of child externalizing behavior problems, parental distress, abuse risk, family conflict and cohesion, and children’s levels of anxiety and depression as well as reductions in parental anger and the use of physical punishment. Effective treatment strategies should be disseminated to community agencies. • Policies should be implemented that focus on a proactive, rather than reactive, approach to dealing with families at risk for physical abuse. For instance, professionals should provide at-risk parents with nonjudgmental support and assist them in obtaining mental health services in an effort to prevent future incidents that meet the legal definition of physical abuse. This would require that child protection agencies offer support, guidance, and/or appropriate referrals to families following incidents that may not meet full criteria for the current standards of substantiation of physical abuse. • Empirically rigorous research is needed to further examine the efficacy of CBT strategies for treating children who have suffered physical abuse and their offending parents and to safely incorporate the child into the parent’s treatment. • There may be value in not only designing and testing treatments for children who have suffered physical abuse but also in evaluating the benefits of integrating such treatment into programs designed for abusive parents. Future research should examine the added benefits of providing treatment directly to the child victim in conjunction with the offending parent.
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SUGGESTED FUTURE READINGS
Donohue, B., Miller, E., Van Hasselt, V. B., & Hersen, M. (1998).
Ecological treatment of child abuse. In V. B. Van Hasselt & M. Hersen (Eds.), Sourcebook of psychological treatment manuals for children and adolescents (pp. 203278).
Hillsdale, NJ: Lawrence Erlbaum. Kolko, D. J. (1996).
Individual cognitive-behavioral treatment and family therapy for physically abused children and their offending parents: A comparison of clinical outcomes. Child Maltreatment, 1, 322-342. Kolko, D. J., & Swenson, C. (2002).
Assessing and treating physically abused children and their families: A cognitivebehavioral approach. Thousand Oaks, CA: Sage. Runyon, M., Basilio, I., Van Hasselt, V. B., & Hersen, M. (1998).
Child witnesses of interparental violence: A manual for child and family treatment. In V. B. Van Hasselt & M. Hersen (Eds.), Sourcebook of psychological
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treatment manuals for children and adolescents (pp. 203278).
Hillsdale, NJ: Lawrence Erlbaum. Swenson, C. C., & Brown, E. J. (1999).
Cognitive-behavioral group treatment for physically abused children. Cognitive and Behavioral Practice, 6, 212-220.
Melissa K. Runyon, Ph.D., functions as the treatment services director of the Center for Children’s Support and as assistant professor of psychiatry at the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine (UMDNJ-SOM).
The center is a nationally recognized program specializing in the medical and mental health evaluation and treatment of alleged victims of child abuse. Prior to this appointment, she founded and directed the Child and Family Treatment Service (FACTS) program at the University of Miami School of Medicine Child Protection Team. She has published and presented nationally in the area of child maltreatment and domestic violence. Dr. Runyon received funding from the National Institute of Mental Health to examine the added benefit of including the child in the parent’s treatment by comparing a parent only CBT treatment approach to a combined parent-child CBT approach for children and families at risk for CPA. In addition, she currently serves as co-investigator on a federally funded, multisite grant to evaluate treatment of children who have suffered child sexual abuse. She is also on the editorial board for the journal Trauma Practice. Esther Deblinger, Ph.D., received her M.A. and Ph.D. in clinical psychology from the State University of New York at Stony Brook. Currently, she is the clinical director of the Center for Children’s Support and professor of psychiatry at the UMDNJ-SOM School of Osteopathic Medicine. In collaboration with her colleagues at the center, she has conducted cutting-edge research, funded by the
Foundation of UMDNJ, the National Center on Child Abuse and Neglect, and the National Institute of Mental Health, examining the impact of child sexual abuse and the treatment of PTSD and related difficulties. As a result of this work, she developed a cognitive-behavioral therapy program that was recognized for its effectiveness in treating child sexual abuse with a 2001 “Exemplary Program Award” presented by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. She is also a frequent invited speaker at national and international conferences and has coauthored numerous journal articles. She is the coauthor of the professional book Treating Sexually Abused Children and Their Nonoffending Parents: A Cognitive Behavioral Approach (1996) as well as the children’s book Let’s Talk About Taking Care of You: An Educational Book About Body Safety (1999).
Currently, she is on the editorial boards for the journals Child Maltreatment and Trauma Practice. Erika E. Ryan, Ph.D., is a staff clinician at the UMDNJ-SOM’s School of Osteopathic Medicine’s Center for Children’s Support. She received her degree in clinical psychology from the University of North Carolina, Greensboro. Reena Thakkar-Kolar, Ph.D., is a staff clinician at the UMDNJ-SOM’s School of Osteopathic Medicine’s Center for Children’s Support. She provides both individual and group therapy to children who have experienced abuse and conducts forensic evaluations concerning allegations of sexual abuse. She also collaborates on ongoing research using the center’s clinical database. She received her degree in clinical psychology from Northern Illinois University, where her emphasis was on the long-term somatic effects of women with a history of sexual abuse.
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