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Copyrighted and posted by permission of Jenna Bernier at Massachusetts Citizens for Children. Originally posted at http://masskids.org/cta/cta_iv_ch14.html
As described earlier, the experience of witnessing violence or the trauma of having been neglected or physically, sexually or verbally abused in childhood have been linked to a variety of serious and enduring problems for a vast number of its victims. Depression, anxiety, psychiatric disorders, delinquent behavior, substance abuse, spousal abuse, and violence are all too common.
As a West African proverb states, “Rain does not fall on one roof alone.” The effects of child abuse are not felt only by its victims, but in so many tangible ways, by all members of the community. Any effort that hopes to succeed in ending child maltreatment must be committed to ensuring that children receive the full complement of therapeutic services they require to recover as fully as possible from the effects of their abuse or neglect. The challenge to the State, the legislature and the public-at-large is how to ensure these children the services they need and deserve – in other words, how to help them heal.
The Mental Health Care Crisis in Massachusetts
Research shows that the effectiveness of treatment is optimized when provided soon after the traumatic occurrences. Great strides have been made in understanding which interventions work best to maximize the recovery of children who have experienced or witnessed violence or have suffered from neglect. This new information must be incorporated into clinical and protective practices, as well as into public policies that affect children. These are difficult to address, however, until we successfully confront the escalating problems in our state’s mental health system. Few would challenge the assertion that the mental health care system in Massachusetts is in dire crisis. A study conducted by the Children’s League of Massachusetts in 2000 [221] documents a critical shortage of services for children who require mental health care. Though many of these children suffer from organic mental illnesses and have loving and devoted families, the population of children that requires mental health care also includes the victims of serious abuse and neglect.
Residential and Outpatient Care
Recent reports have heightened the public’s awareness of the plight of children trapped in psychiatric wards or mental health units where they become more despairing as they wait for appropriate referrals to therapeutic homes. Others who need specialized in-patient level care are turned away from child psychiatric wards due to a shortage of beds.
The need is so acute that children often wait long periods of time in Emergency Rooms waiting for a bed to become available. The lack of timely and appropriate residential services can compound these children’s already fragile coping abilities. For example, in one publicized case, a traumatized child whose family was seeking placement for him was sent home from an Emergency Room only to cut himself with a knife and then beat his 3-year old brother.[222]
The Children’s League study also concluded that youth participating in residential treatment programs have grown more difficult to serve. They report an increase in the severity of emotional and behavioral issues they face. Children are presenting more serious levels of pathology, their numbers are increasing, and their hopes for treatment and recovery are diminishing due to the shortage of beds and the lack of qualified treatment providers in our state.
The private sector is not the only group to report these critical shortages. The Department of Mental Health reported in 2000 that 2,500 children were on waiting lists for services.
Hospitals have also reduced social services and treatment in response to reduced funding. Parents on the North Shore, Fall River and other communities report waiting lists of up to five months for outpatient treatment services. Other outpatient child psychiatric services at the major medical centers in Boston that offer new treatments for trauma-surviving children are operating at a loss to the parent institution, and many have been, or are being, reduced or eliminated.
Other services within non-profit provider organizations are also operating at a loss and are subsidized by endowments or income from other revenue generating programs. These funds can only serve as temporary sources of support.
Evaluations
Massachusetts also faces a critical shortage of evaluation options for children who present as possible victims of sexual abuse. Currently in our state, children who engage in sexually inappropriate behaviors that suggest prior abuse, or children who have disclosed their abuse – but to another child – cannot receive appropriate treatment without a comprehensive sexual abuse evaluation. Unfortunately, the heightened cost of these evaluations has become a major obstacle for institutions like New England Medical Center, Boston Medical Center, and others, in documenting and treating child sexual abuse.
For many children, this lack of evaluation resources threatens to turn the silent tragedy of child sexual abuse into an invisible one. One example, involves Children’s Hospital of Boston and the Sexual Abuse Treatment Team (SATT) operating within its Department of Psychiatry. Although the hospital has received national acclaim for its work in evaluating children identified as potential victims of sexual abuse, recently the services normally provided to these children have been too costly to maintain.
In 2000, the SATT team was dissolved as a cost saving measure. The disincentive to continue operating was understandable – the more evaluations they performed, the greater the financial loss to the hospital. Although, the Child Protection Team still functions at Children’s Hospital and has absorbed some of the SATT functions, there is still a large deficit in available evaluation and treatment services for these child victims.
Specialized treatment options for children whose sexual abuse has been confirmed is also sorely lacking. Research shows that the best treatment for these trauma victims is abuse-specific treatment, yet there are too few experienced clinicians with knowledge of trauma and sexual abuse in Massachusetts. Inadequate reimbursements by managed care systems have been a major predicament for clinicians and institutions currently providing these services and a major disincentive to attracting others into this field of practice.
Given the long-term benefits and cost savings of quality care for these children, reimbursements that cover actual costs must be provided to hospitals and practitioners with expertise in child abuse evaluation and treatment. These reimbursements must include support for collateral contacts with family members, teachers, and other service providers.
Many maintain that current mental health services for victims of abuse and neglect are organized in ways that frequently undermine recovery and at times even re-traumatize children. Reimbursement structures have pushed private providers into “fee-for service” arrangements that have resulted in part-time, temporary working patterns and high clinical staff turnovers. This places an unfair burden on already vulnerable children who very much need to develop a consistent and ongoing therapeutic relationship.
Innovations in Trauma Treatment
Although some traumatized children continue to benefit from traditional therapy and abuse-specific treatment, research is showing that some new treatment approaches can be far more effective for many traumatized children.
Multisystemic Therapy (MST)
One effective treatment strategy for traumatized children is the “social-ecological” model, or the “Multisystemic” Therapy (MST) approach. This therapeutic model is based on an understanding of the child as inextricably linked to family, community, and school. It argues that in order to meet the mental health needs of traumatized children, careful attention must be paid to the child’s environment and the “social-ecology” which has broken down in many different ways.[224]
Children who have been abused often display a broad range of emotions and behaviors including fear, aggression and dissociation. A core theme of the MST approach is that trauma from the abuse or neglect causes a “dysregulated” nervous system and an accompanying family and social environment that cannot contain the dysregulation.
An initial goal of treatment is to create calm and stability and to help build cognitive structures in the traumatized child that help him place discriminating thought between a stimulus and his response to it. This is accomplished by helping a child first become aware of his feelings, then label his feelings and finally, develop strategies that regulate feelings once they are labeled. By developing these cognitive supports, children come to learn that they have new, more positive choices in their behavior.
When examining the child’s environment under this model, questions are raised about the child’s safety and basic needs, to what degree the overall environment is stressful, and whether the child is in the right educational setting.[225] Therapeutic contacts with the child and his or her family emphasize the positive, and use strengths in the child’s environment as levers for change.
Interventions target specific and well-defined issues. Everyone involved becomes aware of the specific problems and their roles in perpetuating or solving them. An understanding develops about the sequences of behavior among the various systems in the child’s life, e.g. how an intrusive symptom of the trauma can impact on school issues that can then influence a specific family response to the child. The interventions eventually promote responsible and therapeutically appropriate behavior and decrease irresponsible behaviors in all these settings.
MST, currently being used with violent and aggressive children, traumatized children, homicidal and substance abusing children, has the following core components:[226]
Outcome Data
Data from outcome studies are encouraging. In one study involving 200 chronic juvenile offenders, youth who received MST showed:
A decreased rate of 22 percent recidivism versus 71 percent in the control group.
Fewer violence- or drug-related arrests and significantly greater improvements in family cohesion.[227]
In a randomized trial of MST versus clinic-based parent training among DSS families with abuse and neglect histories, results showed:
Significantly greater improvements in the MST parent group including, more effective parental behavior management and more appropriate parental responses to children, suggesting a reduced risk of maltreatment.[228]
In another study of severely traumatized children, 113 children and adolescents were approved for emergency psychiatric hospitalization. Youth entering the study met the criteria for severe emotional disturbance, and utilized multiple service agencies, including mental health, juvenile justice and social services. A randomized trial of MST versus inpatient hospitalization and “treatment as usual” was conducted. The results were stunning.
The MST population had greater improvements and exhibited fewer symptoms;
Family structure and cohesion was improved;
School attendance improved;
No additional hospitalization was warranted for 57 percent of the MST group. Overall days of hospitalization in the MST group were reduced by 72 percent, and days in other out-of-home placements were reduced by 49 percent.[229]
It has been estimated that one team of 3 MST therapists can effectively treat 50 families a year at a cost of $5,000 per family. The annual cost of an entire program is about $250,000.[230] When considering the short-term saving of preventing out-of-home placements, residential care, psychiatric hospitalizations, as well as the long-term savings of preventing imprisonment, substance abuse and chronic medical and mental illness – MST is an approach that can document significant success and savings.
Trauma and Movement Therapies
Psychodrama and other social group rituals involving movement and imagination are some of the oldest ways in which individuals and communities have historically dealt with trauma. These approaches are now being used as formal interventions to assist traumatized children.
As we have seen, children who are victimized by trauma are often unable to develop or experience mastery and sense of self, or to separate themselves psychologically from the violent physical experiences that produced their trauma. New research suggests that the neurobiological effects of trauma are as real as their emotional consequences. The body appears to “keep score” of traumatic memories and is a theatre where the memory of trauma is often reenacted.
Research by van der Kolk and others has major implications for the role that physical education, sports, and art can play in healing and promoting self-confidence and mastery. By creating what van der Kolk refers to as “islands of competence”, traumatized children can develop new coping strategies and behavioral skills that can promote healing, something, he argues, that may not be achieved through traditional talking therapies alone.
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