Effective Treatment Components for Young Children Exposed to ViolencePublic
Exposure to violence, which includes child abuse, neglect, witnessing domestic or community violence, crime, and sexual assault, is a national concern. Over the course of a year, 68% of children under age 17 are exposed to at least one form of violence (Finkelhor, Turner, Shattuck, & Hamby, 2015). Young children (toddlers and preschool-aged children) are especially at risk for violence exposure. Physical abuse, neglect, witnessing domestic violence, and fatalities are reported at higher rates for younger children than older children (Children's Bureau, 2017; Fantuzzo & Fusco, 2007). Violence exposure can cause negative psychosocial consequences in children such as internalizing (e.g., anxiety) and externalizing (e.g., physical aggression) symptoms (National Child Traumatic Stress Network, n.d.; Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003). Particularly for young children, violence exposure may impair the formation of secure attachment, which can have a detrimental effect on the development of sense of security and self-regulatory capacities (Cook, Blaustein, Spinazzola, & Kolk, 2003). Research supports that evidence-based treatments (EBTs) for childhood trauma are most effective at alleviating the effects of violence exposure on children (Listenbee & Torre, 2012; Racco & Vis, 2015). In clinical practice, however, EBTs for childhood trauma are underutilized (Allen, Gharagozloo, & Johnson, 2012). There are at least two possible reasons for this research-practice gap. First, many EBTs for childhood trauma typically target an individual type of trauma (e.g., sexual abuse) or specific age group (Landolt, Cloitre, & Schnyder, 2017; National Child Traumatic Stress Network, n.d.), which requires clinicians to become familiar with a large number of EBTs. Due to financial barriers, however, it is often unrealistic for clinicians to obtain high-level training in multiple EBTs for the diverse children they treat (Chorpita, Becker, Daleiden, & Hamilton, 2007). Second, there are many available EBT options for childhood trauma, but choosing the “right one” for individual children can be challenging for clinicians. Clinicians often have limited access to or time for staying abreast of recent research, restricting their ability to select the most informed treatment (Chorpita et al., 2007). Moreover, EBTs for childhood trauma have significant overlap in their treatment components such as psychoeducation and relaxation (National Child Traumatic Stress Network, n.d.). Therefore, distinguishing the potential benefits of one treatment from another is not always obvious. To address the aforementioned research-practice gap, it is necessary to reduce the time and monetary burden on clinicians. Almost 90% of clinicians use specific treatment components, as opposed to a whole set of EBTs for childhood trauma, to better fit with children’s needs (Thomas, Zimmer-Gembeck, & Chaffin, 2014). As such, using specific treatment components may be a feasible and more manageable treatment alternative, especially for clinicians with limited resources. According to Chorpita, Daleiden, and Weisz (2005a), different EBTs (not limited to EBTs for childhood trauma) share overlapping treatment components; these overlapping components may be more effective than non-overlapping components at improving child symptoms such as depression and traumatic stress (Chorpita et al., 2005a). In the majority of EBTs for childhood trauma, there are four specific overlapping treatment components: trauma narrative (telling a story of trauma), relaxation skills, cognitive restructuring, and psychoeducation (Chorpita & Daleiden, 2009). Unfortunately, there is little evidence demonstrating that these treatment components are individually effective in treating children exposed to violence. Research that has investigated treatment components for improved mental health outcomes, especially for young children exposed to violence, is limited. Schewe (2008) and Schewe, Risser, and Messinger (2013) examined the associations between a variety of treatment components and overall child outcomes using non-standardized therapists’ self-reports of child functioning. Using therapist self-report of child outcomes could result in biased assessment of child outcomes (Kent, O'leary, Diament, & Dietz, 1974). Deblinger, Mannarino, Cohen, Runyon, and Steer (2011) examined whether the trauma narrative component of trauma-focused cognitive behavioral therapy is essential to achieve positive outcomes. However, no research to date has investigated the relative effects of a wide range of treatment components on internalizing and externalizing symptoms of a community sample of young children exposed to violence using a standardized measure of child outcomes rated by caregivers, which can also ameliorate potential therapist bias. The goal of this study was to identify treatment components that were most effective at alleviating the negative effects of violence exposure in young children aged 1.5-5 years. The specific aims of this study were to: Aim 1a. Develop a strategy for collapsing mental health treatment components into a parsimonious set of treatment factors for children. Aim 1b. Develop a strategy for collapsing mental health treatment components into a parsimonious set of treatment factors for caregivers. Aim 2a. Identify which treatment factors are most strongly associated with a reduction in post-treatment internalizing symptoms. Aim 2b. Identify which treatment factors are most strongly associated with a reduction in post-treatment externalizing symptoms. Identifying treatment components and factors most strongly associated with reducing internalizing and externalizing symptoms associated with exposure to violence will have important practice implications. By disseminating the results to clinicians, they could quickly learn necessary skills (effective treatment components), resulting in minimizing the time and monetary burden on clinicians in training. Clinicians could also prioritize the most effective treatment components based on children’s symptoms rather than implementing an entire treatment protocol. This study used secondary data collected from 12 community-based mental health agencies across Illinois from 2001 to 2015. The data included 2,694 children who received treatment in those agencies. This study included children aged 1.5-5 years because child internalizing and externalizing symptoms were assessed by the Child Behavior Checklist for Ages 1.5-5, which targets children aged 1.5-5. Factor analysis and a series of multiple linear regression methods were used to analyze the associations between treatment factors and post-treatment internalizing and externalizing symptoms.