Concepción inicial de vía de hecho.

Three studies106–109_{examined the effectiveness of CBT specifically with children who had experienced}

physical abuse.

Description of studies

Location

All three106–109_{studies took place in the USA.} Sample sizes

Participants Age

The mean ages of children in the studies by Kolko107,108_{and Runyonet al.}109_{were 8.6 years and}

9.88 years, respectively. Adolescents in the LeSure-Lester106_{study were aged 12}

–16 years.

Gender and ethnicity

The 12 participants in LeSure-Lester106_{study were African American males, 28 of 36 completers in the}

Kolko107,108_{study were boys, and, of those who completed at least three sessions of therapy in}

the Runyonet al.109_{study, 28 of 44 were girls.} Recruitment

In the Runyonet al.study109_{all but five of the families in the final sample were referred by child protection}

service agencies. Those in the Kolko107,108_{study were referred by Child Protective Services (CPS)}

caseworkers. In the LeSure-Lester study,106_{participants were recruited from a group home where they had}

been placed by CPS.

Maltreatment

Participants in all three106–109_{studies had experienced physical abuse or (four cases in the Kolko}107,108_{) study}

severe or frequent forms of physical discipline with a risk of injury.

Interventions and comparison

Kolko107,108_{evaluated the impact of two interventions: a manualised FT treatment for physically abused}

children and a manualised CBT intervention for individual children and their parent(s). In the CBT arm, children and parents received therapy from separate therapists, who implemented parallel protocols based on social learning principles that were designed to address cognitive, affective and behavioural problems. Treatment for the children addressed their perceptions of family stress and their environments; training to develop coping and self-control skills; and interpersonal effectiveness. The intervention for parents focused on their views on violence and physical punishment, their attribution style and expectations, self-control and contingency management. There was throughout an emphasis on teaching intrapersonal and interpersonal skills. The FT was based on Belsky_’s227_{interactional or ecological model approach to child}

maltreatment. It sought to_‘enhance the cooperation and motivation of family members by promoting understanding of coercive behaviour and by teaching the family positive communication skills and how to solve problems together’(p. 326).227

The control group received routine community services from providers not associated with the project, as mandated by family service workers. Services were based on an extensive risk assessment and included

‘home visits to provide support and information, family skills specialists who taught homemaking and

related skills, and parenting information and support groups_’108_{plus regular telephone contact from the}

caseworker (p. 326).

Runyonet al.109_{assessed the added value of providing treatment to children [combined parent}

–child

cognitive_–behavioural therapy (CPC-CBT)], as well as parents (parent-only CBT). Children in the CPC-CBT arm received an intervention covering psychoeducation; affect regulation; coping skills; cognitive coping; assertiveness skills and anger management; general safety skills; application of skills; development of a personal safety plan; role perspective-taking skills; problem-solving skills; preparing a letter of praise; developing a TN; and agreeing and sharing a joint TN (with parents). In addition to the usual parents_’ programme (seeComparisons), parents in the experimental arm received input on parent training with the child; refinement and rehearsal of personal safety plans with the child; attention to abuse clarification and the development of the joint TN plus coaching in parent–child interactions; behaviour rehearsal of coping skills; parenting skills and safety plan; sharing of TN; and abuse clarification.

The parent-only CBT control arm received an intervention that comprised disclosure of the referral incident, engagement and assessing parents_’goals, motivational interviewing and commitment to no violence (two sessions), followed by psychoeducation and an introduction to anger management skills (two sessions), continuation of coping skills (three sessions), review and applications of skills, including ABCs of parent_–child interactions, development of personal safety plans (three sessions); review of ABCs of parent_–child interactions and integration/generalisation of skills (four sessions) and parent training (parent only, two sessions).

LeSure-Lester106_{provided CBT to groups of two to three participants. The intervention was designed to}

teach participants the feelings associated with anger and aggression, relaxation and self-talk, and alternative ways of coping. It comprised a three-stage education and training module, beginning with education relaxation techniques. This was followed by education and GE and then education and anger control. The therapist used vignettes (as the basis for discussions) that reflected the participants_’natural environments, that is, the residential setting. Participants in the control arm received‘traditional indirect therapy_’consisting of open-ended discussions and communications of the participants_’self-reports of activities and current events in their daily lives. The therapists were said to have exercised warmth, empathy and genuineness_–no specific coping skills were taught.

Number and duration of sessions

Each intervention in the Kolko107,108_{study entailed at least 12 1-hour weekly clinic sessions over a}

16-week period, for a total of about 18 hours of service. Those in the routine community services (control) arm received variable amounts of help, ranging from services delivered on a once or twice per week basis for an indefinite period of time, to treatment plans comprising up to 20 hours of home-based service per week for up to 3 months.

In the Runyonet al.109_{study, parents in the}

‘combined intervention’attended 16 2-hour group sessions

over a 16- to 20-week period. Groups were initially conducted concurrently for the first hour and 45 minutes, with the last 15 minutes involving joint parent_–child sessions based on families_’needs. The balance between concurrent and joint time shifted over the course of the intervention so that in sessions 12_–16 the joint sessions lasted 60_–75 minutes. Parents in the_‘Parent only_’condition received a similar CBT parenting intervention, but spent more time discussing the implementation of behaviour management strategies. Parents in the_‘Combined_’arm spent less time on parent skills training and more time preparing their_‘clarification letter_’(a letter that demonstrated that they took full responsibility for their abuse behaviour) and preparing for, and interacting with, their children in joint sessions. This was one of only a few interventions that included the non-offending parent.

In the LeSure-Lester106_{study, participants in both arms received 26 weeks of traditional indirect therapy,}

and were then randomised to continue with that therapy or to receive 26 weeks of CBT. Both therapies were delivered for 1 hour, twice per month.

Outcomes and measures used in studies of cognitive–behavioural therapy for physically abused children

Post-traumatic stress disorder

Only Runyonet al.109_{assessed the impact of intervention on PTSD, using the KSADS-PL}268

(seePost-traumatic stress disorder). This was the primary outcome in this study.109 Depression

Kolko107,108_{used the CDI}80_{to assess the intervention}

’s impact on depression.

Behaviour

Runyonet al.109_{and Kolko}107,108_{both used the CBCL}260_{to assess change in child behaviour, along with the}

LeSure-Lester106_{used a rating system of behavioural appropriateness developed within the residential}

setting, and comprising aggression towards peers, towards staff and compliance with house rules (all scored low or high).

Risk of bias: randomised controlled trials of cognitive–behavioural therapy for physically abused children

Sequence generation

Kolko107,108_{used a computer-generated procedure based on Efron}

’s biased coin toss and was assessed

as low risk of bias. Runyonet al.109_{used a computer program to randomly determine the treatment}

type for each group, and on that basis was deemed low risk of bias. No information was provided by LeSure-Lester106_{and so this study was judged unclear.}

Allocation concealment

The LeSure-Lester study106_{was judged as}

‘high risk’, as the author was both the provider of the

intervention and the researcher. The project co-ordinator in the Runyonet al.109_{study was blind at}

pre-treatment so we concluded that allocation was concealed at this point (low risk of bias). Kolko107,108

provided no information and so was judged unclear risk of bias.

Blinding of participants and personnel

High risk: participants and personnel were not blinded in any of the three trials.106–109 Blinding of outcome assessors

Runyonet al.109_{stated that the project co-ordinator (who conducted all assessments)}

‘remained blind, to

the extent possible, to condition assignment_’but it is not clear to what extent this was achieved. The determination of unclear risk of bias was made. Risk of bias was high in the study by LeSure-Lester106_as

outcome data were provided by staff in the residential care home. Kolko108_{reported that}

‘[P]roject staff

administering the assessment protocol were unaware of the treatment conditions to which participants were assigned_’and was judged low risk of bias, although the same data were self-reported.

Incomplete outcome data

Attrition in the Kolko107,108_{study was around 6% (one case) in the FT arm, 20% (five cases) in the CBT arm}

and 17% (two cases) in the routine community services groups. Although these cases did not appear to be different in characteristics, the differential attrition between the two active treatment arms resulted in a judgement of high risk of bias (the reasons for dropout might be related to the intervention). No attrition occurred in the LeSure-Lester106_{study, so this was judged as}

‘low risk’. The Runyonet al.109_{study was}

judged as_‘high risk of bias_’: 25% children who completed 3 weeks_’therapy did not provide data post test, and their pre-test scores were carried forward. Attrition increased at follow-up and the authors present no means or SDs at this assessment point.

Selective outcome reporting

The LeSure-Lester106_{study was assessed as low risk for selective outcome reporting. This study}106 _{is small,}

modest in design and implementation, and data are given on those outcomes that the intervention was seeking to address (using‘home-made’measures). Kolko107,108_{and Runyonet al.}109_{appear to have}

reported on all outcomes covered in the methods section, but, in the absence of a published protocol for either study106_{both were assessed as unclear for this domain.}

Other sources of bias

LeSure-Lester_’s106_{study was compromised by the conflation of roles held by the author, that is, researcher}

and therapist.

Results: cognitive–behavioural therapy for physically abused children

Post-traumatic stress disorder

The Runyonet al.109_{study reported significant pre- to post-improvement on the total number of PTSD}

symptoms among all children, with the adjusted mean post-test scores for those in the combined CBT parent and CBT child group being significantly lower than those for the parent-only CBT group.

Child depression

In the Kolko107,108_{study, children}

’s reports on the CDI80indicated a significant reduction in severity of

depressive symptoms over time [χ2_{=16.01(3);p<0.001], but reports were said to be‘generally low and}

similar across time, indicating no significant group differences_’108_{(p. 333).}

Child behaviour

As measured by the Youth Self-Report (YSR) of the CBCL, children in all three groups in the Kolko107,108

study (CBT, FT and routine services) reported a significant reduction over time in both internalising symptoms [χ2_{=33.54(3);p<0.0001] and externalising symptoms [χ}2_{=12.26 (3);p<0.002], with both}

CBT and FT showing most change on these measures. No effect was found for social competence. Parent report on the CBCL indicated lower ratings of serious internalising behaviours over time (p<0.07),

particularly for the two treatment arms. Parents reported a significant reduction in externalising behaviour over time [χ2_{=9.53(3);p<0.02]. Based on an inspection of the means over time, CBT appeared to show}

the greatest initial change and FT the greatest change at follow-up (1 year) compared with routine community services, which showed minimal change during that period.

A significant interaction was reported on the CCI [χ2_{=13.12(3);p<0.04], reflecting the greatest decrease}

in scores for CBT. This measure (scored by telephone interview with the parent) estimates the presence or absence of common individual behavioural or emotional problems commonly displayed in boys or girls within the previous 24 hours.

Runyonet al.109_{reported significant pre- to post-improvement in internalising and externalising scores}

(CBCL) for the CBT parent-only condition.

LeSure-Lester106_{reported greater rates of behaviour change from pre-test to post-test for the six}

adolescents who received CBT. Using the rating system used by staff within the home, these six adolescents demonstrated greater rates of behaviour compliance (t=_–5.64;p<0.001) and less

aggression towards staff (t=–4.56;p<0.001) and other residents (t=–5.64;p<0.001).

Child global functioning

The Kolko107,108_{study reported a significant increase in KSADS scores over time for all children in the study,}

with no group differences. This study107,108_{found no difference between the CBT, FT and control groups in}

reduction over time on fears related to abuse.

Family functioning

Kolko107,108_{reported the results of subscales for the Family Environment Scale (FES) and the Family}

Assessment Device (FAD). Overall, children and parents in the CBT and FT arms reported more improvement over time than those in routine services.

The effectiveness of cognitive–behavioural therapy for children who have been physically abused

Summary

We identified only three studies106–109_{of CBT interventions for children and young people who have been}

physically abused. Each focused on children of somewhat different ages, from middle childhood to

adolescence. One study107,108_{compared a CBT intervention for children and their parents with systemic FT; one}

and the third study106_{compared a small group version of a CBT provided to African American adolescents living}

in a group home as a direct result of their maltreatment, compared with non-directive group discussions. Although very different, the three CBT interventions106–109_{shared some common characteristics, namely a}

focus on children_’s thoughts, feelings and behaviour. There was a marked psychoeducational component in both the Runyonet al.109_{and the LeSure-Lester}106_{study, aimed at helping children to recognise and}

understand the consequences of abuse, and develop appropriate coping and problem-solving skills, including the development of skills to minimise risk of abuse107,108_{or personal safety plans.}109

The three106–109 _{studies are all extremely small and the overall quality is, at best, moderate in relation to risk}

of bias. Together with the fact that we can summarise the evidence only narratively, considerable caution is required in interpreting the data. All three106–109_{studies report improvement in children}

’s internalising

and externalising behaviour problems (common sequelae of physical abuse), but one109_{of the studies}

found an improvement in externalising behaviour in the parent treatment group only.

The one109_{study examining PTSD reported a reduction in symptoms in all children, with the most}

significant reduction occurring for those where both parents and children received CBT. Depression, examined in one109_{study, reduced over time in both the experimental and comparison groups.}

Both CBT and FT generally outperformed routine community services, resulting in greater reductions in children_’s externalising behaviour and on child-reported parent-to-child violence and parent-reported child-to-parent violence.

Completeness and applicability

All three106–109_{studies were conducted in the USA. Two}107–109_{studies were concerned with families who}

had come to the attention of services because of maltreatment, but where the child remained in the home. They aimed to minimise the risk of further physical abuse and to address the adverse consequences of past abuse and current maladaptive parenting. In Kolko107,108_{maltreatment was judged as}

‘mild/

moderate_’in 87% cases, although almost half the families had children that had been hit with an object, and 50% had children who had been smacked with an open hand. In the Runyonet al.109_{study, 53%}

families had a substantiated allegation of physical abuse or had acknowledged the use of excessive physical punishment (e.g. 65% had hit their children with an object). Many of the children in these three studies would be subject to a child protection plan in the UK, and in the Runyonet al.109 _{study (although}

not in the Kolko107,108_{study) the inclusion criteria required children to have either four PTSD symptoms or}

an elevated score (T score of≥65) on at least one externalising behaviour subscale on the CBCL.260In this

study, siblings were included in the treatment as long as they too could meet these criteria and were a focus of child protection workers_’concerns. These studies106–109_{therefore have relevance to the UK}

context, although they are limited in their scope and the evidence base is sparse.

LeSure-Lester106_{evaluated an intervention that was designed specifically to address the aggressive behaviours}

of boys who had been removed from the family home as a result of maltreatment. Although the focus on addressing maltreatment-related aggression is highly relevant to the UK context, the study106_{says little about}

the intervention, and the outcome measures focus on resident_–staff interaction (with an emphasis on compliance) and peer–peer violence within the home. Although the intervention is reported to have made a significant impact, the size of the study,106_{plus the absence of measures or time periods to indicate the}

generalisability or likely maintenance of reported behaviour change, mean that its applicability is limited.

Quality of the evidence

Studies of CBT for children who have been physically abused are few in number, poorly reported, and overall of limited quality, although poor reporting may account for many of the identified risks of bias.

Economic evidence

Cognitive–behavioural therapy: children who have experienced

In document UNIVERSIDAD SANTO TOMAS UNIVERSIDAD KONSTANZ Bogotá, 2016 (página 62-82)