Bloque IV. El mundo actual
GEOGRAFÍA DE ESPAÑA. PROGRAMACIÓN DIDÁCTICA
The most direct way of preventing the negative consequences of DVA for children is to prevent or end the violence itself.38Systematic reviews highlight the lack of evidence for effective interventions to prevent
the initiation of DVA and, therefore, to prevent children’s exposure to it.39,40There is some evidence that
community-based advocacy is a promising strategy for reducing the frequency and severity of DVA (especially physical violence) once it has taken place, but replication of these results is needed.40Furthermore, few
studies examining the effectiveness of advocacy quantify the effects of reduced DVA on children’s health and well-being (see Chapter 3 for exceptions).
The most common approach to preventing or reducing the harm associated with DVA is to provide services directly to children and their parents once abuse has taken place.41Based on frequently used
definitions set out by the Institute of Medicine,42interventions offered after exposure to DVA can be
categorised as selective or indicated prevention (preventing full-blown disorder) or as treatment. Selective preventative interventions are offered to all exposed children or to parents of exposed children based on the increased risk of maladjustment, irrespective of children’s clinical profiles. Indicated preventative interventions are targeted at children showing signs or symptoms of mental, emotional or behavioural disorders who do not meet diagnostic criteria for these disorders. Interventions for children with diagnosed conditions are known as treatments. In this report we refer to all interventions aimed at exposed children as targeted; where appropriate, we distinguish between the populations of the children who were specifically targeted.
Two systematic reviews have identified a range of (often) complex targeted interventions delivered solely to children, or to children and their non-abusive parents following exposure to abuse. Rizo et al.41categorised
interventions evaluated in 31 studies into four categories: (1) counselling/therapy; (2) crisis/outreach;
(3) parenting; and (4) multicomponent. They noted that, despite the different approaches of the programmes, they shared common aims for children (e.g. learning about and dealing with IPV, enhancing communication, reducing psychological distress and enhancing well-being) and non-abusing parents (developing knowledge of the impact of DVA on children, developing parenting skills, increasing self-esteem and parenting efficacy). Owing to the methodological shortcomings of the studies reviewed, the authors were not able to draw conclusions about the effectiveness of specific interventions, and recommended that studies seek to recruit larger samples, account for missing data, follow up participants beyond the end of the intervention and use randomised experimental designs with statistical techniques to account for the correlated nature of the data. A second review, conducted by the British Columbia Centre of Excellence for Women’s Health (BCCEWH),43
built on the work by Rizo et al.,41although it also included qualitative evaluative studies and grey literature.
The authors categorised interventions into seven categories to reflect the therapeutic technique, the target population and whether the intervention was single- or multicomponent. This review concluded
children improved child outcomes, moderate evidence for psychoeducational interventions delivered to children, moderate evidence for parenting-focused interventions, and mixed evidence for psycho-educational interventions delivered to mothers and children. However, these conclusions were founded mostly on non-experimental research. It is also notable that of the studies identified, only three were conducted in the UK (two peer-reviewed studies; one study in the grey literature). Nevertheless, the findings of this review informed the recent National Institute for Health and Care Excellence (NICE) guidance on DVA.44
Stakeholder views on targeted interventions
Research conducted in the UK has suggested that children most frequently report that they want to feel safe and that they want someone to talk to about their experiences,45–48identifying talking as a strategy to
reassure them that they are not alone.45In these earlier reports, children often identified their mothers as
the person to whom they most want to be able to talk and the person from whom they most want support,47although they also felt reticent about sharing their experiences owing to concerns that they may
upset and burden their parent.46,47Likewise, it was noted that mothers may be reluctant to talk to children,
thereby creating a ‘conspiracy of silence’ in families affected by DVA.49,50In an evaluation of materials
designed to assist mothers and their children to rebuild their relationships in refuges (shelters) and
community-based settings in the aftermath of DVA (discussed in detail in Chapter 4), mothers and children described the positive benefits of engaging in shared activities, including spending time together, and of enhanced communication, both in general and with regard to experiences of abuse.49,51Children also
identified teachers, family members and peers as people to whom they would talk, and several evaluations highlighted the significant role that specialist domestic abuse workers have in helping children to
understand their experiences.49
A UK Delphi consultation involving just under 300 participants52sought consensus among survivors of child
sexual abuse, DVA, rape and sexual assault, as well as among experts in the field, on an effective mental health service response for people affected by these issues. With regard to interventions for children exposed to DVA, a broad range of approaches was viewed as helpful in reducing the harms associated with DVA, including play therapies, attachment-based approaches, cognitive–behavioural therapy (CBT) for older children, child psychotherapy, eye movement desensitisation and reprocessing, and, in some instances in which the abusive party remains in the family setting, family therapy. Approaches that were deemed to be inappropriate for this group were mediation/reconciliation, joint therapy with an abuser and cognitive approaches that are not suited to the cognitive maturation of the child. The inclusion of the abusive parent or party in therapeutic interventions represented a key area of disagreement among respondents. With regard to the process of delivering services, professionals and survivors agreed that the choice of therapeutic intervention for children should be needs-led and guided by the age and maturity of the child, their individual experiences and the degree of victimisation, and that children should be able to access interventions independently of their parents and their parents’ therapeutic requirements.
UK policy context
Government policy in England and the devolved nations recognises the impact of DVA on children and emphasises the need for support for those who are at risk of, or who have experienced, DVA.53–55English
policy places a particular focus on prevention and early intervention, whereas other nations explicitly recognise the need for targeted services for children once they have been exposed to DVA. Overall, national policy has been largely focused on the response to children by the health and social care sectors. In 2011, a government-commissioned review of child protection in the UK56emphasised the high prevalence of
children experiencing DVA in the home and the links between DVA and child protection, and argued that service development should reflect this high prevalence. In 2014, guidelines developed by NICE44to
underpin the response of health- and social-care professionals and commissioners to DVA made the specific recommendation that interventions should be commissioned that aim to strengthen the relationship between the child and their non-abusive parent or carer through the delivery of joint or parallel sessions that include advocacy, therapy and other support that addresses the impact of DVA on parenting. This is consistent with the more general recommendation in the World Health Organization (WHO) guidelines for children to be offered psychotherapeutic interventions. In 2010, following an independent review of child
and adolescent mental health services (CAMHS), the UK Government identified children experiencing DVA as a vulnerable group requiring mental health services engagement.57This was reiterated in a second review
of CAMHS, which recommended the development of a better service for vulnerable groups of children and young people, including those who have been exposed to DVA.58
UK service delivery landscape
Despite the importance of specialist provision for children exposed to DVA being recognised in UK national policy, mapping studies indicate that provision for these children is patchy. Humphreys et al.59mapped the
availability of support for children and families affected by DVA. A telephone questionnaire completed by nearly all of the 326 specialist DVA service providers approached indicated that 69% of services in England and 89% of services in Wales, Scotland and Northern Ireland employed specialist children’s workers, with the most frequent forms of support offered being group-based support for pre-school-aged (72% in England, 89% in Wales, Scotland and Northern Ireland) and school-aged children (69%, 89%), one-to-one support (this did not include counselling, 61%, 89%) and advocacy for children (72%, 86%). However, services reported that these efforts were being hampered by underfunding. A total of 12% of English refuge groups and 14% (n = 10) of refuge groups in the rest of the UK reported that they were unable to provide any children’s services owing to a lack of funding; and 42% of refuge groups in England and 60% of refuge groups in the rest of the UK were dependent on volunteers to keep their children’s programmes going.
As part of the same study, a survey of children’s charities found that, of the 449 (60%) charities that responded, < 2% reported offering dedicated projects dealing specifically with women, children and/or men from families affected by DVA, although a large number of non-specialist projects (74%) considered DVA to be relevant to service users and dealt with it during the course of their work. In a third component to the study, 20% of social services departments reported that there was no provision for work with children, women or men in DVA situations in their local area, and specific service provision for children living in situations of DVA featured in only 20% of children’s services plans.
A second mapping study of services in London, undertaken a decade later, described a similar picture of service provision, marked by significant gaps and unsustainable services.50In line with the earlier study,
a survey of key individuals and services with a role in responding to DVA indicated that the majority of specialist services (56%) were provided by the voluntary sector. The majority (76%) of respondents also perceived gaps in DVA services for children, with the most frequently mentioned being a lack of counselling, group work and school-based prevention activities. However, the low response rate to the survey (19%, 193/1020) means that its findings are prone to participation bias. Radford et al.50noted
that some of the gaps in service provision had been created or exacerbated by funding difficulties, with interviewees reporting innovative services being run for a pilot period and subsequently closed owing to a lack of sustainable funding.
Qualitative interviews (n = 79) with professionals identified a particular gap in support that fell between universal services and the acute specialist mental health services provided by CAMHS. In addition, documentary analysis identified limited evidence of support being provided for children living with
domestic violence where the risk (of serious harm) to the mother was not perceived to be high, suggesting that children’s need for support was not perceived as independent from that of their non-abusing parent. Radford et al.50also noted that proactive responses to DVA by frontline services, such as the police, often
had limited impact owing to the lack of support available to children in the community. There were also gaps noted in services for young people who had grown up living with DVA and were now abusive in their adult relationships. Violence from older boys towards their mothers was also a particular concern.
Mothers reported particular difficulties in securing timely access to children’s services, in particular to CAMHS as well as, in some cases, negative experiences of engaging with social workers who had made them feel responsible for abuse. However, other mothers reported a more helpful response.
In England and Wales, CAMHS have a remit to deliver services to children experiencing high levels of distress and mental health disorders. However, despite exposure to DVA being the most frequent type of trauma experienced by children and young people,13a CAMHS mapping exercise carried out in 2008–957
found that only 7% (n = 320) of participating services described themselves as providing targeted services for children experiencing DVA. There is little published material describing what these specialist services are.60The coercive and often chronic nature of DVA, which is specifically directed at a child’s parent
by a perpetrator with whom the child almost always has an ongoing emotional relationship, coupled with the distinct possibility of re-exposure, means that standardised treatments, even those that are trauma-informed, may not be appropriate for this group of children and parents.61,62Research with adult
survivors of DVA suggest that psychological interventions that do not directly address DVA may be perceived as unhelpful, and that DVA-informed interventions are preferred.63