What evidence-supported interventions are currently available in the area of treatment, both in clinical and social terms?
This question is answered in Chapter 4 for children, and in Chapter 5 for adults who were abused during childhood.
The importance of a good assessment
Before exploring the issue of what evidence-supported treatment interventions are available, the Committee would like to emphasise the crucial importance of a careful, integrated assessment. This must involve an accurate analysis of the situation in terms of safety, environmental factors, the role of parents as indivi- duals and as those who are entrusted with the child’s upbringing. Careful note is also taken of the child’s development, and of its mental and physical condition. It is also important to take note of the positive aspects. In general, the assessment of adults who were abused during childhood involves the very same elements. The one exception is that, where appropriate, the parent’s role relates to their own performance in terms of parenting. Given its multifaceted nature, assess- ment should be conducted along multidisciplinary lines.
Without good assessment, there is no basis for a proper decision about the types of care and treatment needed.
Evidence-supported clinical interventions
For both children and adults, there are only a small number of evidence- supported clinical interventions. For both groups, TF-CBT and EMDR are the best researched and, for the moment, the most effective interventions (at international level) for treating the symptoms of PTSD. Moreover, there is little literature specific to the treatment of abuse.
In the case of various DSM-IV disorders, there is evidence to support the effectiveness of interventions. This has also been incorporated into various guidelines for treatment. However, many of these studies and guidelines fail to take account of the effects on diagnosis and treatment of a background of abuse.
This seems less relevant to adults, as the issue of whether or not the patient has a background of abuse has no implications for the treatment outcomes of many DSM-IV disorders. In the case of borderline personality disorder,
dissociative identity disorder, and complex PTSD, however, there are indications that it is better if unresolved issues from the past are involved in the treatment process. At international level, a three-stage model is used for these complex disorders. The first aim is stabilisation (1), then, if possible, exposure is used (2), while the final step involves a process of integration (3).
The effects in children are less likely to manifest as autonomic disorders. Also, the psychological problems are more closely related to the abuse. Accordingly, in the treatment of children, it is very important to make specific allowance for the nature and severity of the abuse in question.
Evidence-supported social interventions
In the social area, there are parenting support interventions for parents. PCIT is the best studied of these, and it also appears to be genuinely effective. Triple-P Level 4/5, Functional family therapy (FFT), Parent Management Training Oregon (PMTO), and Multi System Therapy - Child abuse and neglect (MST- CAN) can be described as promising. However, these interventions have not been adequately tested for effectiveness in the specific setting of child abuse. There are also many general, non abuse-specific parenting support interventions whose effectiveness is supported by little or no research. Several studies are currently being carried out in this area. Many are funded by the Netherlands
Organisation for Health Research and Development’s Youth Programmes, although these are nearing the end of their term, and there is uncertainty about future follow-up.
When a parenting intervention is used, it is important that it be abuse- specific, and that it be embedded in the wider context of treatment. Preconditions for treatment
A number of preconditions for good-quality treatment have been identified, based on the current level of knowledge, and on the Committee’s knowledge and experience.
For children and adults who were abused during childhood, an integrated, multidisciplinary approach to assessment and treatment is essential.
In children, assessment must be carried out by a multidisciplinary team, so that all aspects of the child’s development (physical, social, emotional, etc.) and possible variations thereof can be identified. The victim’s entire system should also be involved in their assessment and treatment. Is important to continually assess who needs what, where, and when. It is inefficient to use a single intervention without considering the context and development over time.
In the course of their educational training programmes, practitioners must learn to converse with their patients about sensitive issues such as child abuse and sexual abuse. This is an essential skill in the treatment of adults. The educational programme should focus on recognising the effects of abuse. Instruction should also be given in the associated diagnosis of trauma-related disorders such as complex PTSD and dissociative disorders.
The treatment available to children and adults is, wherever possible, of proven efficacy, is administered in accordance with protocol, and the results are monitored. Care practitioners should be well trained in assessment and in intervention methods.
In the case of children, assessment and, where necessary assistance and treatment must take place in various areas, within a few weeks of notification. In addition to an examination of the immediate safety level, a determination is made (based on a sound assessment) about whether assistance or treatment is required (and if so, what type) as well as rapid action in this regard.
Available evidence-based guidelines merit implementation and compliance. This is the responsibility of the professional groups involved. Where such guidelines are unavailable or outdated, it is important to develop or update them.
All things considered, the Committee concludes that - given the specific knowledge and experience required - the role of caring for the victims of child abuse should be reserved for specialised professionals.
6.4 Availability and accessibility of evidence-supported interventions