With increasing awareness of the impact of trauma on children’s health and development, child welfare, mental health, and family support providers are in need of interventions that help children and youth heal and recover from abuse and neglect. And at times it can seem like each day brings news of a novel, evidence-based treatment that has been shown to improve the well-being of children who have been maltreated.
But the reality is that interventions are not all created equal nor supported equally by research. Many interventions have only preliminary research to support their effectiveness or have been studied with certain clinical populations (such as sexually abused children) and not specifically evaluated with others (children identified as polyvictimized). The other part of the picture is what treatment providers know from "practice-based evidence:" that some interventions get better results with certain children than others, improving some but not necessarily all treatment goals. Abused and/or neglected children often present with complicated challenges to treatment. They commonly display complex traumatic stress symptoms resulting from years of cumulative, chronic, and multiple types of traumatic exposures. Maltreatment disrupts the child’s fundamental task of cultivating a secure sense of self, derailing healthy development and well-being. Because of the complexity of need among maltreated children, providers must be discriminating in their selection of treatment approaches; and to be discriminating means taking into account the particularities of an intervention and the evidence in support of it.
Clearly, continuing to build the evidence base supporting interventions to promote the well-being of maltreated children is needed. The marked urgency of this need is discussed a new report, released today by the Agency on Healthcare Research and Quality (AHRQ), which presents the findings of a highly rigorous systematic review of the comparative efficacy or effectiveness of trauma treatments for this population. The review, which examined the evidence base for psychosocial and/or pharmacological interventions, found that many show promising child well-being and child welfare benefits. However, the authors found insufficient evidence to draw firm conclusions about the effectiveness of most approaches. That is not to say that most treatments are ineffective. Rather, the upshot of this review is that the nature of intervention research with this vulnerable population presents significant challenges resulting in a dearth of evidence. These gaps, they write, reflect the complex challenges of caring for maltreated children, including engaging and retaining families in treatment and research.
Two approaches did had a more robust evidence base than others, based on large trials evaluating the effectiveness of the approaches in the field: a home-visiting approach with maltreating parents (SafeCare®) and a foster parent training program (Keeping Foster Parents Trained and Supported (KEEP)). Other approaches that are widely used in the field , including several recognized as EBTs – Trauma-Focused Cognitive Behavioral Therapy, Child-Parent Psychotherapy, and Parent-Child Interaction Therapy – emerged with more preliminary evidence based on small-scale efficacy trials (intervention research carried out under the best of circumstances and not in the real world).
One notable aspect of an AHRQ systematic review is its attention to the issue of clinical diversity in defining the clinical problem for which treatments are being evaluated, with the goal of understanding more clearly ‘what works for whom.’ In the report, the authors discuss the immense challenge they faced in seeking to limit clinical diversity in the review and emphasize that decisions may have resulted in excluding studies that may have bolstered the evidence for some interventions. For example, preventive intervention studies with children and families broadly at risk for abuse or neglect were not included, nor were studies that targeted domestic violence exposure. Studies that combined younger children and older youth (age 15 years and beyond) were also excluded, unless the study authors looked at whether treatment effects varied by age.
The Administration on Children, Youth and Families (ACYF), which has emphasized the use of evidence-based practices in its discretionary grants and demonstration projects, is supporting implementation of many of the interventions found to be promising or well-supported in the AHRQ review, including SafeCare®, KEEP, TF-CBT, CPP, and PCIT. With funding provided in fiscal year 2012, at least 45 grantee sites will deliver one of these evidence-based interventions; many more will provide interventions with some demonstrated effectiveness in improving functioning for children who have experienced or are at risk of experiencing abuse or neglect.
AHRQ’s report provides valuable information about what works for a particularly vulnerable population of our nation’s young people. Perhaps more importantly, it contains a call to action for researchers and funders to expand the evidence base and move the field forward to improve the odds for maltreated children.
Bryan Samuels is the Commissioner of the Administration on Children, Youth and Families. Samuels has spent his career formulating service delivery innovations and streamlining operations in large government organizations on behalf of children, youth, and families.