A Case for Specialized and Specific Intervention and Treatment Strategies With Abused Young Children Diagnosed With PTSD
Various disciplines and roles converge in cases of child abuse. Child protection workers, forensic Psychologists, expert witnesses, treating clinicians, and in many cases, law enforcement may all be involved. Current knowledge and research concerning PTSD, especially in young abused children, suggests that some forensic methods historically used by child protective services, police, and treating therapists are largely inadequate. These methods and interventions, even when carefully administered, may be in direct conflict with what is known about the relationship between trauma, memory, symptom development, and later treatment. Further, some methods surrounding fact-finding and subsequent treatment may profoundly affect future functioning problems for the child. The struggle of the field to design adequate means of questioning and training to front line workers has led to legitimate criticisms concerning abuses and efficacy of forensic questioning of abused children. There is a need to continue development of valid,reliable, and individualized victim sensitive methods to access needed information for court use and treatment training that prohibits further harm to the child.
A review of the literature reveals that the area of forensic questioning of young children in relation to child abuse is fraught with differing opinions and controversy. The clear need for courts to have accurate information concerning perpetration of abuse on children by adults will continue to exist as long as child abuse does. In the guidelines for the evaluation of allegedly abused children, the American Psychological Association Committee on Professional Practice and Standards (1998) indicates that forensic data and expert witnessing may help the court in understanding, gaining perspective, and increasing the fairness of determinations. Professionals in psychological treatment may be asked to determine if abuse has been perpetrated, and may use the diagnosis of Post Traumatic Stress as a proof that it has. (Regan, Johnson, Alderson, 2002). In the case of People v Stritzinger (1983), the Supreme Court ruled that unavailability due to a “mental infirmity” must be determined either by the witness refusing to testify, or on the recommendation of an expert witness. While the expert may recommend the child not testify due to PTSD, the expert would be on shaky grounds to state that the PTSD is proof of the abuse. While Fisher and Whiting (2001) agree that some aspects of PTSD symptoms are consistent with a child’s behavioral reactions to abuse, an unreliable pattern of abused children with PTSD make using the diagnosis as a proof a very flawed reasoning. They do add though, that if abuse has been founded, the diagnosis becomes a framework to determine level of impact on the child and as a treatment springboard. This would also then seem to be recursive, with the diagnosis of PTSD following a founded case to suggest the question: should the child be returned to the custody of, say, a parent offender, or a non offending parent who failed to protect the child, and the child is highly reactive to as a reminder of the abuse? Since the persistence of PTSD symptoms are likely closely related to the intensity, volume of critical incidents, and duration of abuse, it would appear that there is no current predictive tool to ascertain how long treatment will take. This situation serves to complicate custody issues, not to mention issues of the child having visitation contact with a person who could be a perpetrator. Further, if the child’s symptoms worsen following contact with their biological parent(s), is it ethical to desensitize a child to contact with their perpetrator in order for the child to return the perpetrator’s care? If there is no “return home” goal, and the child will be adopted, what is the therapeutic point of continuing exposure?
There is of course, no current, valid, and reliable tool to predict if an individual will develop PTSD following a trauma. (Walters, Bisson, Shepherd, 2006) Perry and Azad (1999), in a study on the incidence of PTSD, found that 34% of a sample of children who had been identified as being sexually abused, and 58% of children identified and being both sexually and physically abused met the criteria for PTSD. In addition, the study found that all of the children, while not fully PTSD, had clinically significant symptoms. The children in the study that had only partial symptoms may very well continue development on to full PTSD status. Thus, children diagnosed with PTSD as a result of abuse become a special concern outside of the population of children who have experienced abuse, but have not been diagnosed with PTSD.
Though common sense informs that special care needs to be given to children who have experienced traumatic events, the issues of their post-trauma care can become quite complex. Lieberman and Van Horn state that:
Responses to early trauma need to be understood as the initial manifestation of long-term risks to the child’s unfolding development. (p. 112)
Briere and Spinazzola (2005) assert that in the case of a lengthy history of family interpersonal trauma, a complexity of traumatic stress develops that negatively effects the child’s attachment with the parent. Such complexity of this population of child victims gives rise to the need for specialized attention, study, and formulations of forensic and treatment approaches. In a study concerning the “pathways” to PTSD in abused children, Kaplow, Dodge, Jackson, and Saxe (2005) found that behavioral signs noted immediately after disclosure of abuse might constitute discrete reactions that include avoidance, anxiety, and dissociation. In turn, these then become foundations for further and longer-term symptom development. Briere (2006) notes that the connection between trauma and dissociation may not be as simple as it first appears; there may be multiple components that produce the dissociation effects, including early attachment issues, emotional neglect, and neurobiological disturbances. Briere also states the possibility that dissociation may exist before trauma and be a risk factor for victimization. Again, this points to possible ethical questions: is any forensic questioner trained adequately to assess what may be very subtle and internalized symptoms presenting? One might assume, due to the nature and purpose of forensic examination, the child may reveal critical incident material that was not formerly revealed. Is there any data to show that forensic questioning does no further harm? If the long term research answer to that question is eventually found to be true, professionals may be trapped by the terrible dichotomous question: catch the perpetrator, or heal the child?
In addition to these complexities, the age of the child when victimization occurs becomes a factor in forensic examination and treatment, along with the traditional problem in most witnessing, memory. Nader (2001) states that at issue in younger children are their very age: they may have “literal interpretations, animistic thinking, faulty hypotheses, and inaccurate associations.” (p 281) Nader also asserts that age not only plays a role in perception, but also what details the child attends to, and how the child’s state of mind at the time of the trauma affects encoding of the memory for later recall. And of course, memory of the child victim is key to child protection assessments, police investigations, courtroom proceedings, and to a lesser degree, subsequent treatment.
Leiberman and Van Horn (2001) address the problem of the traumatized child’s behaviors in relation to memory:
Traumatized reminders tend to remain unidentified when they operate outside of the child’s conscious awareness or when the child cannot use language to describe what is happening. The child’s behavior may be strongly influenced by stimuli that act as triggers for memories of traumatic experience. (p118)
This assessment also seems to point to the problem of preverbal memories that do not readily find verbal expression or discernment by the child or the forensic investigator. Ceci and Bruck (1995) expands on the memory issue by asserting that due to the overwhelming amount of simulation during abuse there are likely some parts of the trauma experience that were never encoded in memory, so were never ‘stored’. Furthermore, they cite studies that demonstrate that errors in children’s accounts are most often omission rather than commission errors. Such studies reinforce the oversimplified truth that just as in adult female rape victims, child victims do not generally lie about sexual abuse.
With such complexity, subtle nuance, and discrete aspects, how victim witness information is gained and used in child abuse cases becomes likewise a complex and delicate matter. Public opinion, media enthusiasm, multiple court opinions and those falsely accused of maltreatment of children all attest to the struggle to get the process accurate, fair, and unbiased. Many of the criticisms of particular cases, usually targeting child protection agencies and workers, while made by individuals not educated in the nature of trauma or PTSD in children, have validity and serve to press the field into doing a better job. (Wexler, 1995)
In 1990, Congress enacted the Victims of Child Abuse Act that contains a detailed Article (IV) to guide investigations, prosecutions, and corrections of the Justice Department. These guidelines are an obvious improvement over a system that appears to have had a public reputation for at least some inconsistent and even unethical forensic and clinical approaches. But a simple review of these guidelines reveals that a body that does not nearly understand the nuances and complexities of the problems has created them that child (PTSD) victims suffer. There appears to be no such required guidelines for most county level child protection services. Also in the mix of complications in achieving the truth and attaining justice is the difference in training and philosophical foundations between law enforcement, courts, and the field of psychology. (Wrightsman, 2005) Even a cursory review of questioning tactics between the disciplines yields a wide difference in styles, approaches, and objectives. Not all of these approaches may be sensitive to the victim’s emotional, developmental or mental state. In fact, a very real question is exactly how many police departments have a specially trained staff member to question a child victim. Clinicians may cringe at the image of a rough and tumble officer who has never questioned a child abuse victim doing their best to pick their way through a child’s critical incident account.
Children usually reveal issues of abuse by either deliberately or spontaneously telling someone, or they make an unintentional reference to the abuse. (Ceci, et al., p.75) While these could be done for the first time in the presence of a child protection worker or police officer, they more likely are done first in the presence of a trusted adult. The time lapse between the first telling and the second forensic telling is a time frame that bears study as to the emotional impact and time impact on the child’s memory. This becomes especially concerning in child protective services that have extraordinarily large caseloads in ratio to workers, where time between report and questioning may be days, or even weeks.
In addition, such aspects as linguistic problems associated with the child’s developmental level and cultural environment add to the challenge of accuracy. (Ceci, et al. p. 76) One also needs to consider the variable of culture, ethnicity, and quite possibly religious background. Should the forensic investigator be less than sensitive, or just perhaps ignorant of a particular culture, response of the child would quite conceivably be altered.
In cases of sexual abuse, London, Bruck, Ceci, and Shuman (2005) conducted research that found child sexual abuse accommodation syndrome (CSAAS) to be quite valid. The effects of CSAAS are generally accepted as impacting the pattern of disclosure in a particular case, with gradual disclosures, not to mention recantations quite common. A very simple and unpublished experiment in a county in Pennsylvania asking five child protection workers if they had ever heard of CSAAS yielded a negative response in all five. If those so closely associated with child protection are not aware of valid supportive research that has been around for approximately twenty years that so articulates child victim’s experience, there indeed is much training to do.
Multiple cases presented sensationally in the media attest to the importance of questioning techniques. The use of leading questions, questions that are posed in a manner assuming a specific answer, or questions that are too complex for the child’s age are common examples of problematic methods that can cause the child to offer often elaborate confabulated material. (Wrightsman, 2005) Such inadequate methods that ignore the child’s developmental level can produce dramatic, hysterical reactivity in the community, as in the case of People v Raymond Buckey. A number of collected studies indicate that children do make commission errors about things they have never experienced, and can create fantastic, well-constructed, believable accounts of abuses that have never occurred to them. Especially when faced with an adult questioner who is using repeated suggestive methods and has a confirmatory bias, children’s witness accuracy suffers. (Ceci, et al., 1995)
Compounding simply bad questioning and investigative techniques, is the issue of how the symptoms of PTSD interact with forensic questioning. The DSM groups symptoms into three basic categories of re-experience, psychobiological alterations, with avoidance, numbing and detachment comprising the last category. Wilson, Friedman, and Lindy (2001) contend that there may be a need to add three more categories to fully articulate PTSD, including problems in interpersonal relationships, disturbance of ego structure, and alterations to the victim’s psychological makeup. Schuder and Lyons-Ruth (2004) articulate the list further by describing a variety of attachment behaviors that can be seen in traumatized infants. There is some evidence that there are child specific behavioral signs of PTSD, such as precocious development and behavioral regressions. (Nader, p284)
In light of what has been demonstrated thus far in the research on the effects of PTSD in abused children, a diagnosed child pressed into courtroom testimony appears to be contraindicated as to future treatment concerns. It would stand to reason that due to the nature of forensic evidence and information gathering, either by a forensic mental health professional, child protection worker or a police detective, all of whom are focused less on treatment than on the goal of successful litigation, future treatment is a secondary concern. It would seem that the very approach of an investigator and the nature of the questions would have the clear potential to trigger re-experiencing, avoidance, numbing, detachment, and physical agitation. If unenlightened questioners, or questioners not taking into account the child’s developmental level are added to this mix, it would seem likely that triggering may occur with some reliability. This would appear to be a ripe subject for research and testing. Even a child who has experienced abuse and is not diagnosed with PTSD may find the courtroom experience daunting. Wrightsman (2005) explains:
It can be argued that for any victim of sexual abuse or rape, whether an adult or child,the experience of facing your alleged attacker in court is particularly stressful. The trauma is compounded if opposing attorneys view the children as especially susceptible to intimidation during cross examination, and judges remain oblivious to efforts to “break down the child on the witness stand.” (p 285)
Though one might hope that the aforementioned Article VI of the Victims of Child Abuse Act guidelines would directly address questioning tactics by attorneys, examination of the Article reveals no such measures. It should be noted, though, that the Article does provide for measures that make an attempt to be sensitive to the child’s emotional state such as video taped or closed circuit video testimony with an adult supportive attendant in close proximity to the child. But even these may not be enough to mitigate all of the possible cues and triggers to (post traumatic) stress reactivity. One wonders why these same supportive measures (perhaps with the foster parent or therapist of the child attending) are often not provided routinely, and as mandatory in cases of repeated forensic exam per CSAAS.
The legal and therapeutic aspects of child abuse cases are inextricably entwined. Without accurate information and proofs of abuse, the child may be returned to a perpetrator. The process of gaining that accurate information and proof may negatively impact the child’s symptoms and progression of treatment. Crouch, Smith, and Ezzell (August 1999) cite the fact that research in developing valid and reliable tools to measure relevant variables of outcomes is lacking. One of those variables that bear study is the determination of abuse process and the subsequent legal forensics process to ascertain if there are long lasting effects of the child moving through such a gauntlet. While psychologists may use a collected battery of standardized tests and measures in the determination of a PTSD diagnosis, these may not be sensitive enough to pick up discrete impacts and effects of the abuse on the child. The tools may even misidentify the impacts and effects as an entirely other diagnosis. (Briere, Elliott, 1997) It stands to reason that the same measures may be inadequate to determine if the protective process itself is causing further harm to the child. There are tailored checklists and inventories available, such as the Trauma Symptom Checklist for Children and the Child Sexual Behavior Inventory (Biere, Spinazzola, 2005), but these appear to have inherent limitations. The TSCC is a self report for children ages eight to sixteen, and the CSBI, while evaluating children between the ages of two to twelve, only evaluates sexual behaviors. Given the complexity of ‘complex PTSD’, there may be no adequate tool to ascertain the full, unique impact of the critical incidents on a specific child. Schuder, et al. (2004) speaks about ‘hidden trauma’ that is an integral part of the child’s relational experience and may include behavior sets and interaction qualities that are not noticed as problematic by even a trained observer. Even with the current state of the art questioning environments and protocols, expectations of adults for children to readily speak with a relative stranger following what may be a traumatic and embarassing abuse episode, and that challenges the child’s family loyalty is a tall order.
It is well established that the diagnosis of Post Traumatic Stress Disorder was developed out of the middle of the last century’s experience with combat in various wars. The diagnosis was not designed with abused children in mind. Marshal, Spitzer, and Liebowitz (1999) conducted longitudinal studies that used Acute Stress Disorder criteria that suggest that there is a need to reevaluate the DSM approach to stress syndromes. This clearly is the case when considering the expansion of understanding of the experiences and behaviors, and special needs of abused children with PTSD diagnoses. Briere and Spinazola (2005) opine that clinicians often may need to make decisions on what part of the stress complex is most relevant, and that ever more precise tools are needed to fully understand the unique dimensionality of a survivor of trauma. Such understanding should lead to improvements in the forensic questioning of child victim witnesses and legal interventions, as well as treatment. A valid and reliable progress measurement tool for use at the commencement and duration of treatment would bring a wealth of information to the process and outcome of treatment efforts.
There are several efforts attempting to design best practices training programs in forensic interviews of abused children, among them the American Prosecutors Research Institute’s National Center for Prosecution of Child Abuse, the American Professional Society on the Abuse of Children, and the National Children’s Advocacy Center. (Siegal, 2004) The National Children’s advocacy Center states on their website that their training has an efficacy of gaining enough credible factual witness information to prosecute in 64% of their cases (www.nationalcac.org) The National Center for Prosecution of Child Abuse program strives to get training to half of the nation by 2010. There was no current information on the website concerning how many States have thus far been sufficiently trained.
It would appear that Daubert case may point to more than just the ‘junk science’ worry; it may in fact point to the need for some vehicle to educate judges as well as front line workers in the care of abused and PTSD diagnosed children. In May of 1996 in the Supreme Court of Tennessee, a dissenting opinion from Judge Leon Burns typifies the this particular difficulty:
The social worker’s testimony discounted all the familiar facets of impeachment. First, she told the jury that recollection and memory, often and first-line attack in credibility skirmishes, was not important with child victims and should not be considered. Secondly, she discounted the importance of detail, another fertile basis for cross-examination and impeachment. Finally, and more subtly, she explained away the importance of inconsistencies in children’s testimony.
Clearly, Judge Burns was not afforded adequate educational forensic information on disclosure patterns and the many biological effects of PTSD on a child. Had Judge Burn’s opinion been in the majority, the child in question (and perhaps many children to come) may have had a very different outcome.
As stated thus far, there are likely many variables of outcomes from forensic examination of a child who is traumatized by abuse. It perhaps goes without saying that ill managed or outright botched forensic efforts leave behind children who have been further damaged by the ordeal. One might expect that if some kind of ‘psychological first aid’ were to be provided very soon after the child revealing, this might mitigate development of PTSD symptoms, and thus make for a more accurate forensic exam, but Bryant (2007) found that there was no solid validity to the claim that critical incident debriefing was effective in preventing subsequent PTSD. Regardless of the preventive hope for CID, the practice does provide the victim with a here-and-now supportive care. A review of the Field Operations Guide of the National Child Traumatic Stress Network (2006) shows a highly supportive approach that might be typified as quite gentle, un-pressured, and decidedly ‘un-questioning’. Without such debriefing support at the time of forensic questioning (and one might reasonably contend that a goodly number of children do not receive such debriefing), the initial forensic effort with its primary focus and objective on fact finding, has the great potential to add unnecessarily to the child’s stress load..
Court examination is of course, forensic in nature, and due to the basic philosophy of adversarial face-to-face confrontation of one’s accuser, drastically in counterpoint to PTSD treatment in children. Wilson, et al. state that a “core treatment approach removes obstacles so that the organism can heal on it’s own.” (p40). Most reasonable adults would agree that placing a child on a witness stand, either in front of a jury or just a judge would qualify as an intimidating ‘obstacle’ to the child’s best interest of healing from PTSD. Walters, Bineman, and Wright argue that hearsay testimony by professionals who have worked with the child, though clearly not the norm in a court hearing, is a clearly reasonable alternative to risking further damage to the child. While protecting the child, this may place the clinician in a gray area where the dual role as the therapist and expert witness may come up. Strasburger, Gutheil and Brodsky (1997) note that this can be come very ambiguous, but also may be somewhat unavoidable when clinicians identifying themselves as expert witnesses are unavailable due to locality and economic reasons. In addition, clinicians serving a case may be routinely asked to provide clarification in the form of education concerning PTSD in children to help judges more fully understand the issues.
As time marches on, it becomes ever more clear that specificity in treatment needs to be developed to address the particular idiosyncratic presentations of abused children diagnosed with PTSD. The literature is rife with calls for even more research to study the efficacy of existing treatments and to develop new ones. (Lombardo and Gray, 2005) This wheel turns exceedingly slow. Nader (2004) advises that the practitioner who is going to work with PTSD children who are victims of abuse needs to have a good working knowledge of psychotherapeutic principles as well as a specific, experienced trauma background.
Most models of treatment for PTSD in children are simply derived from adult models, mirroring the earlier criticism of more specific diagnosis criteria for children with the disorder. Most current approaches include multiple recounting of the critical incidents, re-attribution of erroneous responsibility, regaining a sense of safety, and helping the child regain a sense of control in their lives. (Nader, 2004) Other well-known approaches such as cognitive-behavioral therapy, with a focus on trauma seem to be consistently cited as providing significant improvement over other forms of treatment such as child-centered therapy. (Cohen, Deblinger, Mannarino, and Steer, 2004). Other therapies such as Eye Movement Desensitization and Reprocessing (EMDR) have considerable continuing debate over efficacy and validity with adults, let alone children.
Lieberman and Van Horn (2004) begin to refine a more child sensitive approach by noting that two very important focus areas for children with PTSD as a result of interpersonal violence are re-establishing care giving routines and positive reciprocity between the child and care giver. Gaensbauer (2004) refines this child sensitive approach further, stating that clinicians intervening in the child’s life must take care not overwhelm and allow the child’s emotions to get out of control due to history material. He also comments on “spontaneous play”, but is not clear if this is in opposition to structured play therapy (p. 199) Gaensbaur goes on to note that: “probably the most important contribution we can make as therapists to the child’s recovery is to help parents to deal with the child’s symptoms in the home environment.” (p.199) This certainly would apply equally to foster parents when a child has been removed from an abusive parent(s). Gaensbaur addresses the behavioral acting out related to PTSD by suggesting a two pronged approach that includes firm limit setting and demonstration of empathy for the child’s expressed emotions as attached to the critical incidents. (p. 200)
This author’s anecdotal experiences in the field treating abused children with PTSD for some ten years is that there are many front line clinicians that while having adequate training and experience in psychotherapy and other multi modal techniques, have but a rudimentary understanding of PTSD. In addition, they generally and largely rely on behavioral approaches and techniques to address an abused child’s behavioral expressions of the disorder. Admittedly anecdotal study of the efficacy of such singularly behavioral techniques has demonstrated that the application appears to reliably escalate the child’s symptoms and move them towards ultimate life and developmental altering decompensation. The problem appears to be that children with PTSD often present strong oppositional symptoms that are likely attached to their allosatatic reactivity. This may be in addition to co morbid diagnoses. Many adults, even trained clinicians, reflexively react to a child’s opposition with an increase of pressure by way of behavioral techniques. Such a shift to a behavioral pressure stance can be quite subtle, and even unconscious on the part of the adult, but no less real in effect on the child. Adults, who serve as child protection workers, police officers, attorneys, therapists, and judges, to a child, may begin the cuing and triggering of the child’s stress just by their titles.
Conclusions and Directions
There appears to be enough evidence to show how children who have been abused experience and demonstrate PTSD is qualitatively different from adults. Specific research into these qualities and even possible child-specific symptoms and discrete behavioral episodes need to be explored. Ascertaining if current formats of forensic questioning contribute to driving PTSD symptoms deeper, contribute to their escalation and intensity, or are supportive of healing appears to be a fair area of concern. The development of ever more specific and specialized forensic and treatment approaches, as informed by valid scientific research on child victim’s expressions of PTSD is needed. Accurate tools to guide the process of treatment and measure outcomes are needed. High quality comprehensive education of all professionals involved with child victims about the nature and peculiarities of PTSD in children would allow for more accurate and effective litigation and movement of the child towards and through treatment. There is no specialized, specific, and individualized treatment modality for treating PTSD in children who have been victims of interpersonal abuse. Though all of the mentioned therapy alternatives certainly implicitly contain empathy and gentleness, none articulate gentleness as a key aspect of treating abused children. Perhaps after all of the research and articulation of therapeutic and legal approaches and modalities, simple gentleness may be the healing salve that is needed. Certainly pressing a child through a legal process does not qualify as ‘gentle.’ It is time for the clinical healers to move forward out of repetitions of ‘the need for more research’ on the development of more effective forensic and therapy approaches, and do the developing right now, in the field.
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- Dr. John Birere
Further pertinent academic research
- The Wounded Healer Journal
Enduring resource site for healing PTSD.
- American Academy of Experts in Traumatic Stress
Locate a treatment specialist.
- Trauma Information Pages
Good basic stress disorder information.
- Author's professional website.
Child specific treatment; free content.