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As our understanding of the impact of early trauma on brain development has grown, so too has the introduction of trauma-informed therapeutic approaches and practices for working with children and young people. The core principles of trauma-informed care/practice as outlined by the National Centre for Trauma Informed Care (NCTIC) include:
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Understanding trauma and its impact;
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Promoting safety;
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Ensuring cultural competence;
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Healing happens in relationships;
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Integrating care; and
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Understanding recovery is possible.
(NCTIC cited in Steele & Kuban, 2013:53)
Trauma/Attachment Focused
The effect of disrupted attachment relationships can to some extent be addressed through intensive psycho-education work with, for example, carers and teachers, so as to improve their understanding of why children/young people behave the way they do. This psycho-education aims to modify the person’s response to the child/young person and assist them to respond to challenging behaviour in a manner that is informed by attachment-based principles. Psycho-educational work can occur with a variety of stakeholders at any phase of intervention, including early work focused on stabilising the systems around the child/young person. The outcome of this training is to teach the caregiver to gently lead or guide the child/young person into different ways of relating with others (Golding, 2008).
Attachment-focused therapeutic interventions such as Attachment-Focused Family Therapy (Hughes, 2007) and Dyadic Developmental Psychotherapy (Hughes, 1997) are examples of evidence-based approaches. This work is often a long-term intervention, and occurs in the context of systems having been stabilised. Parent-child or carer-child dyadic work is where the therapeutic focus is on the dynamics of the relationship between the parents or carers and the children. The emphasis of this work is on helping the parent or carer to take the initiative in developing a relationship with the child, enabling the child to directly experience the parent or carer as consistent and nurturing. Dyadic work often involves helping the adults understand their own responses through exploration of the carer’s own attachment history. This type of work aims to help the parents/carers understand how the child needs them regardless of how much the child may be behaving as if he or she does not need anyone (Dozier, Stovall, Albus, & Bates, 2001).
Exploring Trauma
Addressing the trauma experienced as a consequence of an abusive or neglectful childhood is particularly difficult and challenging for any child/young person. Therefore, therapeutic interventions focused on exploring past trauma and losses cannot effectively take place until the child/young person’s safety and attachment needs are met. Trauma therapeutic approaches such as psychodynamic approaches, psycho-education, life story work or family therapy are all interventions which are carefully integrated to address the ‘felt’ safety of the child/young person, their relational engagement or attachment needs, self regulation skills, self reflective information processing, positive affect enhancement and traumatic experience integration (van der Kolk, 2005).
Systemic Approaches
Golding (2008) identifies a framework for understanding the needs of children/young people with complex presentations. Golding’s approach recognises that problems often occur simultaneously across multiple levels of functioning and across multiple systems. As a result, interventions need to be tailored to the child/young person’s specific needs.
Working from this theoretical and conceptual framework enables multiple issues to be addressed simultaneously. For example, working directly with the carer and the child/young person’s wider system (school, child protection staff and care provider) by providing education on the impact of trauma and abuse has the ability to increase each stakeholder’s empathy for the child/young person and their capacity to tolerate particularly difficult behaviours. This in turn has the capacity to stabilise the child/young person’s systems, allowing opportunity to forge relationships even prior to individual work commencing (Golding, 2008). Once the child/young person is then at a stage where they are feeling safe within supportive systems, they may then go on to develop personal relationships and attachments.
Trauma-Specific/Focused Interventions
Trauma-specific or trauma-focused interventions directly address the impact of trauma on a child or young person through the goals of decreasing symptoms and facilitating recovery (Fallot & Harris, 2001). A number of systematic reviews of trauma-informed approaches have been undertaken in the United States and there appears to be some consensus regarding the most appropriate and commonly used interventions for this cohort. A recent study in Australia, ‘Approaches targeting outcomes for children exposed to trauma arising from abuse and neglect: Evidence, practice and implications’, identified and rated the evidence for approaches being utilised in Australia, which are aimed at preventing and treating outcomes in children exposed to trauma associated with abuse and neglect (Australian Centre for Posttraumatic Mental Health & Parenting Research Centre, 2014:1). This study identified that Trauma-Focused Cognitive Behavioural Therapy was the only approach which met the criteria for being ‘Well Supported’. Eight approaches, including Child Parent Psychotherapy and Parents Under Pressure, met the criteria for ‘Supported’ programs. The report concluded that while there are many approaches that exist, few have been evaluated and therefore there is little evidence available to indicate whether they are effective for improvising outcomes for this cohort (Australian Centre for Posttraumatic Mental Health et al., 2014:6).
Whilst acknowledging that there is a clear need for further analysis and evaluation of trauma-specific/focused interventions, it is still useful to explore some of the key practices and therapeutic approaches to working with children and young people who have suffered abuse and neglect. Its inclusion in this paper is not an endorsement as to effectiveness, rather an acknowledgement that these approaches are currently the most commonly utilised.
Therapeutic Interventions
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Key Features of the Intervention
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Trauma-Focused Cognitive Behavioural Therapy
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Addresses distorted/maladaptive beliefs and attributions related to the abuse. Children are encouraged to talk about their traumatic experiences, process the experiences, overcome problematic thoughts and behaviours and develop effective coping and interpersonal skills (Child Welfare Information Gateway, 2012). Strong evidence base from the United States.
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Neurosequential Model of Therapeutics
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Focuses on understanding that violence, abuse and neglect lead to traumatic symptoms and alter the brain in ways that lead to emotional, behavioural, social, cognitive and physical difficulties (Perry, 2006:29, cited in NSW Department of Health, 2011:24). Interventions require a thorough assessment of a child’s social, emotional and cognitive stage as well as an understanding of the age at which the trauma occurred, in order to determine the parts of the brain that are likely to have been compromised as a result of the trauma experienced. Relationship building, regulating emotions, and working with schools, parents and carers may occur before ‘talking’ therapy with the child commences.
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Neurological Reparative Therapy
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This is a model for treatment and not a practice; it ‘provides a map for the process of repairing the brain‘ (Ziegler, 2011:27). It is a practical application of the new understandings of the brain and how it is affected by trauma. There are five main goals which include, to ‘facilitate perceptual changes of the self, others and the child’s inner working model’ (Ziegler, 2011:69) and enhance the parts of the brain that process and integrate information.
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Dyadic Developmental Psychotherapy
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This treatment model has been developed by Dan Hughes and is an attachment-focused model of family therapy for children who have suffered abuse, neglect and multiple placements. The aim of the model is to facilitate attuned relationships between the child and caregiver as well as the therapist and child, and therapist and caregiver. The model is based on the premise that the development of a child is dependent upon and highly influenced by the nature of the parent-child relationship (Dyadic Developmental Psychotherapy, 2012).
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Marte Meo Model
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A developmental model which focuses on the everyday moments of life known as ‘Action Moments’, where a child’s development takes place. The model uses video footage to allow for an analysis of a parents’ and child’s interaction and the child’s developmental progress. The elements of a child’s development that are not yet present are identified and parents/caregivers are given the skills to work with their child to maximise development (The Benevolent Society, 2011:48).
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Multisystemic Therapy
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This is a community-based, family-driven treatment for antisocial/delinquent behaviour in youth (Life Without Barriers, 2013). The aim is to improve youth and parent functioning, reduce abusive parenting behaviour, and decrease abuse and placement. It is an intensive therapeutic program that targets the natural ecology of the child or young person (i.e. family, peers, school etc). Suitable for children aged 10–17.
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Attachment/Parent-Child Focused Interventions:
Circles of Security – Parent/Infant Program
Parent-Child Interactive Therapy
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This is a 20 week, group-based program designed to enhance relationships between parents and their young children and aims to bring a shift from a ‘disorganised attachment back to a secure attachment pattern’ (The Benevolent Society, 2011:49). Parents undergo a videotaped individual attachment assessment with their child, which allows for safe feedback to parents about their relationship with their child.
This intervention focuses on difficult/concerning/problematic child behaviour. Most effective for children aged 2-7. Parents learn specific skills to increase positive attention to the behaviour they want to encourage, and specific disciplinary techniques to respond to undesired behaviours. Parents receive live coaching from their therapists behind a one-way mirror via wireless ear bud, and lead the child through a series of tasks, as well as practice specific responses to both desired and undesired behaviour (Child Mind Institute, 2013).
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Expressive/Sensory-Based Interventions and Therapies:
Art Therapy
Sand Play
Music Therapy
Drama Therapy
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These interventions acknowledge that for many children that have experienced trauma, there are no words to assist children to communicate what has happened to them. These therapies therefore offer children opportunities to communicate without words (Steele & Kuban, 2013) and to convey their thoughts and feelings through mediums such as art, sand play, music and drama.
Art Therapy is defined as the use of art media, images and the creative processes to create products which are reflections of one’s own development, abilities, personality, interests, concerns and conflicts. It is a therapeutic means of reconciling emotional conflicts, managing behaviour, solving problems and reducing anxiety (Malchiodi, 2008:11).
Sand Play is a creative form of psychotherapy that uses a sandbox and miniatures to enable a client to explore deep layers of his/her psyche through the construction of sand pictures. These ‘pictures’ help a child to illustrate their psychological condition (Malchiodi, 2008:12).
This form of therapy uses music to effect positive changes ‘in the psychological, physical, cognitive or social functioning of individuals’ (American Art Therapy Association 2007, cited in Malchiodi, 2008:11).
Requires the use of drama/theatre processes to ‘achieve the therapeutic goals of symptom relief, emotional and physical integration and personal growth’. The process helps the individual to tell their story (Malchiodi, 2008: 11).
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Life Story Work
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Life Story Work is a collaborative approach to working with a child and involves ‘unveiling the story of a child, of her family and of others who have had contact with her (Rose & Philpot, 2005). This intervention is most often used with children in care and for children who have experienced multiple placement changes. Life Story Work enables children to come to terms with the past, to understand what has happened to them and can assist with reframing a child’s internal working model or negative sense of self.
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Relationships-Based Work
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Highlights the importance of developing strong, healing and protective relationships around a child who has experienced trauma, as well as developing strong relationships between services involved in a child’s life.
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