PTSD Linked to Family Violence
Here is another study adding to the literature documenting the correlation between family violence and PTSD. The study has its limits, but is in line with other recent research.
Mild Stress May Be Good for Children
I ran across an interesting entry at Scientific Blogging, explaining a study in Developmental Neuroscience. The study's authors compared images of the prefrontal cortex of spider monkeys, and concluded that those monkeys who had been through mildly stressful experiences showed an increase in certain brain cells, which cells in turn enabled them to deal successfully with stressful experiences later in life. The study's authors noted several limitations, such as that the study was skewed toward female subjects. And, of course, the findings would not hold true for major emotional trauma. Still, it is a very interesting study about the inoculative effect of new and mildly stressful experiences.
To quote the blogger, Andrea Kuszewski, who reviewed the study,
Even as children, being faced with challenging situations is a good thing. We learn to problem-solve, think for ourselves, and build resilience to protect us from harm in future unexpected events. As an added bonus, dealing with stress early on helps us to develop emotional stability as well.
This is one of those studies that reinforces what experienced youth service workers already know -- encouraging children to take on new challenges is good for them. Learning to master skills, whether it is speaking in front of a crowd or camping or sports, is a necessary part of becoming a well-adjusted adult.
Experts May Not Be Objective
A recent project led me to an interesting study in the Scandinavian Journal of Psychology looking at what factors influence the opinions of clinicians about whether child sexual abuse occurred in a given case. It should come as no surprise that the study found that even expert clinicians are human, with many unexamined biases.
What I did find disconcerting was the study's conclusion that the clinicians noticed leading questions, but not other suggestive techniques. The study included interviews that, in addition to leading questions, used (a) inducing stereotypes ("he is bad"), (b) statements that assume abuse ("don't be afraid to tell"); and (c) praise or criticism for certain disclosures from the child. Although experienced clinicians were more likely to note the leading questions, few of them noticed the other three suggestive techniques.
As the study's authors noted, this finding "is surprising as there is ample evidence that a number of suggestive interviewing techniques apart from leading questions may affect children's testimony in a negative way. This is an alarming finding because if the clinicians do not recognize such influences as harmful, it would not be possible for them to take steps to avoid such influences when interviewing children themselves."
The authors recommended more training about suggestive techniques and pre-existing beliefs, as well as (of course) more studies on the subject.
Evidence-Based Training for Psychotherapists
The next issue of Psychological Science in the Public Interest has a provocative article arguing for training psychotherapists in evidence-based treatment protocols. As one would expect, it has drawn a lot of both support and criticism. I, for one, am glad to see the field addressing the question of why so many therapists continue to ignore therapies that studies have shown to be effective.
Children and Domestic Violence
The latest of the Journal of Interpersonal Violence has a fascinating study about the effect of domestic violence on children. It included a small sample, and needs to be replicated, but it is the first major study to look at the effect of the relationship between a child who witnesses domestic violence and the perpetrator. It found no significant difference in regard to Post-Traumatic Stress Disorder, but found that children with multiple father figures showed significantly more troublesome behaviors.
Child Sexual Behavior -- Normal Curiosity or Cause for Concern?
This month's edition of Pediatrics magazine has a report about evaluating sexual behavior in children. It does not break any new ground, but offers an excellent overview of the current state of research into the range of child sexual behaviors. It notes, for example, the connection with parental neglect, as well as witnessing domestic violence.
The History of Cognitive Behavior Therapy
Thanks to World of Psychology, I found an excellent article by American Scholar on Dr. Aaron Beck, the founder of Cognitive Behavior Therapy. The article describes, not just Dr. Beck, but the early history of CBT. It's well worth reading.
I have been an enthusiastic supporter of CBT ever since I discovered it ten or so years ago. I like to think that my enthusiasm stems not from any bias caused by my legal cases, but from my time as a social worker in the early 80s. I spent a lot of time working with abused children and dysfunctional families, and became quite disenchanted with traditional psychoanalysis. It seemed to me to be analogous to using a treadmill instead of going on a hike -- the exercise might be good for you, but you always find yourself in the same place.
CBT v. Psychodynamic Therapy
One of the ongoing discussions in mental health research is about the relative benefits of psychodynamic therapy, probably the oldest form of therapy, and Cognitive Behavior Therapy (CBT), probably the most-researched protocol. Well, fans of psychodynamic therapy now have a new study to cite.
The American Journal of Psychiatry recently published a study comparing short-term psychodynamic therapy and CBT in the treatment of generalized anxiety disorder. The researchers found that both protocols offered significant improvement in anxiety, but CBT showed better results in treating depression.
The study was small (only 57 subjects), and involved adults, so it does not tell us much about therapy for traumatized children. Still, it does reinforce the research showing that short-term therapy is just as effective as long-term.
Hat Tip: World of Psychology
Evidence-Based Treatment
I've been researching evidence-based treatment for a couple of weeks now, and so far the best summaries available are the DOJ study from 2004, and the report of the Kaufman Best Practices Project. The California Evidence-Based Clearinghouse is an excellent resource for learning about various new programs.
If the forensic expert in your case has never heard of these reports, then a Daubert motion is (or should be) in the offing. If the child's treating therapist is not using a treatment program founded in mental health research, then damages are (or should be) a hotly-contested issue.
Evidence-Based Treatment
My first stop after our vacation was the APSAC Colloquium, where I had a great time teaching and catching up with old friends. I particularly appreciated the keynote address by Dr. Ben Saunders. He is a leading advocate of treating child abuse victims according to protocols that are grounded in solid mental health research. His organization has a great list of resources for both mental health professionals and lay people describing the treatment methods that have the most evidentiary support.
Verbal Aggression Related to Child Adjustment Issues
The current issue of Child Maltreatment has a fascinating study on children exposed to domestic violence. Unlike similar studies, this one looked not only at battery-type violence, but also verbal aggression. The researchers found that women and men were equally likely to be involved in aggression and violence, including verbal aggression. They also found significant adjustment issues in children who experienced only verbal aggression.
Like all studies, this one has limits and needs to be replicated. In the legal setting, however, it adds a significant wrinkle to the question of damages. In any case where mental health is an issue, both the expert witnesses and attorneys need to investigate and account for domestic violence, including relatively moderate verbal aggression.
Child Sexual Abuse Accommodation Syndrome is Not A Diagnosis
This article about a convicted child molester whose victim has recanted her testimony caught my eye last week. It wasn't the victim's change of heart that interested me. As a former prosecutor, I am familiar with that phenomenon. Sometimes witnesses think the sentence was too harsh, or they think that they have moved on and recant as a way of extending forgiveness. And sometimes they really did lie in the original trial. I don't know enough about this particular case to have an opinion on what really happened. But I have serious questions about this testimony, presented by the prosecution to challenge the recanting victim:
The prosecution made its case by presenting testimony from a psychologist who theorized that Julie suffered from "child sex abuse accommodation syndrome," one of whose key symptoms is denial. In short, the theory was that her recantation as an adult was a form of denial that she had been sexually abused or that her father did it. Under the theory, her new statement also represented an effort by her to restore a family relationship.
The problem is that CSAAS is not a diagnosis. No one can "suffer from" it. If the expert actually testified as the article describes, then he or she was woefully, even inexcusably, uninformed.
Continue Reading...Oh, Please
Researchers at Carleton University have published a study that illustrates how tunnel vision can expose professionals to well-deserved ridicule from lay people. The study, published in Child Abuse Review, analyzed 47 classic Disney cartoons. The researchers found that 10 of the cartoons had scenes in which children received unwanted physical contact or "threatening approaches from adults," and failed to respond appropriately.
Excuse me? Professional researchers spent numerous hours watching cartoons? And their profound conclusion was that the children in the films did not set a good example? Hello -- we are talking about entertainment here. Not everything that a child watches needs to teach a message. Sometimes a cartoon is just a cartoon.
These researchers likely would scoff at parents wanting to keep Harry Potter out of libraries, but they apparently see no problem with concluding, "Is the unwanted contact and risky situation content appropriate viewing for children, given efforts to teach children sexual safety?" It's a silly question, deserving of the ridicule the study is attracting. Sometimes well-meaning people simply spend too long dealing with one topic, and start seeing it everywhere they look.
Cognitive Behavior Therapy for Eating Disorders
The American Journal of Psychiatry recently published a study on the effectiveness of two types of Cognitive Behavior Therapy for treating eating disorders. The study tracked patients who had undergone either focused CBT, which focused solely on features of eating disorders, or broad-based CBT, which addressed other issues such as depression and low self esteem. The study concluded that both types of therapy are helpful, and that broad-based CBT had better results for complex cases.
Hat tip: The Phrenologist's Notebook
Recovered Memory Research
Psychological Science recently published an important and interesting new study of recovered memories of childhood trauma. I have always been skeptical of claims of recovered memories, but there are good researchers on both sides of the question. The Psychological Science study offers a close look at the mechanics of recovered memories, and finds important differences in the ways that memories are triggered.
Continue Reading...
That Didn't Take Long
Legal blogs already are picking up on the study that I mentioned yesterday. The normally-solid Sexual Abuse Claims Blog quotes one report that "child abuse can permanently alter the way your genes fight stress, leaving victims of childhood abuse more vulnerable to stressful events throughout their life."
Let's all repeat one more time - the study looked at a grand total of 36 tissue samples. To quote a neurobiology professor, "The bottom line is that this is a terrific line of work, but there is a very long way to go either to understand the effects of early experience or the causes of mental disorders."
If you run across an expert who makes this claim about the results of childhood abuse, take a good look at the studies they are relying on. As one of my favorite literary characters said, "Wizards should know better."
Exaggerating Results of Research Studies
News articles about a recently-published neurological study illustrate how easily a poorly-supported claim can become accepted dogma. The current issue of Nature Neuroscience reports a study of the brain tissue of people who had died under varying circumstances. They found significant differences in the brains of people who had suffered abuse as children.
Numerous news agencies reported the study, announcing breathlessly that child abuse "permanently alters" how the brain responds to stress, that child abuse alters the brain, and that child abuse "causes lifelong changes" to the brain. The study, however, proved no such thing.
Continue Reading...
Recovery from Sexual Abuse
The Journal of Mental Health Counseling has an interesting article discussing factors that help children recover from sexual abuse. The focus of the article is "transgenerational trauma and child sexual abuse," but it has a very helpful section summarizing recent research into factors that aid a child's recovery from abuse. Those factors include:
• Self-perception. When children think their pre-abuse lives were positive, they are more likely to have a positive self-image after the abuse.
• Reaction of support network. When adults around the child deny the abuse or support the perpetrator, children are at greater risk for negative symptoms.
• Emotional support . Children who receive support from their primary caregivers show fewer symptoms than children who lack that support. One study suggests that maternal support is a more important factor than the nature of the abuse or the child's relationship to the offender.
Hat tip: The Phrenologist's Notebook
Exposure to Domestic Violence as Child Abuse?
The new issue of Child Maltreatment has a provocative article arguing for treating exposure to domestic violence as a form of child abuse. This argument is gaining credibility in the mental health circles, in light of so many studies showing how children who only witness domestic violence exhibit many of the same symptoms as children who are direct victims.
The article is worth purchasing simply for the list of research studies showing the effects of witnessing domestic violence. Any attorney or expert working on cases involving alleged or proven abuse should be familiar with that research. As I noted in my post about a study released last fall, competent experts must be able to rule out domestic violence as an alternate cause of symptoms and/or damages in litigation.
New Clinical Practice Guidelines
Medical and mental health professionals are treating increasing numbers of children with developmental disorders affecting their capacity to process information and communicate. The Interdisciplinary Council on Developmental and Learning Disabilities (ICDL) has published clinical practice guidelines to help professionals treating such children.
The section on "Home, School and Family Approaches" has many helpful suggestions that teachers and caregivers can use in working with children with special needs.
Abuse Linked to Psychosis
A MedWire News article tells of a study published recently in the British Journal of Psychiatry testing possible links between childhood abuse and psychotic episodes in early adolescence. It comes as no surprise that the study found a strong link between childhood physical abuse and later psychosis. What I found interesting is that the study also found a stronger correlations with childhood bullying and exposure to domestic violence than with sexual abuse.
The importance of this study for youth-serving organizations is that bullying can be every bit as damaging as the forms of abuse that we traditionally watch for and try to prevent.
For lawyers, the takeaway is that in litigation involving this sort of claim, we need to investigate domestic violence in the home and bullying at other venues. Our expert witnesses need to address those issues, and either rule them out or account for them as complicating factors when assessing damages.
More Support for Cognitive Behavior Therapy
The Lancet has published a series of very interesting articles on child maltreatment. In one of the articles, a group of doctors and psychologists from the UK, USA, Canada and New Zealand reviewed various programs to prevent and treat abuse. They concluded that the sexual abuse treatment with the most research support is trauma-focused cognitive-behavior therapy (CBT). They noted weaknesses in many of the studies of CBT, but noted the consensus that CBT "should be considered as the first-line treatment for sexually abused children and their families."
Psychotropic Medications Overused?
.jpg)
While researching my last blog post, I ran across a recent study noting that American children are prescribed antidepressants three times as often as their counterparts in German and the Netherlands.
The study naturally raises the question of whether American children really need all of those prescriptions. In fact, one of the study's authors published a separate study, contending that psychotropic medications are overused among foster children.
Scientifically-Effective Treatment for Trauma
One of the most controversial questions I encounter in litigation involving children is predicting the costs of future mental health treatment. Everyone agrees that children who have suffered a trauma need therapy, but few people agree on what sort of therapy or how much. The American Journal of Preventive Medicine recently published a study concluding that only cognitive behavior therapy (individual and group) has been proven to be effective. (Hat tip: Anxiety Insights blog).
Defense attorneys will like this study for the same reason that plaintiff's attorneys will be skeptical - cognitive behavior therapy requires only 8-12 sessions. It may need to be repeated periodically at developmental milestones, such as puberty, but it does not require long-term, ongoing therapy sessions.
Other therapies that I often see recommended, such as intensive psychoanalysis or psychotropic medication, are simply not yet proven. I have yet to see a Daubert challenge to such recommendations, but more studies like this one certainly would support one.
Non-Sexual Abuse May Lead to Sexualized Behavior in Children
Experts long have considered sexualized behavior in children to be a strong indicator of sexual abuse. Some behavior (masturbation, exhibitionism) is part of the normal developmental process, but other behaviors seem to occur significantly more often in children who have been sexually abused.
But according to a study reported in Child Maltreatment, physical and emotional abuse may cause the same behavior. The researchers followed children at risk for physical or emotional abuse, but who had no reports of sexual abuse. They found that children who had suffered either physical or emotional abuse exhibited more sexualized behavior than non-abused children. "Findings suggest that maltreatment other than sexual abuse, and the developmental periods in which is occurs, may be linked to the development of sexualized behaviors."
The abstract (free) and full text (minimal charge) are available online.
Lawyers handling cases with claims of sexual abuse need to be aware whether the respective expert witnesses have investigated the possibility of emotional or physical abuse in a given case. It is one of those questions that need to be asked, if only to rule it out as a possible cause of the child's symptoms.
The Joy of Conferences
A few weeks ago, I spoke at the Georgia Association of Young Children (GAYC) annual conference, and in late September, I spoke at the conference for the Southeastern Section of the American Camping Association. I thoroughly enjoyed both conferences. It always is good to re-connect with old friends, and to remember why I enjoy so much working with people who work with kids. 
My topic in both seminars was how to implement the recent CDC guidelines on "Preventing Child Sexual Abuse in Youth-Serving Organizations" (PDF available here). I helped edit the final report (finding my name on the acknowledgements page was pretty cool), and was impressed with how much work went into the project. Given the CDC's stature, these guidelines are likely to become an important standard in the field. The CDC imprimatur also means that the guidelines are likely to show up in lawsuits. Plenty of directors will find themselves answering a lawyer's question, "Did YOU implement the CDC's recommendation on page 4?"
I hope to be at the ACA's National Conference in February. If you're there, be sure to look me up and introduce yourself.
