CHAPTER
14
Treatment and Intervention: The Essentials to Healing
As described
earlier, the experience of witnessing violence or the trauma
of having been neglected or physically, sexually or verbally
abused in childhood have been linked to a variety of serious
and enduring problems for a vast number of its victims.
Depression, anxiety, psychiatric disorders, delinquent behavior,
substance abuse, spousal abuse, and violence are all too
common.
As a
West African proverb states, "Rain does not fall on one
roof alone." The effects of child abuse are not felt only
by its victims, but in so many tangible ways, by all members
of the community. Any effort that hopes to succeed in ending
child maltreatment must be committed to ensuring that children
receive the full complement of therapeutic services they
require to recover as fully as possible from the effects
of their abuse or neglect. The challenge to the State, the
legislature and the public-at-large is how to ensure these
children the services they need and deserve - in other words,
how to help them heal.
The
Mental Health Care Crisis in Massachusetts
Research
shows that the effectiveness of treatment is optimized when
provided soon after the traumatic occurrences. Great strides
have been made in understanding which interventions work
best to maximize the recovery of children who have experienced
or witnessed violence or have suffered from neglect. This
new information must be incorporated into clinical and protective
practices, as well as into public policies that affect children.
These are difficult to address, however, until we successfully
confront the escalating problems in our state's mental health
system.
Few
would challenge the assertion that the mental health care
system in Massachusetts is in dire crisis. A study conducted
by the Children's League of Massachusetts in 2000 [221]
documents a critical shortage of services for children who
require mental health care. Though many of these children
suffer from organic mental illnesses and have loving and
devoted families, the population of children that requires
mental health care also includes the victims of serious
abuse and neglect.
Residential and Outpatient Care
Recent
reports have heightened the public's awareness of the
plight of children trapped in psychiatric wards or mental
health units where they become more despairing as they
wait for appropriate referrals to therapeutic homes. Others
who need specialized in-patient level care are turned
away from child psychiatric wards due to a shortage of
beds.
The
need is so acute that children often wait long periods
of time in Emergency Rooms waiting for a bed to become
available. The lack of timely and appropriate residential
services can compound these children's already fragile
coping abilities. For example, in one publicized case,
a traumatized child whose family was seeking placement
for him was sent home from an Emergency Room only to cut
himself with a knife and then beat his 3-year old brother.[222]
The
Children's League study also concluded that youth participating
in residential treatment programs have grown more difficult
to serve. They report an increase in the severity of emotional
and behavioral issues they face. Children are presenting
more serious levels of pathology, their numbers are increasing,
and their hopes for treatment and recovery are diminishing
due to the shortage of beds and the lack of qualified
treatment providers in our state.
The
private sector is not the only group to report these critical
shortages. The Department of Mental Health reported in
2000 that 2,500 children were on waiting lists for services.
Hospitals
have also reduced social services and treatment in response
to reduced funding. Parents on the North Shore, Fall River
and other communities report waiting lists of up to five
months for outpatient treatment services. Other outpatient
child psychiatric services at the major medical centers
in Boston that offer new treatments for trauma-surviving
children are operating at a loss to the parent institution,
and many have been, or are being, reduced or eliminated.
Other
services within non-profit provider organizations are
also operating at a loss and are subsidized by endowments
or income from other revenue generating programs. These
funds can only serve as temporary sources of support.
Evaluations
Massachusetts
also faces a critical shortage of evaluation options for
children who present as possible victims of sexual
abuse. Currently in our state, children who engage in
sexually inappropriate behaviors that suggest prior abuse,
or children who have disclosed their abuse - but to another
child - cannot receive appropriate treatment without a
comprehensive sexual abuse evaluation. Unfortunately,
the heightened cost of these evaluations has become a
major obstacle for institutions like New England Medical
Center, Boston Medical Center, and others, in documenting
and treating child sexual abuse.
For
many children, this lack of evaluation resources threatens
to turn the silent tragedy of child sexual abuse into
an invisible one. One example, involves Children's Hospital
of Boston and the Sexual Abuse Treatment Team (SATT) operating
within its Department of Psychiatry. Although the hospital
has received national acclaim for its work in evaluating
children identified as potential victims of sexual abuse,
recently the services normally provided to these children
have been too costly to maintain.
In
2000, the SATT team was dissolved as a cost saving measure.
The disincentive to continue operating was understandable
- the more evaluations they performed, the greater the
financial loss to the hospital. Although, the Child Protection
Team still functions at Children's Hospital and has absorbed
some of the SATT functions, there is still a large deficit
in available evaluation and treatment services for these
child victims.
Specialized
treatment options for children whose sexual abuse has
been confirmed is also sorely lacking. Research shows
that the best treatment for these trauma victims is abuse-specific
treatment, yet there are too few experienced clinicians
with knowledge of trauma and sexual abuse in Massachusetts.
Inadequate reimbursements by managed care systems have
been a major predicament for clinicians and institutions
currently providing these services and a major disincentive
to attracting others into this field of practice.
Given
the long-term benefits and cost savings of quality care
for these children, reimbursements that cover actual costs
must be provided to hospitals and practitioners with expertise
in child abuse evaluation and treatment. These reimbursements
must include support for collateral contacts with family
members, teachers, and other service providers.
Many
maintain that current mental health services for victims
of abuse and neglect are organized in ways that frequently
undermine recovery and at times even re-traumatize children.
Reimbursement structures have pushed private providers
into "fee-for service" arrangements that have resulted
in part-time, temporary working patterns and high clinical
staff turnovers. This places an unfair burden on already
vulnerable children who very much need to develop a consistent
and ongoing therapeutic relationship.
Innovations
in Trauma Treatment
Although
some traumatized children continue to benefit from traditional
therapy and abuse-specific treatment, research is showing
that some new treatment approaches can be far more effective
for many traumatized children.
Multisystemic Therapy (MST)
One
effective treatment strategy for traumatized children
is the "social-ecological" model, or the "Multisystemic"
Therapy (MST) approach. This therapeutic model is based
on an understanding of the child as inextricably linked
to family, community, and school. It argues that in order
to meet the mental health needs of traumatized children,
careful attention must be paid to the child's environment
and the "social-ecology" which has broken down in many
different ways.[224]
Children
who have been abused often display a broad range of emotions
and behaviors including fear, aggression and dissociation.
A core theme of the MST approach is that trauma from the
abuse or neglect causes a "dysregulated" nervous system
and an accompanying family and social environment that
cannot contain the dysregulation.
An
initial goal of treatment is to create calm and stability
and to help build cognitive structures in the traumatized
child that help him place discriminating thought between
a stimulus and his response to it. This is accomplished
by helping a child first become aware of his feelings,
then label his feelings and finally, develop strategies
that regulate feelings once they are labeled. By developing
these cognitive supports, children come to learn that
they have new, more positive choices in their behavior.
When
examining the child's environment under this model, questions
are raised about the child's safety and basic needs, to
what degree the overall environment is stressful, and
whether the child is in the right educational setting.[225]
Therapeutic contacts with the child and his or her family
emphasize the positive, and use strengths in the child's
environment as levers for change.
Interventions
target specific and well-defined issues. Everyone involved
becomes aware of the specific problems and their roles
in perpetuating or solving them. An understanding develops
about the sequences of behavior among the various systems
in the child's life, e.g. how an intrusive symptom of
the trauma can impact on school issues that can then influence
a specific family response to the child. The interventions
eventually promote responsible and therapeutically appropriate
behavior and decrease irresponsible behaviors in all these
settings.
MST,
currently being used with violent and aggressive children,
traumatized children, homicidal and substance abusing
children, has the following core components:[226]
- Low caseload - 3 to 5 families per full time therapist
- Services provided in the child's own environment
- Time limited duration of treatment, 3-5 months per
family
- Therapist functioning within a team of 3-4 clinicians
- Appointments at families conveniences, such as evening
hours and weekends
- Daily contact with family - face to face or by phone
Outcome Data
Data
from outcome studies are encouraging. In one study involving
200 chronic juvenile offenders, youth who received MST
showed:
|
|
A
decreased rate of 22 percent recidivism versus 71
percent in the control group. |
|
|
Fewer
violence- or drug-related arrests and significantly
greater improvements in family cohesion.[227] |
In
a randomized trial of MST versus clinic-based parent training
among DSS families with abuse and neglect histories, results
showed:
 |
Significantly
greater improvements in the MST parent group including,
more effective parental behavior management and more
appropriate parental responses to children, suggesting
a reduced risk of maltreatment.[228] |
In
another study of severely traumatized children, 113 children
and adolescents were approved for emergency psychiatric
hospitalization. Youth entering the study met the criteria
for severe emotional disturbance, and utilized multiple
service agencies, including mental health, juvenile justice
and social services. A randomized trial of MST versus
inpatient hospitalization and "treatment as usual" was
conducted. The results were stunning.
|
The
MST population had greater improvements and exhibited
fewer symptoms; |
|
Family
structure and cohesion was improved; |
|
School
attendance improved; |
|
No
additional hospitalization was warranted for 57 percent
of the MST group. Overall days of hospitalization
in the MST group were reduced by 72 percent, and days
in other out-of-home placements were reduced by 49
percent.[229] |
It
has been estimated that one team of 3 MST therapists can
effectively treat 50 families a year at a cost of $5,000
per family. The annual cost of an entire program is about
$250,000.[230] When considering the short-term saving
of preventing out-of-home placements, residential care,
psychiatric hospitalizations, as well as the long-term
savings of preventing imprisonment, substance abuse and
chronic medical and mental illness - MST is an approach
that can document significant success and savings.
Trauma and Movement Therapies
Psychodrama
and other social group rituals involving movement and
imagination are some of the oldest ways in which individuals
and communities have historically dealt with trauma. These
approaches are now being used as formal interventions
to assist traumatized children.
As
we have seen, children who are victimized by trauma are
often unable to develop or experience mastery and sense
of self, or to separate themselves psychologically from
the violent physical experiences that produced their trauma.
New research suggests that the neurobiological effects
of trauma are as real as their emotional consequences.
The body appears to "keep score" of traumatic memories
and is a theatre where the memory of trauma is often reenacted.
Research
by van der Kolk and others has major implications for
the role that physical education, sports, and art can
play in healing and promoting self-confidence and mastery.
By creating what van der Kolk refers to as "islands of
competence", traumatized children can develop new coping
strategies and behavioral skills that can promote healing,
something, he argues, that may not be achieved through
traditional talking therapies alone.
RECOMMENDATIONS
- Establish an entitlement to effective treatment
for abused, neglected and traumatized children in Massachusetts.
The significant effects of abuse and neglect on children's
physical, emotional, educational and social well-being,
and their costly social and fiscal impact on our communities
and state demand that we secure a formal entitlement to
quality care and treatment for these children. An unprecedented
state-level commitment must be made to entitle every child
victim of abuse, neglect or trauma in Massachusetts to
the full complement of therapeutic and other services
and supports needed to recover as fully as possible from
the effects of their maltreatment.
-
Establish waivers within the current Mental Health
Managed Care system to respond fairly to the special needs
of children diagnosed with child abuse, neglect or trauma.
A separate category for trauma-recovering children, outside
the current behavioral managed health care capitation
system, should be implemented immediately in Massachusetts.
Current models of treatment under managed care systems
often assume that children need only short-term, infrequent
and intermittent care. This is not the case for many victims
of abuse, neglect and trauma. A diagnosis of abuse, neglect
or trauma based on a formal evaluation of the child should
trigger a waiver from limitations in the type, duration
and frequency of clinical services provided for this special
population. The management of these children's care and
the specific services they require should be determined
by competent clinicians and multidisciplinary assessment
teams, and not by managed care agents.
-
Expand the range of interventions for abused, neglected
and traumatized children and provide adequate reimbursement
for evaluations and case coordination activities related
to these interventions.
There must be an expansion and support for evaluations
of children who present with possible sexual abuse; specialized
treatment for child victims and child perpetrators of
sexual abuse; therapeutic group homes; and ecological
models of treatment, including Multisystemic Therapy,
that address the unique needs of the traumatized child
within the context of family and community.
Reimbursements must be available for coordination and
collaboration activities between the service provider
or clinician and other collateral professionals involved
with these children. Failure to reimburse for these essential
activities has undermined the provision of quality care.
-
Pilot, evaluate, and implement effective treatment and
interventions based on new research and findings on brain
development and childhood trauma.
Massachusetts is fortunate in that it is home to several
key researchers and institutions working to translate
new brain research findings into more effective interventions
for abused, neglected, and traumatized children. The State
would do well to develop ongoing collaborations with these
experts, including the funding of pilot studies, so that
proven approaches can be incorporated within the state's
child welfare and mental health systems of care.
-
Establish a Board of Education-sponsored scholarship and
payback program for graduates in social service and mental
health fields.
Service providers in mental health and social services
report a significant drop in the numbers of trained and
qualified workers over the past decade. Limitations in
client coverage and reimbursements, non-competitive salaries,
and the high-cost of living in our state have all contributed
to this shortage of specialized workers. One proposal
to address this trend is through a Board of Higher Education-sponsored
college scholarship program, complete with service payback
provisions for graduates willing to enter these fields.
-
Create "blended" funding pools within state agencies
serving children to maximize services, and support inter-Departmental
coordination and collaboration to encourage flexible and
creative use of resources.
Blended funding from a variety of state agency resources
must be pooled to ensure that children and families receive
the services they need. In order to promote the flexible
and creative use of state dollars, collaboration among
agencies must be coordinated centrally through a statewide
mandate, backed with sufficient resources and quality
assurance. The needs of the child and family should be
the central driving force behind collaboration and information
sharing among state agencies and providers.
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Section
IV: Healing Our Children:
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