Utilization of evidence-based treatment models at community-based mental health settings for young children exposed to violence

Highlights

• The use of treatment models for children exposed to violence was examined.

• Play therapy or an integrated approach was used for a majority of the sample.

• Less than one-fourth of the sample received evidence-based treatment models.

• Race and violence type were associated with the use of treatment models.

• It is critical to assure that treatment needs of individual children are met.

Abstract

Background: Little is known about which therapeutic treatment models are being used most commonly at community-based mental health settings to treat young children exposed to violence. Objective: We aimed to (1) explore the use of commonly applied treatment models for young children exposed to violence across community-based clinical sites and (2) examine the associations of the use of these models with child demographics and type(s) of violence to which the child was exposed. The models examined included Cognitive Behavioral Therapy (CBT), Attention, Regulation, and Competency (ARC), Child-Parent Psychotherapy (CPP), and Child-Centered Play Therapy (CCPT). Participants and setting: Participants were 500 children aged 0-6 years, who were exposed to violence and received treatment at 1 of the 12 community-based sites. The mean age was 48.1 months (SD = 13.9 months). Methods: Descriptive analyses were conducted on child demographics, type of violence, and treatment model(s) employed. Binary logistic regressions were conducted to examine the associations of treatment model(s) used with child demographics and type of violence. Results: 76.2% of the sample received CCPT or an integrative approach, rather than evidence-based treatments (e.g., CBT, CPP). Black children were more likely to receive CCPT (OR = 6.490; 95% CI = 1.262, 33.375). Hispanic children were less likely to receive ARC (OR = 0.234; 95% CI = 0.074, 0.738). Associations between type of violence exposure and treatment model utilization were also found. Conclusions: Our results underscore a need to disseminate EBTs, as well as to assure that treatment needs of individual children are met.

Introduction

Children in the United States are exposed to violence at an alarming rate. In a national sample of 4,000 children and youth between 0 and 17 years old, 40.9% had more than one direct exposure to violence, crime, or abuse, while 10.1% had six or more exposures (Finkelhor, Turner, Shattuck, & Hamby, 2015). The U.S. Department of Health and Human Services (USDHHS) reported that children ages 0–6 years were at greatest risk of experiencing child abuse and neglect (USDHHS, 2018).

Exposure to violence, one type of potentially traumatic event, can have a profound impact throughout one’s lifespan. Early exposure can encumber cognition, speech, and emotional regulatory abilities in young children (Tarullo, 2012). More specifically, children under 6 years old with experience of violence exposure may experience higher levels of difficulties (e.g., fussiness, crying, sleep disturbance, clinginess, separation anxiety, restrictive play, posttraumatic play, temper tantrums, regression of skills) as compared to their peers (Mongillo et al., 2009, Pears and Fisher, 2005, Scheeringa et al., 2003). Adolescents exposed to violence as children were more at risk for substance abuse, grade repetition, delinquency, high-risk sexual practices, internalizing disorders, externalizing disorders, and engaging in violence toward others (Fang and Corso, 2007, Felitti and Anda, 2010, Gold et al., 2011, Ulzen et al., 1998, Wilson et al., 2012). Years later, adults with childhood experiences of violence had increased rates of mental illness, multiple chronic diseases, financial stress, poor work performance, lowered educational attainment, lowered quality of life, and premature mortality (Felitti et al., 1998, Risser et al., 2006). Left untreated, the effects of early exposure to violence can negatively influence multiple stages of an individual’s life.

Numerous therapeutic treatment models exist for children and their families that effectively help combat the effects of early exposure to violence. Evidence-based treatments (EBTs) have been shown to effectively reduce symptoms, increase resilience, or reduce incidence of violence in young children exposed to violence (U.S. Departments of Justice and Health and Human Services [USDJHHS], 2011). These EBTs include Brief Strategic Family Therapy, Alternative for Families-Cognitive Behavioral Therapy (AF-CBT), Child Parent Psychotherapy, Functional Family Therapy, Parent-Child Interaction Therapy (PCIT), Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Combined Parent Child CBT, Eye Movement Desensitization and Reprocessing (EDMR), and Trauma Systems Therapy (TST; USDJHHS, 2011). Furthermore, the National Childhood Traumatic Stress Network (NCTSN) has identified 48 treatment models as “treatments that work” for exposed children and their families (NCTSN, n.d.). With many options available, understanding factors that are associated with therapists’ treatment model selection may be beneficial for training, service planning, and mitigating the effects of early violence exposure.

When selecting an appropriate therapeutic treatment model, therapists consider an array of factors. Some of these factors include each model’s target populations (e.g., psychiatric disorder, age, sex, race/ethnicity, culture), advantages, limitations, supporting evidence, and level of effectiveness. Most importantly, matching individual children’s mental health needs to treatment models is essential (Eslinger, Sprang, & Otis, 2015). Thus, selecting the most appropriate treatment model can prove arduous for therapists.

Understandably, therapists tend to rely on their own clinical experience above research when making treatment decisions (Stewart, Stirman, & Chambless, 2012). When therapists rely solely on clinical experience, they may have trouble reasonably predicting the most appropriate treatment models for their clients (Kadden, Cooney, Getter, & Litt, 1989), or they may have difficulty reliably identifying when their clients are not responding to a particular treatment intervention (Hannan et al., 2005). When choosing a specific model, some therapists may feel they are ‘fitting’ their clients into a prescribed treatment, instead of prioritizing individual client variations and contextual needs (Beutler, Someah, Kimpara, & Miller, 2016).

Research indicates that lack of fidelity to a specific model may impact effectiveness (Beutler, Someah, Kimpara, & Miller, 2016). However, relying solely on a specific treatment model can be problematic. For example, when the landscape of treatment changes over time, a treatment model previously used may not align with current research or fit the patient’s present needs. Moreover, some therapists may worry that EBTs may not show effectiveness outside of the controlled conditions employed in research settings or with complicated client profiles (Stewart, Stirman, & Chambless, 2012). Therefore, some therapists may opt for an integrative approach and incorporate elements from two or more treatment models without regard for evidence concerning the effectiveness of treatment (Beutler, Someah, Kimpara, & Miller, 2016).

Training can assist therapists with informed decision-making regarding treatment model selection. For instance, one study found that after receiving training for an intensive trauma-focused EBT, therapists were more likely to believe that structured therapy approaches are effective (Allen, Wilson, & Armstrong, 2014). Still, many therapists were deterred by the time and money it takes to learn new treatment models (McCarthy, 2015).

Previous research indicated EBT underutilization (Higa & Chorpita, 2008). For example, using a national sample of 157 therapists, a study found that most therapists had not been trained in and had not employed EBTs on a regular basis (other than TF-CBT) to treat maltreated or violence-exposed children (McCarthy, 2015). To date, however, no existing literature has elucidated which treatment models are being used most commonly in the community with children exposed to violence, nor does it suggest what factors are associated with therapists’ treatment model selection in community-based settings. In particular, it remains unclear whether child demographics (e.g., sex, race/ethnicity), the specific type of violence, or level of supporting evidence influences treatment model selection. Sex and race may impact types of violence or trauma experienced (Hussey et al., 2006, Kendler et al., 2001, Mersky and Janczewski, 2018, Scher et al., 2004, Tolin and Foa, 2008) and subsequent symptomology (Pineles et al., 2017, Simmons et al., 2015, Youssef et al., 2017). As such, these factors may influence treatment decisions by proxy and should be examined independently.

The main goals of the current study were to explore which treatment models were used in community-based mental health settings for young children exposed to violence and whether those models were used exclusively or as part of an integrative approach to treatment. A secondary aim was to describe whether the use of treatment models was related to specific child demographics (i.e., age, sex, race/ethnicity, or the type of violence to which the child was exposed). Lastly, the study aimed to provide contextual information regarding the level of supporting evidence for the treatment models used in the community. As the current study was descriptive and exploratory in nature, no formal hypotheses were generated. A unique feature of the current study was to investigate the use of different treatment models in regard to child demographics at multiple community-based settings (in both urban and suburban areas).