We identified therapies according to 10 different therapeutic approaches, as summarised below. Detailed descriptions of each approach are also provided.
Cognitive–behavioural therapies:
cognitive–behavioural therapy (CBT)
behavioural therapies
modelling and skills training
trauma-focused CBT (TF-CBT)
eye movement desensitization and reprocessing (EMDR).
Relationship-based interventions (RBIs):
attachment-orientated interventions
Attachment and Biobehavioral Catch-up (ABC)
parent–child interaction therapy (PCIT)
parenting interventions
dyadic developmental psychotherapy (DDP).
Systemic interventions:
Psychoeducation
Group work with children
Psychotherapy (unspecified)
Counselling
Peer mentoring
Intensive service models:
Activity-based therapies
Cognitive–behavioural therapies
Cognitive–behavioural therapies are a group of interventions that draw on a number of theories of learning, both to account for, and address a range of, emotional, psychological and behavioural problems. They have a wide application, ranging from addressing health and mental health problems to more interpersonal and social problems, such as social skills deficits and delinquency. As such, they have considerable relevance to the problems associated with child maltreatment. Before describing the core features of a cognitive–behavioural approach, we briefly describe the therapeutic approaches associated with earlier behavioural and social learning theories, as these continue to form important components of complex cognitive–behavioural interventions.
Behavioural therapies
The earliest interventions were essentially behavioural, drawing on operant (instrumental) and classical (respondent) conditioning paradigms of learning, associated, respectively, with BF Skinner and I Pavlov. Operant conditioning focuses on how behaviour changes with changes in the environment, as when a child’s antisocial behaviour increases as a result of adult attention (reinforcement). Classical conditioning focuses on associative learning, whereby a person learns to respond in a particular way (e.g. becoming anxious) to a neutral stimulus (e.g. a place) by dint of the pairing of the neutral stimulus with a traumatic event (e.g. sexual assault, humiliation).
Although now rarely viewed as adequate conceptualisations of human behaviour, operant and classical conditioning continue to inform the interventions required to address complex social and psychological problems, such as those associated with child maltreatment. Strategies drawing on both operant and classical conditioning are used in psychosocial treatments. The most commonly used classical or respondent-based technique is relaxation training. Children are trained to relax in the face of a hitherto stressful stimulus (e.g. a memory of sexual abuse) either as a way of neutralising the impact of the stimulus (where it forms part of an exposure therapy) or as the means of providing an opportunity to practise other ways of coping, such as ‘reframing’ (locating the responsibility for the maltreatment with the perpetrator rather than blaming themselves; practising positive self-talk). Some of the included studies evaluate a purely respondent approach to anxiety management. Operant techniques, such as differential reinforcement (essentially ensuring unwanted behaviour is not reinforced and positively reinforcing prosocial or wanted behaviour) form an important part of interventions that are designed to address the behavioural problems that are often associated with maltreatment, particularly for younger infants and children.
Modelling and skills training
Social learning theory224,241 recognises that we are not simply the product of our environments: we do not simply respond to stimuli – we interpret them. What we think influences what we do and how we respond to other people and events, and our experiences lead us to expect certain outcomes from certain courses of action under certain circumstances. Furthermore, a large proportion of our behavioural repertoire (e.g. our social skills, our ability to problem solve) comes not from simple respondent or operant processes, but by learning from others. We learn how to do things and how to behave by watching other people or via processes of vicarious learning (e.g. by books or verbal instruction). Reinforcement will play a part in determining whether or not we adopt or use certain responses, and some may find it difficult to manage particular situations if they have not had the opportunity to develop the appropriate skills, including social skills. Social learning theory informs our understanding of how certain forms of maltreatment may be associated with the certain outcomes, for example in understanding how witnessing intimate partner violence can exert a ‘modelling effect’ on children, particularly boys, which – in the absence of opportunities to learn alternate ways of managing conflict or frustration (for example) – can lead to intergenerational cycles of violence.778 The understanding of the importance of modelling and behaviour rehearsal (with feedback and positive reinforcement) is used to inform a number of psychosocial therapies that aim to help individuals find more adaptive ways of responding to situations.
Cognitive–behavioural therapies
In contrast with traditional learning theory, cognitive theories afford the mind a central role in understanding behaviour, and in developing interventions designed to address psychosocial problems. Unlike the behaviour therapies, which emerged from laboratory-based experiments, cognitive therapies developed from clinical practice, largely in the field of depression, and thus predated the empirical data that have subsequently accrued. For example, Beck 1979779 argued that depression resulted from the reciprocal interaction of three things: a negative way of viewing oneself, one’s situation and one’s prospects (cognitive triad), rigid ways of thinking about the world (schema) that often develop early in life or based on the interpretation of prior experience, and which result in negative, automatic thoughts, and biased and erroneous thinking (faulty information processing). It is thought that children who have experienced maltreatment may well develop unhelpful ways of thinking about themselves, their situation and their prospects, which may cause them difficulties or prevent them overcoming associated problems. For example, children who have been maltreated may well blame themselves for what has happened to them; they may have internalised a negative self-image; they may have ‘learned’ that nothing they do can bring about a sought-after outcome (to be loved, thought well of), resulting in poor self-efficacy or indeed depression. Many of the psychosocial interventions designed to address the problems experienced by maltreated children are concerned to influence these cognitive sequelae. Cognitive–behavioural therapies seek to do so quite directly by helping individuals to identify maladaptive beliefs and ways of thinking, to challenge them (reality testing) and to replace them with more realistic and positive ways of thinking.
Trauma-focused cognitive–behavioural therapy
Trauma-focused CBT (TF-CBT) is a manualised intervention developed by Cohen, Mannarino and Deblinger.267 TF-CBT directly addresses traumatic symptoms, alongside other components that are typical of CBT interventions, such as coping skill training and symptom management, cognitive restructuring and gradual exposure. However, key differences are a greater focus on graded exposure, creating an appropriate account of the trauma [a trauma narrative (TN)] and cognitive processing of experiences. This focus builds on findings from research that support a model of trauma in which traumatic memories and related symptoms are maintained by cognitive biases and avoidance strategies. The TN component aims to address this in order to reduce symptomology and process traumatic memories.100 TF-CBT combines joint child–parent sessions and individual sessions for both child and non-offending parents. Parent involvement provides opportunities to address misperceptions and to validate parental reactions to their child’s traumatic experiences, to train parents to support their child’s therapeutic work and to provide a supportive environment at home (e.g. the studies by Cohen et al.95,96 and Cohen and Mannarino93).
Eye movement desensitisation and reprocessing
We identified two controlled studies (both randomised trials) of EMDR. EMDR is a manualised intervention developed by Shapiro et al.690 Because its core features combine strategies from the learning theories outlines above, we have included it in the group of cognitive–behavioural interventions. EMDR involves the identification and processing of traumatic memories using bilateral stimulation, desensitisation through imaginal exposure, and challenging and replacing maladaptive beliefs about the trauma. The information processing model suggests that this helps to process traumatic memories into long-term memory, thereby reducing trauma-related symptoms, such as hypervigilance, as well as replacing unhelpful beliefs, related to the trauma, with more adaptive ones.120
Relationship-based interventions
Attachment-orientated Interventions
Attachment describes an infant’s strong disposition ‘to seek proximity to and contact with a specific figure and to do so in certain situations, notably when . . . frightened, tired, or ill’.780 It is a behavioural system that is a product of human evolution, designed to trigger protection in the face of perceived danger and to alleviate its associated response, fear. Most infants develop an attachment to their primary carers, and, for most infants, the relationship with the mother is the first intimate relationship in which they engage. From these attachment relationships children start to form a sense of who they are, what they can expect from others, and what behaviour it is useful or dangerous to engage in. Infants whose primary carer provides sensitive and responsive care develop what is called a secure attachment. Carer sensitivity and responsiveness to their infant’s needs helps to ‘shape their physiological regulation and biobehavioral patterns of response’ (p. 624),123 and, as infants develop a secure attachment (sometime towards the end of their first year), they use that attachment and associated feelings as a secure base from which to explore their worlds.
Emotional and physical neglect or abuse, and exposure to violence, can result in insecure attachments or sometimes disorganised attachments, which, if unresolved, will contribute to a wide range of problems in later development, including poor socioemotional development, self-regulation difficulties, maladaptive behaviour, sleep disturbance, language delays, poor peer relationships, school underachievement, and psychopathology and delinquency in later life.130,781,782 It has also been associated with a disturbed hypothalamic–pituitary–adrenal axis, which is important for self-regulation and stress management.124 Disorganised attachment styles develop when children are emotionally and physically depending on someone who is also a source of fear and anxiety. Unsurprisingly, disorganised attachments styles are prevalent among children living in families in which there is child maltreatment, parental depression, parental history of loss or trauma, parental dissociation, parental frightening behaviour or marital discord.783 The cascade of negative outcomes associated with a disturbed attachment has been referred to as ‘toxic stress’.784
There is a sizeable literature focused on interventions that are designed to promote maternal sensitivity and responsiveness (see van Ijzendoorn et al.783). In this review, we included only those interventions that specifically focused on families when maltreatment was deemed to be an issue. Although these interventions might arguably also be viewed as secondary prevention (and therefore not appropriate for this review), the nature of attachment is such that interventions designed to promote secure attachments inevitably focus on the primary caregiver. Given the significant impact on subsequent development, these interventions were judged to meet the inclusion criteria of a psychosocial intervention dealing with the adverse consequences of maltreatment for children.
Attachment interventions generally involve caregiver–infant sessions, and aim to enhance parental sensitivity to emotional and behavioural cues in order to improve a child’s attachment security (e.g. Moss et al.130). This may involve child development training, parenting skills, coping strategies, developing social support networks, enhancing the caregiver’s capacity to provide safety, child–caregiver joint narrative of trauma experiences, addressing negative maternal representational models in the parent–child interaction, providing a corrective emotional experience for caregivers or addressing a caregiver’s own attachment difficulties stemming from childhood.123,124,127–130 In attachment-based interventions, the focus of the intervention is not the caregiver or the child but rather the caregiver–child relationship.785 This relationship is used as a vehicle to address a child’s emotional, cognitive and social functioning difficulties.127–129
Attachment and biobehavioral catch-up
Attachment and Biobehavioral Catch-up (ABC) is informed by both attachment theory780 and neurobiology.125,126 ABC focuses specifically on disorganised attachment styles, which are associated with frightening or frightened parental behaviour rather than purely a lack of attunement or insensitivity by the parent.122 This form of attachment has been found to mediate disrupted maternal behaviour and children’s behavioural difficulties and dysregulation.786 Children’s behavioural level and biobehavioural level dysregulation is characterised by externalising behaviour problems, conduct difficulties and disrupted cortisol patterns (which are associated with stress reactivity).125,126
Attachment and Biobehavioral Catch-up (ABC) is a manualised didactic intervention which was designed to decrease parental frightening behaviour and increase parental sensitivity.787 In contrast with more general attachment-based interventions, the focus of ABC is on parental behaviour change rather than changing parental internal representations.122 The aim of the intervention is to help children learn self-regulatory skills by changing the way parents interpret their children’s behaviour, over-riding their own issues that interfere with their caregiving and providing an enabling environment for developing self-regulation skills.125,126
Parent–child interaction therapy
Parent–child interaction therapy (PCIT) was developed by Sheila Eyberg.222 PCIT draws on the work of Diana Baumrind (on parenting styles), as well as attachment theory and learning theory. In its original form it was designed to help parents to establish a secure and nurturing relationships with their child, and enhance prosocial behaviour while decreasing undesirable behaviour. Unlike parent training, PCIT involves in vivo child–parent dyadic sessions in which parents are taught behaviour management techniques, often being coached through a one-way mirror.138 To an extent, PCIT resembles a behavioural version of play therapy [Children’s Depression Inventory (CDI)] and behavioural parent training (parent-directed interaction).
Most studies of PCIT seek to minimise the risk of maltreatment or future maltreatment and secure children’s well-being by promoting nurturing parenting and reducing those parental practices that have been linked to maltreatment and attachment disorders, such as inappropriate discipline, coercive cycles of behaviour and negative communication.137,788
Dyadic developmental psychotherapy
Dyadic developmental psychotherapy (DDP) is designed to address the impairments associated with attachment disorders and complex childhood trauma.789,790 The intervention uses the child–therapist relationship to establish a relational context in which the child can learn how to engage with, and benefit from, relationships with others. The therapist seeks to establish a relationship that mirrors the general principles characteristic of parent–child relationships that facilitate secure attachments, for example attunement, reflecting back to the child his/her subjective experiences (including the trauma s/he has experienced) and helping him/her to make sense of these ‘with acceptance, curiosity and empathy’. In the same way that attachments develop as a result of experience (preverbally), DDP emphasises the importance of healing experiences. In order to benefit from DDP, children need to be in a safe and secure environment (at home or in substitute care) and parents (or carers) are active participants in the therapy, either being with the child in the sessions or watching the therapy through a one-way mirror.791
Child–parent psychotherapy
Child–parent psychotherapy (CPP) is a home-based, manualised intervention provided on a weekly basis for 1 year by trained master’s level therapists.124 It is described as a ‘supportive, non-directive, and nondidactic’ intervention that ‘includes developmental guidance based on the mother’s concerns’ (p. 794).124 When children are aged ≤ 1 year, this therapy is referred to as Infant–Parent Psychotherapy; when they are older, the intervention is called, alternately, Pre-School Parent Psychotherapy or Toddler–Parent Psychotherapy.
Parenting interventions
In general, parent training interventions aim to change unhelpful or maladaptive parenting practices in order to improve child development and well-being. As such, most parenting programmes that address maltreatment are concerned with secondary prevention, but we found three studies114,139,140 with a specific focus on improving outcomes for children who have been exposed to maltreatment, and these studies were included. One study114 evaluated the effectiveness of a parenting programmes designed to help foster parents and parents to co-parent children in foster care, with a view to ameliorating the child behaviour problems associated with, and return the children to, the care of their biological parents. A second assessed the impact of training maltreating mothers in elaborative and supportive reminiscing about positive and negative everyday past events with young children, as a means of addressing multiple sequelae of maltreatment.140 The third specifically examined the impact of the Webster-Stratton IY programme on children’s autonomy, as well as positive parenting, recognising that autonomy is an important subjective state and a critical behaviour acquired in the early years, and which is related to the quality of parenting.139
Systemic interventions
Systems theory posits that individuals are embedded in, and influenced by, a number of interacting systems, including – most importantly – the family. Within systems theory, the problems affecting an individual are conceptualised as a function of the relationships and patterns of interaction that surround him or her, with the resulting implication that effective interventions necessitate locating individual problems within that context and – in many circumstances – directing intervention at the family, rather than simply the individual. Systemic analyses can also be applied to other social systems, such as wider family networks, groups or organisations. Given the inclusion criteria, systemic interventions were included only when they directly focused on ameliorating the consequences of maltreatment for the children in the family (as opposed to halting it and creating a supportive family system that was capable of promoting optimal child development).
Systemic family therapy
There are many forms of FT,792 most of which are informed primarily by structural family systems theory793 and drawing on a wide range of techniques from other interventions, such as CBT. This can make assessing its effectiveness quite challenging, as some forms of therapy are essentially systems-focused cognitive–behavioural interventions.
Multisystemic therapy
Multisystemic therapy (MST) is a short-term, multifaceted intervention for children and young people with serous psychosocial and behavioural problems. It differs from FT in that it includes a combination of multiple systems in the treatment focus, such as family, peers, school, neighbourhood or community. Consistent with social ecological theories of human development, this broader focus is based on the view of the programme developers – that children’s difficulties are caused and maintained by multiple factors within these systems and their interaction. The intervention therefore focuses on identifying and targeting these factors in order to reduce symptoms and distress142,794 and promote health.
Psychoeducational interventions
At the heart of psychoeducational interventions is the view that helping people to understand how their problems have arisen and how they are maintained is an important first step in empowering them to address those problems. Information or education is therefore at the heart of psychoeducational interventions. It may include information about available resources that people might access and direct instruction on coping strategies or change strategies. The educational component is often combined with other activities designed to support change, and psychoeducational interventions are often run in group formats in order to enable the modelling of acceptable behaviour, modifying of inappropriate behaviour and the development of social competencies.152
Group work with children
Group psychotherapies (or therapeutic groups) are interventions in which the group format is central. The group itself is deemed to be ‘therapeutic’, providing a number of essential components, such as a feeling of universality, reducing isolation, extending social networks, social skills practice, healthy relationship building170 and normalising.171
The interventions’ group content includes psychoeducation, as well as skills training and experiential learning. This may include assertiveness training, narrative therapeutic activities, such as storytelling169 or body image and self-esteem enhancement.170 Many of these interventions are based on social learning theory.169
Psychotherapy/counselling
Common to all psychotherapeutic interventions that address individual, familial and community-level issues, is a non-judgemental, insight-orientated approach with a strong focus on the therapeutic alliance795 and dynamic relational processes with therapists or group members. Using these processes to work through past and current relationships, losses and disruptions, is thought to address underlying psychological processes in relation to traumatisation and to enable long-term change.155 Many the studies we identified provided only very general descriptions of these talking-based therapies (such as ‘psychotherapy’ or ‘counselling’), often with little or no information on the underpinning theory of the approach used.
Peer mentoring
Peer mentoring aims to help those children whose social functioning has been adversely affected by maltreatment to acquire key developmental skills, namely the ability to form and maintain effective peer relationships. Maltreated peers with high levels of prosocial behaviour are paired with withdrawn maltreated children and trained to involve them in their play.
Intensive service provision
Treatment foster care
Enhanced Foster Care is designed specifically to meet the developmental, social and emotional needs of children in foster care with particularly challenging behaviour. A multidisciplinary team works with specially trained foster parents to reduce behavioural difficulties, increase regulatory abilities and increase a young person’s secure attachment-related behaviour through a consistent and predictable environment. It involves high rates of positive reinforcement for desirable behaviours, clear limit setting, 24-hour crisis intervention for foster parents, support groups for foster parents, group therapeutic support for children and FT for relationships with biological family.183
Therapeutic residential/day care
Like milieu therapy, therapeutic residential care entails creating a nurturing, stable and consistent environment and a predictable routine for children and young people who need specialist help, and whose problems make it difficult to provide that help in any other way. Indeed, for some maltreated children their experiences of maltreatment, combined with adverse care experiences, may mean they cannot be managed in substitute home-based care settings, such as adoption and fostering. A variety of specific interventions are used in the therapeutic residential care studies included in this review, among which are therapeutic parenting, life story work,553 trauma-focused psychological therapy,551 addressing cognitive distortions, improving impulse control, social skills training, risk management, sex education and behaviour modification,557 as well as preparation for independence for older adolescents.562
Therapeutic day programmes aim to meet the developmental needs of children in terms of fine motor, language, and social and emotional skills.559 Therapeutic day programmes are held in classroom environments and usually run intensively over numerous full days per week. The programmes can include milieu therapy (see below), developmentally appropriate play and activities, structured interaction, individual and parent counselling, and education services, within a psychologically safe environment that is consistent and predictable.195,196,558,563
Milieu therapy is a therapeutically planned approach to a residential or day-care environment that is designed to provide a safe environment in which adults can assist children to address the consequences of maltreatment. Safety, containment, structure, support, involvement and validation are key therapeutic activities. Like therapeutic communities (the terms are sometimes used interchangeably), the aim is to provide a safe, nurturing environment that can engage the ‘whole child’ in processes of psychological change. Through multiple and repeated experiences that are carefully controlled (safe), children can learn about their behaviour and how to discuss distressing feelings and find alternative ways of expressing these. They can develop their self-esteem, learn to trust others, and learn to negotiate relationships and to acquire problem-solving skills. Milieu therapy draws on a range of theoretical frameworks, including attachment theory and object relations theory. Staff use their understanding of transference and countertransference to identify how a child’s feelings and behaviour towards others reflect those with parents, siblings and significant others in their lives, and use this to facilitate change.
Co-ordinated care
Co-ordinated care refers to interventions designed to provide a single point of entry to services, combined with a seamless system of service delivery. It has much in common with initiatives designed to improve interagency working. It is designed to address some of the weaknesses that are inherent in a reliance solely on case management.
Activity-based therapies
Arts therapy
Children who have been maltreated can find it difficult to verbalise their experience, and may feel intimidated by the therapeutic environment and overwhelmed by the verbalisation of abuse experiences. Using a variety of media – such as paint, clay, photos, poems, storytelling or music – arts-based therapies are thought to help facilitate the non-verbal and verbal expression of thoughts, feelings and life narratives. In this way, arts can provide a non-verbal medium for therapeutic communication and cognitive processing for children for whom verbal forms of therapy are not possible. It can help to bridge the gap between the internal world and the limitations of verbal language, particularly in latency age children,199 and provide a mode of communication for children who are unwilling or unable to talk about what has happened to them.200
Play/activity interventions
Play or activity interventions, depending on the age of the target population, are based on the premise that play and activity are vital for healthy development. Play therapy views play as a ‘natural medium in which children express themselves’ (p. 28).576 It therefore provides a way to communicate complex ideas that would be otherwise difficult, through verbal means and helps children make sense of their internal and external worlds.576 Furthermore, deficits in imaginative play have been observed in children who have experienced maltreatment that have been negatively associated with positive affect, peer interaction and problem-solving.203 Activity-based interventions, such as sports or game based interventions, view activity as an appropriate medium for adolescents because it is more enjoyable than one-to-one office-based therapy, requires the development of social skills and peer relations, has physiological benefits through physical exercise and requires cognitive skills, such as impulse inhibition and planning.201
Interventions included under this category are those identified by the author as imaginative play training, challenge/initiative games and the sports-based intervention ‘Do the Good’.
Animal therapy
Animal therapy (or animal-assisted therapy) uses animals as part of the therapeutic process. Animals (from dogs through to horses) are used to assist with the therapeutic process and strengthen treatment strategies. They are thought to aid the therapeutic environment through the provision of warmth, acceptance, empathy and unconditional love.204 Animal therapy is based on research that has found that the presence of animals has improved the communication skills of children participating in therapy, lowered anxiety while undergoing therapy and improved motivation for therapy, as well providing opportunities to teach boundaries and appropriate touch in maltreated populations.205
