Elias is a five year old Mexican American male who has recently been referred to the community counseling center due to the exposure of sexual abuse by his stepfather. Elias was a client of this community center approximately 18 months earlier. Elias had been referred for poor impulse control and hyperactivity. At that time he was diagnosed as having Attention Deficit Hyperactivity Disorder (ADHD). He also met with the agency psychiatrist who had prescribed Elias Focalin. His cased was closed after only a few sessions due to the family’s inconsistency and withdrawal from services.
At this point in time Elias has been attending his sessions with his mother and baby brother. Stepfather’s whereabouts are unknown and he has not had any contact with the family since the abuse was exposed. Elias has returned to taking Focalin, since he failed to continue taking his medication after withdrawing from services. However, there have been no changes noted in his behavior since he has begun to take the medication. The psychiatrist believes that this may be due to the low dosage he has prescribed Elias and because of such, the psychiatrist has opted to slowly increase the dosage and closely monitor any changes.
The clinician notes that Elias is extremely hyperactive and exhibits minimal impulse control. Other than his high levels of restlessness, Elias shows no observable signs or symptoms of reaction to the sexual abuse. When clinician has attempted to process with Elias about the abuse or his feelings about the abuse, Elias has changed the subject or ignored the clinician all together. Mother states that she has noticed no changes in his behavior since the abuse was discovered.
Practice Effectiveness Questions The special population in discussion is children, the social problems in focus are sexual abuse and attention deficit hyperactivity disorder (ADHD), which leads the target client group to be children who have experienced sexual abuse and have been diagnosed with ADHD. Our client is Elias who is a child, who has experienced sexual abuse and is diagnosed with ADHD. For the purposes of this discussion our practice effectiveness questions are:
1) What are effective interventions for children who have been sexually abused? and 2) What are effective interventions for children who have been diagnosed with ADHD? Search Description Procedures The databases utilized for this search were: Google Scholar, Social Work Abstracts, Child Welfare Information Gateway, Academic Search Complete, Professional Development Collection, PsycARTICLES, PsycINFO, SocINDEX with Full Text Sociological Collection, Academic Search Premier, and JSTOR. It was also helpful to review the journal entitled Sexual Abuse: A Journal of Research and Treatment for relevant articles.
While searching the aforementioned databases, the following keywords were utilized: ‘sexual abuse and ADHD’, ‘sexual abuse and interventions’, sexual abuse and co-morbidity’, ‘ADHD and co-morbidity’, ‘children and sexual abuse’, ‘sexual abuse and interventions. ’ All articles selected were peer reviewed, found in scholarly journals, and published within the last ten years. In searching for relevant articles regarding treatment of sexual abuse, most articles addressed interventions designed to treat perpetrators of child sexual abuse; a few articles were uncovered that discussed treating adult survivors of childhood sexual abuse.
Fewer still were articles that identified interventions for children who are recent or current victims of sexual abuse. In order to find information relevant to our target client group, we began pulling sources from reference pages of relevant articles which provided more focused research relevant to treatment of children who have experienced sexual abuse. Results The result of our exhaustive search of available literature led us to identify eight articles to focus on.
Out of these articles, four dealt specifically with children who have experienced sexual abuse, two focused on abuse of children which included physical abuse along with sexual abuse, two were focused primarily on ADHD, four focused on co-morbidity of either post-traumatic stress disorder (PTSD) or ADHD and sexual abuse, and four specifically discussed treatments and interventions. Half of the selected articles were literature reviews while the remaining four were reporting from the standpoint of a primary source on research studies of treatments and interventions.
The research studies varied in their sampling and control or comparison groups; only two studies were able to utilize a true experimental design with random assignment of study participants to control and experimental groups. The literature reviews provided an extensive overview of relevant studies and interventions from a secondary source standpoint. The eight identified sources provided an assortment of research-based perspectives as well as a sampling of evidence based on authority by those who reviewed the literature and discussed their findings in literature reviews. Research Findings
Description of Articles In the article Sexually Abused Children Suffering from PTSD: Assessment and Treatment Strategies by David Heyne, Neville J. King, Paul Mullen, Nicole Myerson, Thomas H. Ollendick, Stephanie Rollings, and Bruce T. Tonge states that sexual abuse of children is a major societal problem because of its high prevalence and devastating impact on the victimized child. Children who have been sexually abused often demonstrate anxiety, depressive moods, improper sexual behaviors, nightmares, social withdrawal, sleep difficulties, anger, shame/guilt and school problems.
The authors did diagnostic interviewing with their participants. The authors interviewed thirty six children and sixty nine percent were primarily diagnosed with PTSD. Within the thirty six children four of the children with full PTSD had no other diagnoses. Nine had one co morbid diagnoses, ten had two co morbid diagnoses, and two had three co morbid diagnoses. PTSD is not always prevalent and at times other emotional and behavioral problems are prevalent. In fact, many studies confirm that on clinical evaluation a large proportion of sexually abused children meet diagnostic criteria for PTSD (Heyne, at el. , 2003).
This particular article showed that often there are other diagnoses that go along with PTSD but in an article by Peggy T. Ackerman, Roscoe A. Dykman, Jerry G. Jones, W. Brian McPherson, and Joseph E. O. Newton, did research on groups that have been affected sexual, physically abused, or both. The article Prevalence of PTSD and Other Psychiatric Diagnosis in Three Groups of Abused Children (Sexual, Physical, and Both) was a study done with children that are sexually and or physically abused. Fortunately, many children who are victims of horrifying events do not develop PTSD or other psychiatric disorders (Ackerman at el. 1998).
Very little is known as to why some victimized children do and others do not develop psychiatric disorders. Even such basic variables as gender, ethnicity, socioeconomic status, intelligence, and age at time of trauma, have been inadequately studied. They were in a large children’s hospital in which sexual and or physically abused children were referred. The groups were divided into three, sexually and physically abused and both. Through the finding there were more boys who were physically abused and girls who were sexually abused. Anxiety and behavior disorders were more frequent than mood disorders.
In concordance with clinical observation, abused boys, regardless of type abuse, had higher rates of behavioral disorders and abused girls had higher rates of two internalizing disorders: separation anxiety (caregiver reports) and phobic disorder (child report) (Ackerman at el. , 1998). Studies show most clearly that children who have been jointly physically and sexually abused are at greatest risk for psychiatric disturbance. There are many different treatment interventions one can go through to minimize PTSD and attention deficient disorders.
Maryka Biaggio, Darlene Staffelbach, Dan Weinstein wrote the article ADHD and PTSD: Differential Diagnosis in Childhood Sexual Abuse which shows different interventions used for victimized children. Treatment interventions for ADHD children predominantly consist of behavior management, social skills training, and stimulant or other medication. Treatment interventions for children with PTSD generally consist of management and alleviation of emotional distress using play, psychodynamic and cognitive behavioral therapy modalities (Biaggio at el. 2000). Relaxation techniques and hypnosis have also been effective in treatment of PTSD in children.
Misdiagnosis may lead clinicians to use inappropriate interventions for PTSD. Side effects experienced by ADHD children on stimulant medication may include difficulty falling asleep, lack of appetite, irritability, headaches, stomachaches, nausea, dizziness, tachycardia, muscle tics or twitches, slowed physical growth, and skin rashes (Biaggio at el. , 2000). Another undesired onsequence of ADHD misdiagnosis in SAC (sexual abused children) is the failure to address and treat the trauma symptoms of children who actually have PTSD. Given the risk of wrongly prescribing, untreated trauma, and negative impact on self-esteem for children misdiagnosed with ADHD, it is unfortunate little attention has been given to this issue (Biaggio at el. , 2000).
Increased attention to clinical decision-making in the differential diagnosis of ADHD and PTSD may lead to more appropriate, beneficial, and timely interventions. Darcie) Allison M. Briscoe-Smith and Stephen P. Henshaw’s article entitled: Linkages between child abuse and attention-deficit/hyperactivity disorder in girls: Behavioral and social correlates, was an excellent source to explore the relationship of sexual abuse and ADHD and begin to discuss the co-morbidity of these events for children. The article described a research study carried out with a sample of 228 females at a summer camp for girls with ADHD over a three year span.
Each year cohort groups were created to identify the prevalence of abuse among girls diagnosed with ADHD and those who had not received a diagnosis of ADHD. Out of the twenty-four identified cases of abuse histories, twenty of these girls were diagnosed with ADHD, and of those abuse histories ten were sexual in nature which is much higher than any other form of maltreatment documented by the researchers. All girls who had abuse histories had a co-morbid diagnosis of Oppositional Defiance Disorder.
The study found that girls with both ADHD and abuse histories were more likely to display externalizing behaviors and be negatively received by their peers. The study also analyzed the relationship between the prevalence of an abuse history and the rejection from peers and found aggression to partially mediate that relationship. The authors concluded that girls with ADHD were at increased risk of having abuse histories and questioned the accurate diagnosis of ADHD.
It was suggested that the girls who had histories of abuse may more accurately be diagnosed with PTSD and/or share a co-morbid diagnosis with PTSD. Judith A. Cohen and Anthony P. Mannarino conducted a research study comparing two interventions to treat children who have been sexually abused; their findings were published in the article entitled: Interventions for Sexually Abused Children: Initial Treatment Outcome Findings. This article was one of few that specifically addressed interventions for children with the focus being treatment of sexual abuse.
The sample consisted of 49 children between the ages of 7 and 14 who were randomly assigned to either sexual abuse specific cognitive behavioral therapy (SAS-CBT) or nondirective supportive therapy (NST) for a twelve week duration. The study found that children in the SAS-CBT group improved significantly in social competence and in the reduction of feelings of depression. Also, substantially higher percentages of children involved in SAS-CBT experienced what is considered clinically significant improvements. In regards to deterioration while in therapy, higher rates were found in children who received NST.
For the safety of the other children in the groups, children who were consistently displaying repetitive extreme sexually inappropriate behaviors were removed from treatment groups; seven NST participants were removed from the study as compared to two children participating in SAS-CBT. Parental satisfaction with treatment was high in both treatment groups which either treatment modality. The clinical impressions of the authors conclude that sexual abuse specific cognitive behavioral therapy is superior to nondirective supportive therapy in the reduction of depressive symptoms.
SAS-CBT was also favored due to the benefit of including parents in treatment (NST did not formally include parents). The authors also concluded that there is value and importance in providing a directive therapy technique in dealing with the effects of trauma caused by sexual abuse. Assessment of Evidence Implications of Evidence Interventions for sexual abused victim’s trauma may include based cognitive behavioral therapy, play therapy, parental involvement- parent training, behavioral therapy, coping skills training, psycho-education, and prevention awareness.
PTSD interventions may include trauma based cognitive behavioral therapy, and play therapy. Attention deficit disorder can also be treated with behavioral management techniques, medication, social skills training, play therapy, parent training, behavioral classroom interventions and summer treatment programs. Many sexually abused children have other diagnosis along with PTSD and several possible co-morbid diagnosis are more than likely behavioral, but often can be confused with PTSD. When looking at interventions and treatments clinicians need to look at the client’s cultural background so that way we do not intrude on their lives.