Abstract
This case study follows a 7-year-old boy who presented with symptoms of posttraumatic stress disorder (PTSD) following exposure to domestic violence beginning at a very young age. During evaluation of this young boy’s symptoms, it became evident that his mother also was experiencing symptoms of PTSD. Consequently, treatment for both this young boy and his mother was proposed. Cognitive-behavioral therapy (CBT) has been used widely with both children and adults to treat PTSD. Fortunately, treatments have been tailored for young children (e.g., trauma-focused CBT [TF-CBT]; preschool PTSD treatment [PPT]) and for adults (e.g., cognitive processing therapy [CPT]). In the current case study, a combination of PPT and TF-CBT was utilized to treat this young boy, and CPT was utilized to treat his mother. With this course of treatment, this young boy demonstrated decreases in his PTSD symptoms and gained an understanding of coping skills and cognitive restructuring. His mother also demonstrated decreases in her PTSD symptoms. Overall, this dyad showed qualitative improvements in their general emotional and behavioral functioning, their individual self-regulation abilities, their social interactions, and their relationship. This case study provides evidence for the importance of treating both young child and parent when both have been exposed to and traumatized by domestic violence. Furthermore, this case study provides a framework for other health service providers to implement conjoint treatment of similarly traumatized families.
1 Theoretical and Research Basis for Treatment
Child maltreatment and domestic violence co-occur frequently (Slep & O’Leary, 2005). National statistics indicated that 3.9 million children were the subject of at least one report to Child Protective Services in 2013, with 27.4% of children who experienced maltreatment also being exposed to domestic violence (U.S. Department of Health and Human Services [USDHHS], Administration on Children, Youth and Families, & Children’s Bureau, 2015). The youngest of children are represented disproportionately (Slep & O’Leary, 2005). Based on statistics from the Centers for Disease Control, the lifetime prevalence rate of physical domestic violence was 22.3% for women (Breiding et al., 2014). Certainly, domestic violence places both children and parents at risk for posttraumatic stress disorder (PTSD). This case study describes cognitive-behavioral therapy (CBT) with a young boy and his mother, both of whom were exposed to domestic violence.
Young children are particularly vulnerable to emotional and behavioral problems after exposure to domestic violence. For example, research suggested that children exhibit insecure attachments, have more aggressive behavior (Howell, 2011), and exhibit more disruptive behavior, mood, and anxiety problems (Levendosky & Graham-Bermann, 1998). Furthermore, they are significantly more likely to be diagnosed with PTSD than children who are exposed to noninterpersonal trauma (Briggs-Gowan et al., 2010), with child and mother PTSD symptoms correlating positively and significantly (Scheeringa, Myers, Putnam, & Zeanah, 2015).
For mothers, their PTSD symptoms have been related to parenting difficulties. For example, after controlling for depressive symptoms, severity of maternal PTSD predicted overall parenting deficits (e.g., less availability, more dysfunctional interactions [Schechter et al., 2010]; lower responsiveness, sensitivity, and recognition of cues [Ammerman, Putnam, Chard, Stevens, & Van Ginkel, 2012]). In turn, mothers’ parenting behaviors (Gewirtz, DeGarmo, & Medhanie, 2011), emotional and behavioral problems, and low self-esteem (Levendosky & Graham-Bermann, 1998) following domestic violence predicted significantly their children’s functioning. Thus, strategically planned PTSD treatments for both young child and parent are needed.
PTSD and CBT
Generally, PTSD is characterized by the experience of a trauma, followed by intrusive re-experiencing, avoidance of trauma reminders, and physiological hyperarousal. The prevalence of PTSD in the United States is approximately 3.5%, with rates being higher in individuals who were more likely to be exposed to trauma (e.g., military veterans; American Psychiatric Association [APA], 2013). Consistently, 45% of women who experienced domestic violence met criteria for PTSD (Houskamp & Foy, 1991), with meta-analyses suggesting that the median prevalence of domestic violence among women with PTSD was 61% (Trevillion, Oram, Feder, & Howard, 2012).
For 3- to 6-year-olds exposed to trauma, only 13% of those who were highly symptomatic would have been diagnosed with PTSD using Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000) criteria (Scheeringa, Myers, Putnam, & Zeanah, 2012). Scheeringa, Zeanah, Myers, and Putnam (2003) indicated, however, that this prevalence rate was likely an underestimate, as Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for PTSD were insufficient for young children. As a result, new Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) criteria were developed specifically for young children, with 44% of symptomatic children meeting criteria (Scheeringa et al., 2012). Given that PTSD is the most common disorder found in both children and adults who have experienced domestic violence (Nathanson, Shorey, Tirone, & Rhatigan, 2012) and that symptoms of PTSD do not remit over time in either young children (De Bellis & Zisk, 2014) or adults (Woods, 2005), an understanding of how to intervene with families following domestic violence is needed.
Fortunately, CBT has established empirical support as the treatment of choice for children and adults with trauma. For example, treatments, such as Parent–Child Interaction Therapy (Pearl, 2008), family behavior therapy (Donohue et al., 2010; Romero et al., 2010), and parent training (Mariñez-Lora & Cruz, 2017), have been adapted for use with families who have experienced domestic violence. Nonetheless, therapy programs also have been developed specifically for trauma experienced by children and adults.
For children, Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a flexible, components-based treatment that includes psychoeducation, parenting skills, relaxation training, affective modulation and cognitive restructuring skills, trauma narratives and cognitive processing, in vivo exposures, conjoint parent–child sessions and activities, and safety planning (Cohen, Mannarino, & Deblinger, 2010). TF-CBT has demonstrated its effectiveness in many randomized controlled trials, promoting decreases in children’s PTSD symptoms after an average of 10 sessions (Webb, Hayes, Grasso, Laurenceau, & Deblinger, 2014) and with maintenance of these gains at 1-year follow-up. TF-CBT has been used with a variety of different trauma experiences (e.g., motor vehicle accidents, Stevens & Michael, 2014).
Modifications to TF-CBT have been made for young children. Similar to TF-CBT, Preschool PTSD Treatment (PPT; Scheeringa, Amaya-Jackson, & Cohen, 2010) includes psychoeducation, relaxation and coping skills, trauma narratives, in vivo exposure, and safety planning, although PPT relies more heavily on behavioral techniques (i.e., habituation, Subjective Units of Distress [SUDS]) and utilizes homework more systematically across sessions. Parent involvement is paramount. A recent randomized controlled trial demonstrated that children who participated in the 12-week PPT protocol experienced significant reductions in PTSD symptoms, depression, oppositional behaviors, and separation anxiety compared with waitlist control (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011). PPT also has been used to address various trauma experiences (e.g., Puff & Renk, 2015). Thus, good child treatment options were available.
Previous research also indicated that CBT was effective at reducing PTSD symptoms in adult women who experienced domestic violence and was superior to other forms of treatment. With regard to specific CBT protocols, Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993) was selected for this case as it has established prominence as an evidence-based CBT protocol for PTSD. It also addressed the concern that the utilization of behaviorally based exposure therapy without cognitive components could be unwise for individuals who have experienced domestic violence. A healthy fear of violence is key for safety, so the goal should be to validate, process, and reduce distress related to trauma memories; to help clients find a new way to think about their trauma history; and to plan for current and future trauma reminders (Resick & Schnicke, 1993).
Fortunately, CPT combines cognitive techniques (i.e., cognitive restructuring) with exposure (i.e., writing and reading about the trauma; Resick & Schnicke, 1993). The goal of written exposures is to allow clients to feel, process, and re-story their thoughts and emotions about their trauma to decrease their negative emotions associated with trauma memories. These goals are achieved by identifying and challenging “stuck points” (i.e., firmly held problematic thoughts and beliefs about their trauma) through the use of Socratic questioning.
CPT was developed originally to treat PTSD in women who had been raped (Resick & Schnicke, 1993; also see Wilson & Jones, 2010) but has been modified for other issues as well. When comparing CPT and prolonged exposure (PE), an alternate CBT protocol, for adult women who had been raped, both treatments resulted in PTSD symptom reduction and positive psychosocial outcomes at posttreatment (Resick, Nishith, Weaver, Astin, & Feuer, 2002) and at 10-year follow-up (Wachen, Jimenez, Smith, & Resick, 2014). CPT and PE also have been combined with some success in the treatment of PTSD (Gurak, Freund, & Ironson, 2016). A dismantling study of CPT randomized females with PTSD into three groups (i.e., cognitive treatment only, written exposures only, or both cognitive treatment and written exposures). Although all three groups experienced significant improvements in PTSD symptoms, individuals in the cognitive treatment group showed greater reduction in PTSD than those in the written exposures group (Resick et al., 2008).
Treatment of PTSD in a Mother–Young Child Dyad
The following case study describes a young boy, Joey Smith (pseudonym) and his mother, Ms. Smith (pseudonym), both of whom were diagnosed with PTSD following exposure to domestic violence. A combination of elements from PPT (Scheeringa et al., 2010) and TF-CBT (Cohen, Mannarino, & Deblinger, 2006) was utilized to treat Joey. Given Joey’s difficulties with oppositionality, inattention, and hyperactivity, PPT was ideal due to its structure. PPT’s emphasis on drawing as part of trauma narratives also was preferred by Joey. Given that Joey had superior verbal skills and above average intelligence, he also was able to understand and utilize the cognitive components of TF-CBT. CPT (Resick & Schnicke, 1993) was selected for use with Ms. Smith, as she exhibited a number of cognitive distortions, maladaptive schemas, assimilation, and over-accommodation that were causing additional symptoms of depression and generalized anxiety. It is our hope that this case study will provide a framework for future treatment and research for trauma in families.
2 Case Introduction
Joey Smith is a Caucasian boy who turned 7 years of age during the course of his contact with the treatment team. Joey’s biological mother, Ms. Smith, brought Joey to a university training clinic for assistance with his symptoms of inattention, hyperactivity, oppositionality, and anxiety. Joey resided with his biological mother and his younger brother at the time of treatment. Joey’s father lived out of the state and did not have direct contact with Joey given this father’s alleged perpetration of domestic violence against Joey’s mother and episodes of physical abuse against Joey. Joey’s symptoms reportedly began after these experiences and were becoming progressively more impairing. At the time of treatment, Joey was enrolled in the second grade and was demonstrating difficulties with emotional and behavioral problems, family relationships, social interactions, and academic achievement. Joey participated in an assessment, and Ms. Smith participated in a parenting protocol prior to beginning treatment for PTSD symptoms. A doctoral-level clinical psychology student completed all individual treatment sessions for both this young boy and his mother to address their PTSD symptoms while being supervised by a licensed psychologist.
3 History
Mother’s Social History
Ms. Smith indicated that she had a loving relationship with her family growing up but that she was particularly sensitive to criticism throughout her life. Ms. Smith met her ex-husband, Mr. Smith, when she was in her mid-20s. They were married when she was approximately 30 years of age and he was approximately 20 years of age. Ms. Smith noted that Mr. Smith was charismatic, assertive, smart, and charming and that he did not show any indicators early in their relationship that he may become violent. Nonetheless, shortly after Mr. and Ms. Smith were married, Mr. Smith began to demean Ms. Smith verbally, with these behaviors eventually escalating to physical and sexual perpetration. Mr. Smith ultimately disclosed a history of bipolar disorder to Ms. Smith. Ms. Smith noted that she had the courage to end her relationship with Mr. Smith because of her children.
After divorcing Mr. Smith, Ms. Smith and her two children moved in with her parents. Ms. Smith reported that Mr. Smith would come to the home unexpectedly and become verbally and physically aggressive in her children’s presence. Shortly after moving into her parents’ home, Ms. Smith’s mother also was diagnosed with cancer and died within 6 months of her diagnosis. Subsequently, Ms. Smith had a difficult time grieving her mother’s death. When Ms. Smith ultimately sought the treatment that is described in this case study, she lived with her two children and was participating in college courses to learn medical billing. Ms. Smith reported ongoing financial difficulties but received social support from her father and her younger sister.
Mother’s Medical History
Ms. Smith indicated that she felt tired and lethargic much of the time but that she still was managing her daily schedule of managing her children and her work. She also had high blood pressure and visible eczema. She reported a desire to obtain a full medical workup but did not pursue this workup during the treatment described here.
Mother’s Mental Health History
Ms. Smith had not been seen previously by any health service providers for her own symptoms or told anyone about the family’s history. As part of Joey’s assessment, Ms. Smith was re-exposed to her previous trauma when providing Joey’s history. Ms. Smith developed insight into her struggles via her participation in Joey’s assessment and through Circle of Security-Parenting, an eight-session DVD-based and attachment-focused parenting program that teaches parents how to best foster secure attachment with their young children and to reflect on how their history of being parented may be affecting their own parenting (Powell, Cooper, Hoffman, & Marvin, 2014).
Child’s Developmental History
Ms. Smith reported that her pregnancy with Joey was unplanned but welcomed and without complication. Joey was born via a Cesarean section following a full-term pregnancy. Joey weighed approximately 9-pounds 9-ounces at birth and was average in length. Ms. Smith indicated that Joey achieved his developmental milestones within normal limits. Joey bonded well with his caregivers in infancy, demonstrated appropriate reactions to gestures, and had good eye contact. Joey also was colicky, exhibited sleep problems, had difficulty adjusting to new people and situations, and was sensitive to sensory information.
Child’s Social History
Ms. Smith indicated that Joey had a loving relationship with her and could be “overprotective.” Joey generally had a loving relationship with his younger brother as well but could become jealous or impatient. Throughout his early childhood, Joey witnessed significant domestic violence between Mr. and Ms. Smith. After Ms. Smith left this relationship (when Joey was approximately 4 years of age), Joey only had contact with Mr. Smith via telephone about once per week. Joey reportedly had difficulty making friends but interacted with a number of children inside and outside of school.
Child’s Educational History
Joey began Voluntary PreKindergarten (VPK) at 4 years of age. When in kindergarten, Ms. Smith reported that Joey had “meltdowns,” would hit and call other children names, and was impulsive. With regard to academics, Joey’s performance declined as he moved from kindergarten to later grades. At the time of treatment, Joey was enrolled in second grade. He experienced difficulties establishing a strong relationship with his second grade teacher initially; however, Joey and his teacher grew closer (with consultation from the treatment team for this case). He ended the second grade with average grades. Several qualitative emotional and behavioral improvements were noted across the treatment.
Child’s Medical History
Ms. Smith reported that Joey experienced gastrointestinal problems beginning when he was 7 months of age. Joey was medicated for these difficulties and experienced subsequent “endocrinology difficulties” and consequent kidney difficulties. Furthermore, Ms. Smith reported that Joey was diagnosed with asthma when he was 2 years of age and used an inhaler on an as-needed basis. These medical issues likely contributed to Joey being difficult to care for during his infancy. Ms. Smith reported that Joey had seasonal allergies as well as some specific food allergies. When Joey was 7 years of age, he was diagnosed with accommodative dysfunction, convergence insufficiency, and ocular motility dysfunction.
Child’s Mental Health History
Ms. Smith reported that Joey was evaluated by an occupational therapist when he was 6 years of age and was diagnosed with sensory difficulties. He subsequently received 1 hr of occupational therapy per week and accommodations in his classroom. Another graduate student from the same team conducted a comprehensive assessment of Joey’s functioning. These findings are incorporated here in the “Child’s Assessment” section of this case study. Finally, Joey was monitored when pharmacological treatments were added by a child psychiatrist who worked closely with the team.
4 Presenting Complaints
The information provided in this case study is based on Ms. Smith’s report. Ms. Smith reportedly experienced severe and chronic verbal, physical, and sexual abuse by her husband, with this abuse worsening over the course of their relationship. From birth to 3 years of age, Joey witnessed the domestic violence that occurred between Mr. and Ms. Smith. With regard to Joey’s memories of these experiences, there is evidence suggesting that children as young as 3 years of age at the time of their trauma experiences were able to recall single traumatic events and in great detail. Furthermore, children who experienced trauma between 1½ and 3 years of age were able to provide accounts of their experiences, albeit in a more fragmented fashion (Fivush, 1998). Previous literature also suggested that single traumatic events resulted in detailed, vivid memories, whereas chronic repeated traumatic occurrences resulted in patchy, less-detailed memories (Terr, 1991). Consistently, Joey’s memories manifested in a blended trauma narrative.
Ms. Smith reported that Joey experienced intrusive flashbacks and nightmares of the trauma and displayed psychological distress in response to internal and external cues resembling the trauma. Avoidance behaviors became evident as well (e.g., Joey redirecting conversations when others wanted to speak about his father). Negative alterations in cognitions and mood also were evident, as evidenced by persistent and exaggerated negative beliefs about himself. Furthermore, Joey experienced hyperarousal (e.g., angry outbursts) and physiological reactions to trauma reminders (e.g., heavy breathing, racing heart). He also exhibited hypervigilance, exaggerated startle responses, sleep disturbances, and problems with concentration as well as social withdraw, worry about Ms. Smith dying, and somatic symptoms.
In addition to these PTSD symptoms, Ms. Smith reported that Joey was experiencing symptoms of oppositionality. Specifically, Joey disobeyed rules often, argued with adults, and lost his temper frequently. Ms. Smith reported that Joey often was annoyed easily, blamed others for his mistakes, was jealous easily, and was vindictive occasionally. Ms. Smith also reported that Joey threw toys when he was upset; hit, shoved, and made fun of other children often; had stolen toys from other children in his class; and sometimes lied.
Furthermore, Ms. Smith reported that Joey was exhibiting symptoms of inattention and hyperactivity. Specifically, Ms. Smith indicated that Joey had difficulty sustaining attention, was distracted easily, avoided tasks requiring attention, and was forgetful in daily activities. Ms. Smith also reported that Joey made a lot of careless mistakes, exhibited difficulty organizing tasks, and lost things often. Furthermore, Joey had difficulty remaining seated, fidgeted, ran excessively, and acted as if he was driven by a motor. Ms. Smith also reported that Joey was impulsive, interrupted adults, blurted out answers in class, and had difficulty waiting his turn.
Next, Ms. Smith reported that Joey voided urine nearly every night. As such, Joey wore pull-ups to bed each night. Ms. Smith reported that Joey did not appear to be distressed by his nighttime wetting and did not experience enuretic episodes during daytime hours. Finally, Ms. Smith reported that Joey exhibited symptoms associated with developmental delays. For example, Joey exhibited one-sided verbosity, sensory sensitivity, a lack of spontaneous seeking to share enjoyment, and difficulty developing and maintaining friendships. In contrast, Joey did not exhibit stereotyped mannerisms, echolalic speech, abnormalities in voice modulation, poor eye contact, social isolation, inflexibility, fixated interests, or a lack of make believe play.
Following Joey’s assessment, Ms. Smith disclosed her own symptoms, reporting that she demonstrated significant symptoms of hyperarousal, avoidance, negative cognitions and mood, and intrusive thoughts herself. For example, Ms. Smith noted that her heart raced, she felt anxious, and she had negative cognitions (e.g., “I’m not safe”) when she visited locations near where the trauma had occurred, when she spoke about the trauma, or when Mr. Smith contacted her. As a result, she indicated that she often engaged in avoidance. Ms. Smith also reported experiencing numbness during and following trauma exposure. In addressing Joey’s symptoms, Ms. Smith’s trauma was re-activated, thus resulting in other negative emotional states as well as frequent nightmares, agitation, problems with concentration, and hypervigilance.
5 Assessment
Child’s Assessment
Joey’s assessment consisted of behavioral observations, parent- and teacher-report measures, diagnostic interview, and measures of adaptive behavior, intelligence, and achievement. Each component is discussed below.
Mother and teacher reports of emotional and behavioral functioning
Ms. Smith completed the Child Behavior Checklist (CBCL) as an assessment of Joey’s functioning at home, and his teacher completed the Teacher Report Form (TRF) as a measure of his functioning in the classroom (Achenbach & Rescorla, 2001). These measures provide broad-band, narrow-band, and DSM-Oriented scores of children’s emotional and behavioral functioning. T-scores have a mean of 50 and a standard deviation of 10. For broad-band scales, scores that fall at 60 or higher are clinically noteworthy. For narrow-band and DSM-Oriented scales, scores that fall at 65 or higher are clinically noteworthy. Joey’s scores can be found in Table 1.
Child’s CBCL and TRF Ratings.
Note. CBCL = Child Behavior Checklist; TRF = Teacher Report Form; DSM = Diagnostic and Statistical Manual of Mental Disorders.
Indicates clinically meaningful scores.
On the CBCL, Joey’s Internalizing Problems, Externalizing Problems, and Total Problems scale scores fell within the clinical range. On the narrow-band scales, Joey’s Aggressive Behavior, Attention Problems, and Rule-Breaking Behavior scores fell within the clinical range, and his Thought Problems, Anxious/Depressed, and Somatic Complaints scores fell within the borderline range. On the DSM-Oriented scales, Joey’s Oppositional Defiant Problems, Conduct Problems, Obsessive-Compulsive Problems, Attention Deficit/Hyperactivity Problems, and Posttraumatic Stress Problems scores fell within the clinical range.
On the TRF, Joey’s Internalizing Problems, Externalizing Problems, and Total Problems scale scores fell within the clinical range. On the narrow-band scales, Joey’s Aggressive Behavior, Social Problems, and Anxious/Depressed scores fell within the clinical range, and his Attention Problems, Somatic Complaints, and Rule-Breaking Behavior scores fell within the borderline range. On the DSM-Oriented scales, Joey’s Posttraumatic Stress Problems, Oppositional Defiant Problems, Obsessive-Compulsive Problems, Somatic Problems, and Attention Deficit/Hyperactivity Problems scores fell within the clinical range, and his Conduct Problems and Anxiety Problems scores fell within the borderline range.
Psychological symptoms
The Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime Version (K-SADS; Kaufman & Schweder, 2004) was administered to Ms. Smith for further assessment of Joey’s symptoms. The K-SADS is a semi-structured diagnostic interview designed to assess past and current experiences of psychological symptoms in children and adolescents based on criteria in the DSM-IV-TR (APA, 2000). Criteria from the DSM-5 (APA, 2013) also were considered. These symptoms were discussed above.
PTSD symptoms
Ms. Smith also completed the Young Child PTSD Checklist (YCPC; Scheeringa, 2013) at baseline and throughout treatment to monitor Joey’s progress. Young children are rated on 23 items assessing PTSD symptoms and six items assessing level of impairment. To suggest a probable diagnosis of PTSD, the PTSD Symptoms Scale has a cutoff score of 26, and the Functional Impairment Scale has a cutoff score of 4. At baseline, Joey’s PTSD Symptoms score was 46, and his Functional Impairment score was 23 (see Table 2).
Child’s YCPC Scores.
Note. Cutoff score for PTSD Symptoms = 26; cutoff score for Functional Impairment = 4. YCPC = Young Child PTSD Checklist; PTSD = posttraumatic stress disorder.
Adaptive functioning
The Vineland Adaptive Behavior Scales–Second Edition (VABS; Sparrow & Cicchetti, 1989) survey form was used to measure Joey’s adaptive behavior. Each of the scores on the VABS has a mean of 100 and a standard deviation of 15. Joey’s score on the Adaptive Behavior Composite fell within the adequate range of adaptive functioning. There were some significant discrepancies among Joey’s domain scores, however. In particular, Joey’s scores on the Communication, Daily Living Skills, and Motor Skills Domains fell within the Adequate range, whereas his Socialization Domain fell within the moderately low range.
Psychoeducational testing
To measure Joey’s intellectual functioning, he was administered the Wechsler Intelligence Scale for Children–Fourth Edition (Wechsler, 2003), an assessment of intelligence for children who are 6 to 16 years of age. Standard scores have a mean of 100 and a standard deviation of 15. Joey’s Full Scale Score fell within the high average range. Joey’s Verbal Comprehension Index (VCI) and Perceptual Reasoning Index (PRI) scores were significantly higher than his Working Memory Index (WMI) and Processing Speed Index (PSI) scores, however. Specifically, his VCI score fell within the very superior range, his PRI score fell within the superior range, and his WMI and PSI scores fell within the average range.
To measure Joey’s academic achievement, he was administered the Woodcock-Johnson Tests of Achievement–Third Edition (Woodcock, McGrew, & Mather, 2001). Each cluster score is based on a standard score that has a mean of 100 and a standard deviation of 15. Joey’s Total Achievement score fell within the average range. Joey’s Broad Reading, Broad Math, Broad Written Language, Oral Language, and Academic Skills scores all fell within the average range.
Mother’s Assessment
Ms. Smith’s assessment consisted of intake and clinical interviews as well as self-report measures. Each component is discussed below.
Emotional and behavioral functioning
Ms. Smith completed the Adult Self-Report 18-59 (ASR; Achenbach, 2009) as an assessment of her own functioning. This measure provides broad-band, narrow-band, and DSM-Oriented scores regarding the emotional and behavioral functioning of adults. T-scores on these scales have a mean of 50 and a standard deviation of 10. For broad-band scales, scores that fall at 60 or higher are clinically noteworthy. For narrow-band and DSM-Oriented scales, scores that fall at 65 or higher are clinically noteworthy (see Table 3). Ms. Smith’s Internalizing Problems and Total Problems scale scores fell within the clinical range, but her Externalizing Problems scale score fell within the nonclinical range. On the narrow-band scales, her Anxious/Depressed and Intrusive scores fell within the clinical range, and her Attention Problems score fell within the borderline range. On the DSM-Oriented scales, Ms. Smith’s Anxiety Problems and Avoidant Personality scores fell within the clinical range, and her Depressive Problems score fell within the borderline range.
Mother’s ASR Ratings.
Note. ASR = Adult Self-Report; DSM = Diagnostic and Statistical Manual of Mental Disorders.
Indicates clinically meaningful scores.
Psychological symptoms
An intake interview was completed regarding Ms. Smith’s symptoms following the completion of Joey’s assessment. These interviews confirmed a history of traumatic experiences as well as other anxiety and depressive symptoms for Ms. Smith.
PTSD symptoms
Ms. Smith also provided ratings of her PTSD symptoms via the PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL is a 17-item self-report measure assessing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994) symptoms of PTSD. The suggested PCL cutoff score for specialty mental health care clinics is 50 (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996). At baseline, Ms. Smith’s PCL total score was 63, and her difficulties spanned all three symptom clusters. Ms. Smith also completed the PCL during and after treatment (see Table 4).
Mother’s PCL Scores.
Note. Cutoff score for PCL in mental health clinics = 50. PCL = PTSD Checklist; PTSD = posttraumatic stress disorder.
6 Case Conceptualization
Child’s Diagnoses
PTSD
The information gathered showed that Joey met diagnostic criteria for PTSD based on the DSM-5 (APA, 2013). For older children, the primary features are similar to those seen in adults. The DSM-5 (APA, 2013) now includes “PTSD for Children 6 Years and Younger.” Features of PTSD in young children include anger outbursts, social withdrawal, inability to verbalize the trauma, loss of previously acquired developmental skills, and new symptoms of aggression, separation anxiety, and other anxieties (Scheeringa et al., 2003). Young children also can exhibit repetitive play, experience nightmares, or experience somatic symptoms more frequently. The course of PTSD in young children is chronic.
Oppositional defiant disorder (ODD)
In addition, Joey met criteria for ODD (APA, 2013). The primary features of ODD include angry and irritable moods, argumentative and defiant behavior, and vindictiveness. These symptoms manifest as temper tantrums, being easily annoyed, arguing with authority, annoying people deliberately, blaming others for mistakes, refusing to comply with requests, disobeying rules purposefully, and being spiteful (APA, 2013). ODD usually has an onset of preschool age. The average prevalence rate of ODD is 3.3% (APA, 2013). This disorder is more prevalent in males than females and occurs more frequently in children who witness marital discord and parent psychopathology (APA, 2000) or who experience inconsistent, neglectful, and harsh parenting (APA, 2013).
Although oppositionality can sometimes be a symptom of PTSD if symptom onset follows a trauma, Joey’s symptoms of oppositionality appeared to be over and above what could be accounted for by his PTSD diagnosis. As a result, Joey’s symptoms warranted a diagnosis and were targeted and monitored throughout treatment. Furthermore, Ms. Smith participated in Circle of Security–Parenting (Powell et al., 2014) to build a stronger connection with Joey.
Attention deficit/hyperactivity disorder (ADHD)
Joey also met criteria for ADHD, combined type. The three subtypes of ADHD are the Predominantly Inattentive Presentation, Predominantly Hyperactive/Impulsive Presentation, and Combined Presentation. Inattentive symptoms include making careless mistakes, having difficulty sustaining attention, not listening, having difficulty following instructions, failing to finish work, having difficulty organizing tasks, avoiding work that requires sustaining mental effort, losing things, being distracted easily, and being forgetful (APA, 2013). In contrast, hyperactive/impulsive symptoms include fidgeting, having difficulty remaining seated, running or climbing in inappropriate settings, being unable to play quietly, being unable to stay still for extended time, talking excessively, blurting out answers, interrupting others, and having difficulty waiting to take a turn (APA, 2013). The combined subtype includes symptoms in both of these domains.
ADHD often is observed and reported first by parents when they notice excessive motor activity in their toddler, but ADHD is identified more typically during elementary school when demands increase for remaining seated and paying close attention in class (APA, 2013). The prevalence of ADHD is 5% in children (APA, 2013). The etiology of ADHD is unclear; however, several environmental variables (e.g., history of child abuse or neglect) and temperament characteristics (e.g., reduced behavioral inhibition, negative emotionality) have been implicated. ADHD also is quite heritable (APA, 2013). Relevant to Joey’s presentation, longitudinal research indicated that ADHD is a risk factor for PTSD (Biederman et al., 2014), and children with comorbid ADHD and PTSD exhibit more severe psychosocial dysfunction and impairment (Biederman et al., 2013). Ms. Smith and Joey’s teachers employed several behavioral techniques to help Joey manage his ADHD symptoms in the classroom.
Enuresis
Finally, Joey was diagnosed with primary enuresis, nocturnal only (APA, 2013). Symptoms of enuresis include repeated voluntary or involuntary voiding of urine into clothing or the bed. Individuals must be at least 5 years of age to be diagnosed with the disorder, and the symptoms must be present for 3 consecutive months with a frequency of at least twice per week. Primary enuresis is designated when children never established urinary continence, whereas secondary enuresis is designated when children develop enuresis following a prolonged period of established urinary continence. The nocturnal subtype is the most common form of enuresis, in which the individual voids urine during sleep, whereas the diurnal subtype is more commonly known as true urinary incontinence and occurs when the individual is awake. The nocturnal-diurnal subtype describes the occurrence of symptoms during nighttime sleep and during the daytime (APA, 2013). Prevalence rates vary by age (APA, 2013).
Etiological research indicated that nocturnal enuresis is genetically heterogeneous, although heritability was demonstrated through family studies. Enuresis also was associated with reduced bladder capacity, bladder hyperreactivity, and altered circadian rhythms (APA, 2013). Approximately 5% to 10% of children experience spontaneous remission each year following diagnosis of enuresis (APA, 2013). This was true for Joey. Ms. Smith was encouraged to consult a pediatrician if Joey experienced any recurrence or exacerbation of these symptoms.
Autism spectrum disorder (ASD)
Although Ms. Smith indicated concern regarding some symptoms of ASD for Joey, he did not meet criteria for an ASD.
Mother’s Diagnosis
PTSD
Ms. Smith met diagnostic criteria for PTSD based on the DSM-5 (APA, 2013). In adults, the primary features of PTSD are intrusion symptoms, persistent avoidance of trauma reminders or thoughts, negative and maladaptive cognitions or emotions associated with the trauma, and hyperarousal symptoms (APA, 2013). Typically, PTSD symptoms generally worsen in response to reminders of the trauma, new traumatic events, or other life stressors (APA, 2000, 2013) For this mother, traumatic reminders included disclosing details about the trauma during her son’s assessment, living near the location of the trauma, and needing to be in contact with her son’s father. Maintenance factors also included the death of her mother, financial difficulties, and single parenthood.
Summary
Based on assessment findings, it was evident that both Joey and Ms. Smith required treatment for their PTSD symptoms. Given that Joey would need help and support from Ms. Smith when discussing exposure exercises and given that she also met criteria for PTSD, these circumstances presented an even greater need for Ms. Smith to receive treatment for her own symptoms. Given that Joey’s chronological age placed him at the cusp of “young” versus “school age,” an integrative approach was taken with regard to his treatment. Specifically, certain aspects of PPT (Scheeringa et al., 2010) and TF-CBT (Cohen et al., 2006) were used. So that Ms. Smith could process the thoughts and feelings associated with the family’s trauma in a more adaptive and accurate way, the CPT manual (Resick & Schnicke, 1993) was used for her.
7 Course of Treatment and Assessment of Progress
Ms. Smith completed CBCLs and YCPCs to monitor Joey’s progress as well as ASRs and PCLs at baseline and at multiple time points to monitor her own progress. Homework assignments were given across sessions. Joey and Ms. Smith’s sessions are outlined in Table 5.
Summary of Sessions.
Note. PTSD = posttraumatic stress disorder; SUDS = Subjective Units of Distress; STOP = Signals, Take a deep breath, Options, Pick the right choice; ABC = Activating Events, Beliefs, and Consequences.
Child’s Treatment
Session 1 (60 min)
Joey’s first session focused on establishing rapport and treatment orientation. Joey was asked to complete a worksheet including the prompt: “The scary thing that happened to me was . . .” Although reluctant, Joey wrote, “My dad yelling on a scale of 0 to 100 at 50!” At the end of the session, Ms. Smith noted that she had a hard time with the YCPC because of her own trauma and avoidance behaviors.
Session 2 (60 min)
The second session was used to discuss physiological signals of distress. Next, Joey was introduced and oriented to using SUDS for anxiety. See Figure 1 for Joey’s SUDS ratings. He then created a basic hierarchy of anxieties. Psychoeducation about PTSD was provided. Finally, due to Joey’s impulsivity and aggression, he was taught the STOP technique: Signals, Take a deep breath, Options, Pick the right choice.
Child’s Subjective Units of Distress ratings by session.
Session 3 (60 min)
The purpose of the third session was to complete a trauma narrative with Joey. First, previously learned coping skills were reviewed. Joey also was taught progressive muscle relaxation. When prompted to begin his trauma narrative, Joey became avoidant but participated eventually. He then constructed a hierarchy of his traumatic experiences, ranging from his father storming off to his father yelling loudly.
Session 4 (60 min)
During the fourth session, Joey’s knowledge of cognitive-behavioral theory was expanded via the Thoughts–Feelings–Behaviors Triangle. Joey also was informed that a new goal of treatment would be to find a new way to think about his trauma.
Session 5 (60 min)
The purpose of the fifth session was to begin cognitive restructuring regarding Joey’s indirect reminders of his trauma. In the session, Ms. Smith noted that Joey had an entire week of “green” (i.e., good) behavior at school, with no bad notes home.
Session 6 (60 min)
The purpose of the sixth session was to conduct exposures and cognitive restructuring with Joey regarding direct reminders of his trauma. Despite some avoidance, Joey drew the item listed on the bottom of his hierarchy. A comic strip layout was used, and Joey was asked to describe the content, thoughts, and intensity of the emotions that he was experiencing during the trauma depicted. Next, cognitive restructuring was used. During the session, Joey’s SUDS peaked at 50 but returned to baseline as Joey practiced coping skills.
Session 7 (60 min)
The purpose of the seventh session was to continue exposure and cognitive restructuring for Joey’s trauma. Joey drew his least scary reminder of the trauma again in comic strip form. Joey noted that he incorporated coping skills learned in therapy as he re-storied his narrative to down regulate his negative emotions. During the session, Joey’s SUDS peaked at 25% and returned to baseline by practicing coping skills.
Session 8 (60 min)
The goal of the eighth session was to continue exposure and cognitive restructuring. Joey began the session by indicating, “I’m gonna draw a part of the story I haven’t talked about yet.” Joey drew a more detailed narrative. Joey’s SUDS peaked at 10%. Joey’s SUDS decreased as he revisited the story by providing his emotions and thoughts.
Session 9 (60 min)
The general emphasis of Session 9 was to continue exposure and cognitive restructuring with Joey given his recent exploration of his scariest trauma reminder. Joey drew the sequence of his trauma quickly, and his SUDS peaked at 10% and decreased to 0% by the end of the drawing. In an effort to restructure Joey’s thoughts surrounding the trauma, he described coping skills that he could use in future situations.
Session 10 (60 min)
The purpose of this session was to enhance Joey’s success in future situations that may trigger him or cause him distress. He was encouraged to draw a story of how he would like for situations to unfold in the future. Joey provided several examples of alternative thoughts and positive self-talk that he could use if he was reminded of his trauma.
Session 11 (60 min)
The 11th session was used for safety planning with Joey. To begin, innocuous safety guidelines unrelated to Joey’s trauma were discussed. Next, Joey listed initial signs of danger that were related to his trauma. To complete a safety plan, he listed steps that would make the situation less dangerous for him.
Session 12 (60 min)
The purpose of the 12th session was to enhance future safety with Joey. The clinician listed several additional safety measures including communicating feelings and desires openly, paying attention to gut feelings, identifying people and places that provide safety, learning “okay” versus “not okay” touches, and asking for help.
Session 13 (60 min)
The 13th session was spent reviewing Joey’s progress. Occasionally, Joey was paused to process the thoughts and emotions that he was experiencing as he reviewed his work. Joey provided a “happy ending” to his story. He described advice that he would give to other children who experienced trauma. Joey’s progress was celebrated.
Mother’s Treatment
Session 1 (90 min)
The purpose of the first session was to establish rapport with Ms. Smith and conduct a clinical interview regarding her current symptoms. Ms. Smith was encouraged to share her traumatic experiences to the degree that she was comfortable.
Session 2 (120 min)
The purpose of this session was to provide psychoeducation about PTSD and to introduce and orient Ms. Smith to cognitive-behavioral theory. Stuck Points were introduced as cognitive distortions that cause distress and maintain PTSD symptoms. Ms. Smith also provided a brief account of her most severe trauma. For homework, Ms. Smith was asked to write an impact statement (i.e., trauma narrative) describing her trauma and its impact.
Session 3 (120 min)
In the third session, Ms. Smith read aloud her impact statement. An emphasis was placed on processing the emotions that Ms. Smith experienced while writing and then reading aloud the statement. Next, stuck points were identified in Ms. Smith’s impact statement. The ABC sheet was introduced to Ms. Smith to help identify Activating Events, Beliefs, and Consequences. Ms. Smith also was provided with an emotion handout to help identify, to label emotions, and to practice examples in preparation for similar homework.
Session 4 (120 min)
The purpose of this session was to review Ms. Smith’s ABC homework to identify specific thoughts that caused distressing emotions. Next, an ABC sheet about Ms. Smith’s traumatic experiences was completed. Socratic questioning was used to challenge Ms. Smith’s maladaptive inaccurate beliefs. For homework, Ms. Smith was instructed to write a detailed impact statement of her worst trauma and to read the account every day.
Session 5 (120 min)
During this session, Ms. Smith read her entire impact statement aloud. Next, Socratic questioning was used to challenge stuck points identified in Ms. Smith’s narrative. Blame and responsibility also were discussed. To conclude the session, Ms. Smith’s ABC sheets were reviewed. For homework, she was asked to write another more detailed impact statement of her worst trauma, to read it daily, and to complete ABC sheets daily.
Session 6 (120 min)
This session’s purpose was to have Ms. Smith read the second version of her impact statement aloud. Afterward, Ms. Smith’s thoughts and feelings were processed with regard to both writing and reading the narrative. Next, Ms. Smith’s ABC sheets were reviewed. Finally, the Challenging Questions worksheet was introduced so that Ms. Smith could use Socratic questioning herself to reduce negative emotions.
Session 7 (120 min)
The emphasis was on processing emotions that Ms. Smith had while reading her impact statement and identifying additional stuck points. The Challenging Questions worksheet was used to challenge these stuck points, and values clarification was used to identify why Ms. Smith may have been stuck in certain places. For homework, Ms. Smith was to complete Challenging Questions worksheets, write another impact statement, and read it daily.
Session 8 (120 min)
This session was used to read Ms. Smith’s impact statement, to review her Challenging Questions worksheets, and to introduce a list of Patterns of Problematic Thinking. To begin the session, Ms. Smith indicated that she had found an old account of her trauma experiences that she had written when she first separated from her husband. Ms. Smith chose to hand write important phrases from this document and read them aloud in session. Next, Ms. Smith’s Challenging Questions worksheets were reviewed. Given that Ms. Smith indicated that she was experiencing some distress and avoidance while writing her impact statement, she was instructed to write her impact statement one more time in great detail. Homework also included completing the Problematic Patterns of Thinking worksheet.
Session 9 (120 min)
The ninth session was used to review Ms. Smith’s final impact statement, to review her Patterns of Problematic Thinking worksheet, and to introduce the Challenging Beliefs worksheet. The Challenging Beliefs worksheet was introduced to aid in identifying situations, maladaptive thoughts, and emotions; to use challenging questions to examine the automatic thoughts identified; to determine if these thoughts were consistent with any problematic patterns of thinking; to generate alternative adaptive thoughts; to re-rate how much Ms. Smith still believed in the original maladaptive thought; and to identify the resulting emotion. For homework, Ms. Smith was instructed to complete her final impact statement, to complete several Challenging Beliefs worksheets, and to review safety issues following trauma.
Session 10 (120 min)
The purpose of this session was to read aloud Ms. Smith’s final impact statement, review her Challenging Beliefs worksheets, and discuss stuck points related to safety. When Ms. Smith read aloud her final statement, she labeled her and her son’s experiences explicitly as domestic violence and child abuse for the first time. For homework, Ms. Smith was asked to complete Challenging Beliefs worksheets for any distress that arose.
Session 11 (120 min)
This session was used to discuss how Ms. Smith’s trust had been disrupted by trauma. Ms. Smith did not complete any Challenging Beliefs worksheets because she did not experience any maladaptive thoughts or distressing feelings since the last session. Ms. Smith was introduced to the idea of different types of trust. For homework, Ms. Smith was given handouts on power, control, and self-esteem issues.
Session 12 (120 min)
The purpose of this session was to review Challenging Beliefs worksheets and to discuss remaining issues regarding power, control, and self-esteem. For homework, Ms. Smith was given a handout about intimacy issues after trauma. She was instructed to complete Challenging Beliefs worksheets for safety, trust, power/control, esteem, and intimacy. Finally, she was asked to write a final impact statement.
Session 13 (120 min)
This session had several purposes. First, Ms. Smith’s Challenging Beliefs worksheets were reviewed. Next, issues with intimacy were discussed, and stuck points were challenged. As Ms. Smith indicated that her schedule did not allow for her to complete her impact statement at home, Ms. Smith wrote her 1-page impact statement and read it aloud in session. To conclude, Ms. Smith was reminded of the stuck points that she had overcome and how she demonstrated treatment gains. Completion of treatment was discussed.
8 Complicating Factors
One main complicating factor for this case was that both this young boy and his mother were diagnosed with PTSD. If only one of them had received treatment for PTSD, gains in the one treated family member may not have been as great because the untreated family member’s symptoms likely would not have improved (Woods, 2005). Thus, this case demonstrated how more than one family member could be treated simultaneously.
An additional complicating factor was that Joey was diagnosed with ODD and ADHD in addition to PTSD. Joey’s presentation of avoidance coupled with these other symptoms made exposure activities difficult to complete at times. Overall, Joey’s presentation required a careful balance between disallowing avoidance behaviors during exposures while still making activities enjoyable and engaging so that progress could be made. In an effort to provide comprehensive and integrated care, medical management was discussed with Ms. Smith to remediate Joey’s difficulties with inattention, hyperactivity, and impulsivity. As such, Joey was followed by a child psychiatrist who worked closely with the treatment team and who decided to not prescribe medication to Joey initially. Over time, it became clear that many of Joey’s symptoms were not trauma-related and were severe enough to warrant their own treatment, however. As a result, Joey was prescribed Guanfacine and began taking this medication after Session 11.
Finally, Joey chose not to incorporate his experience of physical abuse in his trauma narrative or hierarchy. This reluctance confirmed previous literature indicating that, when trauma is experienced at very young ages (i.e., before the age of 3 years; Fivush, 1998) and is chronic and repeated in nature (Terr, 1991), memories tend to be patchy and less detailed. In fact, Ms. Smith confirmed that Joey’s trauma narrative blended at least two distinct but similar events of violence in the home. Regardless of the clarity of his memories, Joey benefited from cognitive restructuring, positive self-talk, and safety planning in the context of his trauma.
9 Access and Barriers to Care
Access to care in this case was relatively good. In particular, Joey and Ms. Smith’s treatment services were very inexpensive and did not require insurance reimbursement because they were provided at a training clinic. Nonetheless, Joey and Ms. Smith traveled approximately 1 hr each way to and from the training clinic. Further, Ms. Smith made this trip twice per week for her young son and herself to receive services. Not only did these trips take a significant amount of time, financial costs included gasoline and tolls as well as child care when Ms. Smith had her individual appointments. Although financial difficulties did not result in missed appointments, child care barriers sometimes resulted in rescheduled appointments and inconsistent timing of sessions. Such an arrangement may be difficult for community providers.
Although there were relatively few barriers to care in this case study, several general barriers could hinder treatment for families with multiple members who have been diagnosed with PTSD. For example, very few clinics in the community offer evidence-based treatments at free or reduced cost. Families without financial resources, insurance, or reliable transportation are at an extreme disadvantage and may find it difficult to obtain services. Another barrier to care involves the belief of some providers that trauma is not remembered when experienced at young ages (Feldman & Vengrober, 2011), despite documentation that even young children remember and experience subsequent difficulties following trauma (Fivush, 1998; Terr, 1991). Finally, families’ access to clinicians with specialized training in infant mental health and treatment of young children may be limited.
10 Follow-Up
Child’s Improvements
To evaluate Joey’s functioning, Ms. Smith completed CBCLs at pre- and posttreatment. Joey’s scores on the CBCL trended downward and showed several improvements. In particular, Joey’s Internalizing, Externalizing, and Total Problems scores decreased, although they remained clinical. Joey’s Attention Problems, Rule-Breaking Behaviors, Somatic Complaints, and Aggressive Behaviors narrow-band scores also decreased. Joey’s Somatic Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problems DSM-Oriented scores all fell below the clinical range (see Table 1).
In addition, Joey’s PTSD symptoms were monitored via Ms. Smith’s reports on the YCPC. Overall, Joey’s scores on the PTSD Symptoms subscale of the YCPC trended downward and decreased from above to below the clinical cutoff score of 26. Nonetheless, Joey’s Functional Impairment score on the YCPC remained above the clinical cutoff score of 4 (see Table 2). This pattern was not surprising, given that there was some overlap of symptoms between items assessed with this score and impairment from Joey’s ODD and ADHD symptoms. Although PPT provides a module to address oppositionality in young children, it does not provide a full protocol to treat ODD symptoms, and it does not address ADHD symptoms.
With regard to Joey’s qualitative improvements, it was noted that his grades and behavior at the end of his second grade year improved. Ms. Smith also reported that the intensity and severity of Joey’s tantrums and negative reactions were reduced. Of particular importance was Ms. Smith’s report that Joey began to self-regulate and use coping skills in situations that previously would have been overwhelming and distress-provoking for him. Joey’s social functioning also improved greatly over the course of treatment. In fact, Ms. Smith reported that Joey attempted to teach his friends some of the skills learned in treatment when he noticed them becoming upset. Joey’s relationship with his brother and Ms. Smith also improved.
Mother’s Improvements
Overall, the trends of scores on Ms. Smith’s ASRs demonstrated improvement in her functioning. In particular, Ms. Smith’s Internalizing and Total Problems scores decreased below the clinical range. Ms. Smith’s Anxious/Depressed and Intrusive narrow-band scores as well as her Anxiety Problems and Avoidant Personality Problems DSM-Oriented scores fell below the clinical range (see Table 3). Ms. Smith also completed PCLs throughout treatment to monitor and evaluate treatment gains, with her PCL scores declining over the course of treatment (see Table 4).
In addition to quantitative improvements in Ms. Smith functioning, many things suggested clinically significant improvements in her functioning. In particular, Ms. Smith experienced increased understanding of herself, improved mood, and decreased anxiety with treatment. Ms. Smith was able to recognize her stuck points quickly and challenge them with more adaptive and accurate thoughts. She also began to frame herself as a survivor who overcame many hardships. Finally, she reported a decrease in her avoidance behaviors, distress at trauma reminders, physiological arousal, and frequency of nightmares.
11 Treatment Implications of the Case
This case study demonstrated how evidence-based treatments for children (i.e., PPT, TF-CBT) and adults (i.e., CPT) can be implemented concurrently with a young boy and his mother who were both diagnosed with PTSD. Given that domestic violence affects not only the targeted individual but also child witnesses, given the prevalence of PTSD in both children and parents following exposure to domestic violence (Scheeringa et al., 2015), and given the adverse psychosocial outcomes of children and adults following untreated family trauma (Nathanson et al., 2012), coordinated treatment is particularly important. The importance of treating all family members exposed to domestic violence also was highlighted by findings suggesting that mothers’ PTSD symptoms following domestic violence affected parenting behaviors (Ammerman et al., 2012; Schechter et al., 2010) and children’s functioning (Gewirtz et al., 2011; Levendosky & Graham-Bermann, 1998). Furthermore, parent participation and support is integral in young children’s treatment of PTSD. If parents also are exhibiting symptoms of PTSD following trauma, such symptoms may impair their ability to facilitate their young children’s treatment effectively. In fact, child PTSD treatment manuals recommend individual treatment for parents if they also are struggling in the aftermath of trauma (Cohen et al., 2006; Scheeringa et al., 2010).
12 Recommendations to Clinicians and Students
A goal of the current case study was to provide a framework for health service providers to implement concurrent treatment for young children and their parents who both were traumatized by domestic violence. Although evidence-based treatments often provide structured manuals that delineate activities session-by-session, health service providers should allow for flexibility given clients’ ages, ability levels, and symptoms. Furthermore, the manner in which exposure techniques are implemented in both PPT/TF-CBT and CPT should be considered carefully. In other words, the purpose of exposure should be to decrease emotional distress caused by maladaptive beliefs associated with traumatic memories and indirect trauma reminders, while allowing for a healthy degree of discomfort with domestic violence to maintain safety and prevent revictimization.
Next, there are several unique challenges present when working with families who have a history of trauma. For example, when treating both a young child and his parent, issues with cross-contamination across parties should be considered. In addition, health service providers may wish to include conjoint parent–young child sessions once the parent’s PTSD symptoms have been reduced sufficiently and will not interfere with the young child’s treatment. If such sessions are included, health service providers should spend time with the parent planning and preparing appropriate reactions and discussion topics for the promotion of treatment gains.
Finally, the parent–young child relationship is of great importance when treating families. Of course, it is recommended that health service providers have knowledge of trauma in general; however, experience with domestic violence and child abuse would be particularly important given the unique nature of these experiences and their attachment implications. Overall, specialized training and continued consultation are paramount when providing treatments for domestic violence in families.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.