Literature Review

Traumatic experiences in childhood have well-documented negative impacts on child development. Trauma is related to behavioural and emotional difficulties in children (Fletcher, 2003) and to the later development of a variety of adult disorders, including depression, anxiety, health problems and antisocial behaviours (Felitti et al., 1998; Widom et al., 1997; Widom et al., 2006).

Ironically, these adult outcomes are, in turn, related to greater risk of trauma for the next generation (Whitfield et al., 2003). As a result, intergenerational cycles of trauma are unintentionally promoted within the family (Cicchetti et al., 2006; Hughes, 2003; Leifer et al., 2004; Sroufe, 1996; Wiseman et al., 2006).

Although there are a number of empirically validated treatment models for children exposed to specific traumatic events, these models generally fail to address intergenerational patterns of trauma transmission. Treatments are typically centered on the child, with the parent involved peripherally and/or optionally in education programs on trauma and on their children’s ongoing progress in treatment.

The current study examines a model of treatment of childhood trauma that focuses first on interrupting intergenerational transmissions of trauma through education and treatment of children’s caregivers’ unresolved traumatic events from their own childhood, and then on dyadic treatment of child trauma where caretakers are placed in the expert role with respect to their child. Hence, caregivers are involved throughout each session of the ITTM (unless otherwise indicated).

There are a number of good reasons to pursue such a model of treatment:

1. Caregivers suffering from unresolved trauma may unintentionally act out this distress on their children, increasing child vulnerability to problem behavior and symptoms, and risk for exposure to trauma.

Research has clearly demonstrated that elevated trauma symptoms in adults are related to deficits in parenting. Childhood experiences of abuse and neglect are related to deficits in maternal sensitivity and responsiveness and to the development of insecure and disorganized infant attachment (Cicchetti et al., 2006). As children get older, these parents are more likely to have developmentally inappropriate expectations of their children, to be harsh with their children and to interpret child misbehaviour as intentional.

In addition to deficits in parenting, unresolved trauma in caregivers heightens risk that their children will themselves be exposed to traumatic events. Processes of intergenerational trauma transmission were first studied among children of victims of the holocaust. Intergenerational patterns of trauma transmission have also been found among victims of sexual abuse, with children of sexually abused parents more likely to themselves be victims of a sexually abusive trauma due to parents’ latent cooperation with the abuser or blindness to the dangers of situations to which they expose their children (Lev-Wiesel, 2006).

2. Caregiver functioning has a considerable impact on children’s ability to cope with potentially traumatic events.

There is agreement in the trauma literature that family functioning is important in both the development of symptoms and the outcome of the traumatized child. For example, after a natural disaster, separation from parents, maternal preoccupation and altered family functioning were more predictive of symptom development than were exposure to trauma or loss.

Moreover, caregivers with a history of unresolved trauma are likely to be particularly unequipped to help their children manage and regulate their distress and adapt successfully to potentially traumatic events. As a result, children’s whose parent(s) were previously traumatized are more likely to experience trauma symptoms following exposure to trauma than children of parents who without histories of trauma (Nader, 1998).

3. Treatment outcomes for childhood problems are improved when parents are involved.

A third reason to involve parents more fully in trauma treatments concerns the impact of such involvement of treatment outcomes. In the past few years, there has been increased recognition of the importance of caregiver involvement in mental health services for children.

A recent meta-analysis of the impact of parent participation on intervention outcome found that combined parent-child/family therapy treatment, or a parent-only treatment groups showed greater impact on children than child treatment alone (effect size =.25; Dowell, 2005).

Studies have also shown that, for some childhood problems, parent treatment alone is as effective as treating the child. For example, Thienemann, Moore, and Tompkins (2006) found that children diagnosed with an anxiety disorder showed significant improvement on parent- and clinician-rated measures following treatment of parents only. Results such as these have lead to the publication of practice guidelines recommending that parents and families be included in children’s treatment (e.g., American Psychiatric Association, 1998).

4. Reduction in caregiver trauma symptoms may be a key mechanism of change for traumatized children.

Although there is a general recommendation for increased parent involvement in treatment for childhood problems, such recommendations are only partially supported in the literature on child post-traumatic stress disorder. For example, Deblinger et al. (1996) reported that, compared to child only interventions, parent-child interventions resulted in significantly greater decreases in parental assessments of their child’s externalising behaviour, greater improvements in their own parenting skills and lower rates of child reported depression. In contract, results of a number of other well-controlled studies find that childhood trauma can be treated by providing services to children alone (Stein et al., 2003, March et al., 1998).

Conflicting results may be due to differing conceptualizations of parental involvement. In a review of the literature in this area, Stallard (2006) points out that definitions of parental involvement have varied across studies. In some programs, parents attend parallel sessions as children to learn about the impact of trauma. In others, training parents in behavioral management skills or reducing maladaptive beliefs and attributions has been a large part of intervention.

We propose that, to be more effective, caregivers’ involvement in their children’s trauma-related therapy must address patterns of intergenerational trauma transmission with caregivers on their own first. In other words, as part of treatment for their child, parents must receive intervention to reduce their trauma-related symptoms of depression, anxiety, hyper-arousal, and traumatic-re-experiencing.

Resolution of these symptoms is a critical precursor of the caregiver being able to help their own child contain and adaptively cope with trauma-related distress. Moreover, improvements in the emotional functioning of the parent is likely to lead to greater emotional attunement to the child and higher levels of empathy, which in turn, are likely to lead to further improvements in children’s functioning.

In summary, there is growing support for the need to involve parents in treatment for children’s problems in general. When children have experienced a traumatic event investigation and resolution of unresolved trauma in their caretakers may be even more critical.

The Intergenerational Trauma Treatment Model (ITTM) is a multigenerational approach to trauma treatment that incorporates caregiver trauma treatment into the 21-session structure. The ITTM also strengthens the parent-child relationship by increasing the motivation and skills within the caregiver to be the expert for their child and to effectively help their children cope with the effects of trauma exposure (see Appendix A for a full description of the treatment model).

The ITTM utilizes many therapeutic strategies proven to be efficacious with this population including cognitive restructuring, guided exposure, and education on the impact and course of trauma. However, ITTM differs in three important ways from currently available treatments for child trauma:

  • Caregivers are provided with a series of group-based educational, individual, and dyadic treatment sessions.
  • Treatment directly addresses caregivers’ traumatic experiences and resulting impact on the parent-child relationship, and the strength of that relationship with resolution of caregivers’ issues deemed critical to change in children’s emotional and behaviour symptoms.
  • Caregivers’ role as guide of child is preserved by teaching caregivers to act as “co-therapist” to the child rather than assigning this expertise to the therapist, which is important to strengthen parent-child attachment.

Pilot research on the ITTM using has established preliminary evidence for the efficacy of this intervention approach (Copping, 2001). A pilot study of this program was undertaken at a child mental health clinic in Hamilton.

Fifty two families who were receiving ITTM therapy were recruited. Families completed the Trauma Intake Questionnaire to assess children’s past experience of trauma and the Standard Client Information System (SCIS) to assess children’s conduct disorder, oppositionality, attention deficit disorder, separation anxiety disorder, depression, anxiety, and social relationship, caretaker depression and family functioning relating to the caregiver. The SCIS also included a wide range of descriptive and historical information designed to complement the clinical assessment process.

Among twenty seven families, completion of the ITTM was associated with significant reductions in parental depression and in caretakers’ reports of children’s problems with conduct and social relations. Furthermore, the percentage of cases where children rated as having clinically significant levels of problems in at least one area of functioning was reduced from 89% at the time of treatment entry to 56% at treatment termination.

The current study builds on this research by conducting a program evaluation of the ITTM as compared to two control groups: wait-list control and treatment-as-usual using a multi-site, comparative, naturalistic design.

The research is guided by the following hypotheses:

Children who participate in the ITTM will show greater changes in emotional and behavioural symptoms and will have stronger bonds to their caregiver than children in treatment-as-usual or children on the waitlist for services.

A key mechanism of change is interruption of intergenerational transmission of trauma, specifically:

  1. Caregivers participating in the ITTM will show greater changes in emotional dysregulation, efficacy, empathy, and effectiveness than caregivers in the waitlist or treatment-as-usual control.
  2. Change in child emotional and behavioural symptoms will be mediated by changes in caregivers emotional dysregulation, efficacy, empathy, and effectiveness and in improvements to the caregiver-child attachment relationship.

Data is currently being gathered and results are expected within the next 2 to 3 years. Additional clinics are able to join in on this current research if interested.