Tuesday, November 17, 2009

Study Finds Sexually Abused Children in Turkey Exhibit More Psychiatric Disorders at Initial Assessment than Two-Years Later

Prior research indicates that children who have been sexually abused are at risk of developing various negative short and long-term psychological sequelae. However, there is little research on the effects of sexual abuse on children living in non-Western contexts. In this study, Ozbaran et al. (2009) aim to explore the emotional and psychological impact of sexual abuse among a sample of children in Turkey at referral and two years after referral. Over 300 parents and their children (ages 5-16) were referred to the Department of Child and Adolescent Psychiatry at Ege University in Turkey, and 20 parents and their children agreed to participate in the research. At referral, the parent-child pairs (N=20) completed the first evaluation, which included a detailed psychiatric examination of each participant, completion of the Child Behavior Checklist by the mother, and an evaluation of the child’s mental capacity by a clinical psychologist. Over a period of two years, the sample participated in a combination of the following interventions, depending on the child and family’s needs: psychopharmacologic medication, parental support groups, family meetings with social workers, school counseling services, sport and art activities, and outpatient occupational therapy. After two years, the parent and child were asked to return for a follow-up evaluation. The study found that children who were sexually abused had more psychiatric disorders during the first assessment (55%) than during the second-stage evaluation (0%). However, the study also found that there was no statistically significant relationships between psychiatric diagnoses, socio-demographic features, duration of abuse, or abuse type.

The study methodology lacked rigor in that it was not clear that there was a systematized method for conducting the first and second-stage evaluations. However, the implementation of blind psychiatric interview during the second-stage evaluation was strength of the study, because it lessens the likelihood that the therapist’s impressions will be biased. The small sample size (N=20) of the study, ensured that no participants were lost to follow-up. However, the small sample size - and therefore the decreased statistical power - also made it difficult to draw any statistically significant conclusions. The lack of a control group in the study design also made it a challenge to directly demonstrate a causal relationship between sexual abuse and development of a psychiatric diagnosis or behavioral problems. The authors’ statement that the condition of the sexually abused children in their sample improved significantly as a result of time is misleading, because the study design doesn’t discern whether this is attributed to time or to the array of intervention services that the children and their families received during the study period. Lastly, sampling bias may pose a threat to the external validity of the study, as the sample reflected less than 7% of the initial referrals (over 300) to the hospital. This small sample may have characteristics that the general population does not exhibit. In light of these limitations, this study still adds to the sparse literature on the topic of children affected by sexual abuse in non-Western settings and represents an obvious precursor to more rigorous studies.

Ozbaran, B., Erermis, S., Bukusoglu, N., Bildik, T., Tamar, M., Ercan, E.S., Aydin, C., and Cetin, S.K. (2009). Social and emotional outcomes of child sexual abuse: a clinical sample in Turkey. Journal of Interpersonal Violence, 24(9), 1478-1493.

Parenting Program Effective in Improving Mothers’ Parenting and Child Well-Being

Empirical evidence indicates that poor parenting and child exposure to marital conflict are powerful predictors of psychological disorders in children. Yet, these two risk factors have been found to be mediated by preventive interventions. Bodenmann et al. (2008) conducted a randomized control trial in Switzerland to determine the effectiveness of a parenting program to improve parenting skills and children’s well-being. The Triple P-Positive Parenting Program is a multi-level program for parents to enhance their knowledge, skills, and confidence as caregivers. Researchers used public advertisements to recruit couples (N=150) with children between the ages of 2 and 12 years old. Couples were randomly assigned to one of three programs: a parenting-oriented program (Triple P), a marriage-oriented couples coping enhancement training (CCET), or a non-treatment control group. Data were gathered using self-report questionnaires measuring marital relationship, parenting, and child behavior. Questionnaires were administered to both parents at four separate times: (1) two weeks prior to intervention, (2) two weeks after completion of intervention, (3) six-months follow-up, and (4) one-year follow-up. The control group completed questionnaires at the same time as the other groups. Results indicated that mothers in the Triple P group showed improvements in parenting and parenting self-esteem, a decrease in parenting stressors, and lower rates of reports of child misbehavior as compared to the other two groups. Fathers in all three groups showed no improvements in parenting behaviors.

The strength of this study is in its randomized control design, allowing researchers to determine the effectiveness of Triple P, while ruling out the plausible competing hypothesis, a marriage-oriented program. Overall, the attrition rate was fairly small and heterogenous across groups, though there was a higher rate of dropout among fathers (13.3%) than mothers (10.7%). Furthermore, the lack of significant results from the fathers was surprising in that both mothers and fathers equally participated in the Triple P program. On the other hand, it was not surprising considering the authors’ hypothesis that mothers would benefit more from Triple P than fathers, because the former are more likely to be directly involved in child rearing, especially in the Swiss context. This raises an interesting question about the importance of paternal involvement in the efficacy of Triple P, which might indicate an area of future research. One limitation of the study is the single source of data relying on parent self-report. For example, the parent’s positive or negative views of their own parenting skills may have impacted how they rate their own child’s behavior. The study could have been strengthened if data included assessments from external sources (e.g., therapist, clinician) or even child self-reports, (although the authors do concede that the mean age of the children was 6.6 years). Overall, this study adds to the growing body of evidence about what programs are effective for improving parenting skills and child behavior.

Bodenmann, G., Cina, A., Ledermann, T., and Sanders, M.R. (2008). The efficacy of the Triple P-Positive Parenting Program in improving parenting and child behavior: a comparison with two other treatment conditions. Behavior Research and Therapy, 46, 411-427.

Monday, November 16, 2009

Risk & Society

The concept of risk society describes a modern worldview where tradition has broken down and scientific advances, rather than nature, are dominant. The consequences of human actions as a function of modernity and industrialization across a range of areas have introduced a wide array of risks and uncertainties, which exacerbate the risk of the everyday. A central paradox of risk society is that risks are generated by the very methods of modernization that are trying to control them. In this way, the traditional certainties and securities of the pre-modern society can no longer be relied upon. Fundamental to an understanding of risk society is the breakdown of the expert systems of trust in science, which has implications for how children and families function.

Beck (1992) focuses on this breakdown in the expert systems of science by drawing attention to the fact that science often draws different conclusions about the same thing, thus creating mistrust in a society that relies upon certainty and security. For example, as an element of traditional childrearing, there have been conflicting messages about breastfeeding throughout the world, with contradictions coming from both science and the media. On the one hand, this had disastrous consequences for many children in developing contexts, as many mothers chose the financially unsustainable method of formula feeding. Mothers were not able to sustain the expensive modern method of formula feeding, and therefore the baby’s nutrition and subsequent growth suffered. On the other hand, in some developed countries such as the United States, there have been breastfeeding advocacy campaigns aimed at mothers that have relied upon scare tactics rather than evidence-based advice. Mothers who use formula are portrayed as “bad mothers” who are actively harming their children, because they are not using “natural” methods to raise their children. Strong attitudes towards such childrearing practices are driven by ideology and politics and framed by blame, rather than concern for the individual. There are multiple examples of contradictions like this present in risk society.

This example proves that risk society has fundamentally changed the modern worldview, including the way children are raised. Claims about the risks to children’s health and well-being continue to proliferate and revolve around debates about what it means to be a “good parent”. This concept is more often linked to common perceptions of risk than to scientific evidence.

Similarly, Castel (1991) argues that many discourses on risk dissolve the notion of a subject or concrete individual, and put in its place risk factors. He critiques this modern view because it excludes any face-to-face relationship between the carer and the cared, the helper and the helped, the professional and the client. It clusters people as groups of risk factors, and only intervenes in cases when the risk factors produce dangerous combinations within individuals. Castel uses the example of the 1976 GAMIN system in France, when children were screened at a few days, a few months, and two years after birth. The combination of predetermined factors triggered automatic alerts, which prompted a social worker “to confirm or disconfirm the real presence of danger, on the basis of the probabilistic and abstract existence of risks” (p.287-288). Though Castel makes his distaste for such a system known, one must wonder if we are heading towards a global, and perhaps more intrusive, surveillance system such as GAMIN. The main question, however, is whether or not risk society or surveillance of risk factors, can account for the accidental and unpredictable nature of unique human beings.

Beck, U. (1992). Risk Society: Towards a New Modernity. London: Sage Publications.
Castel, R. (1991). From dangerousness to risk. In G. Burchell, C. Gordon, and P. Miller (Eds.), The Foucault Effect: Studies in Governmentality. Chicago, IL: University of Chicago Press.