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Evidence-Based Does Not Mean One Size Fits All

By Barbara Jefferson, LCSW, Clinical Director with the Center for Child Protection , for the 2018 Clinician’s Corner.

As clinicians, there are excellent interventions we are trained in that are considered evidence-based treatment interventions. These treatment interventions can work extremely well for some people, but not for everyone. In my decades of work with children and families who have experienced trauma, I have come to believe that a “one size does not fit all” treatment approach is critical for each child and parent in optimally gaining from their therapeutic treatment process.

Clinical assessment should always drive appropriate treatment planning. Clinical assessment and talking with the child and his or her family is what enables us to individualize the treatment areas to address and to devise an individualized treatment strategy. When implementing evidence-based treatment interventions, it is important to understand that not one single treatment intervention is going to work for every child and every family impacted by trauma, though it can provide a good place to start.

In providing therapeutic services within a trauma-informed organization, we have to be mindful of providing the right interventions at the right time and with the right dose for a child’s specific developmental needs, as well as the family’s specific needs. This timing and dosing of the identified appropriate treatment interventions will be assessed throughout the treatment process for a child and their family.

Our agency had the fortunate experience of being trained in Phase 1 of the Neurosequential Model of Therapeutics (NMT) with Dr. Bruce Perry and the Child Trauma Academy. As a result, our organization and clinical team developed an understanding of the neurodevelopmental issues of how trauma impacts the developing brain of a child. As we all develop the abilities to sit up, crawl, walk, talk, learn to control our behavior and emotions, develop relationships with others, and learn to reason and problem solve, this is done in a neurosequential process. We may be working with a child who is chronologically 10 years old, but is developmentally functioning at the age of a 3 year old.

As a clinical program, we’ve been able to apply this neurodevelopmental assessment approach into our work with children impacted by trauma. This neurodevelopmental assessment approach enables us to determine the areas of the brain most impacted by adverse experiences, as well as relational health factors. As a result, identification of types of treatment interventions to target areas of the brain to facilitate neurosequential development is made possible for each child. For example, it is often thought that trauma focused cognitive behavioral therapy is one of the best treatment options for individuals who have experienced trauma. However, if an individual has experienced developmental trauma and he/she is not able to connect higher level cognitive functioning to their trauma experiences, cognitive behavioral therapy may not be as effective, despite the evidence that it works for many. Rather, we would look for ways to help a parent and child co-regulate through art, music, animals and/or play rather than jump into therapy that requires higher cognitive reasoning that the client is not ready for. As the child progresses within the treatment process, cognitive behavioral therapy can be a valuable and a necessary treatment intervention at the appropriate time.

Specific treatment interventions will change as a child progresses throughout the treatment process using an individualized treatment approach. Whether it be through the Neurosequential Model of Therapeutics, the Trauma Symptom Checklist for Children, the Trauma Symptom Inventory or some other measure, it is critical that a thorough clinical assessment and our clinical judgment drive the identification of treatment goals. Thorough clinical assessment is then partnered with a review of the research evidence related to the presenting issues and expected outcomes in order to select interventions for each individual child and parent. Otherwise, we risk a mismatch of needs and services.

There are significant potential costs to not conducting a thorough assessment before implementing evidence-based treatment interventions. For example, a child who is withdrawn in school may behave that way because of past trauma. An intervention that fails to consider that may be ineffective or could even exacerbate the issue by re-traumatizing the child. In using trauma assessment measures, as well as a biological developmentally sensitive assessment approach, one would consider the timing and severity of both adverse experiences and relational health factors experienced by this child. In the framework of NMT, assessing this child’s developmental risk factors and completing the brain map will help us determine the types of interventions that will be most useful to her based on her specific developmental needs.