Download An effect study of `Creative Expressive Arts Therapy` for sexual

An effect study of ‘Creative Expressive Arts Therapy’ for sexual abused children
in South Africa and a possible moderation effect of social support.
M. E. van Overstraten Kruijsse (3400654), Department of Psychology, Faculty of
Social and Behavioural Sciences, Utrecht University, Utrecht, the Netherlands
Supervisors: Prof. Dr. R. Kleber (The Netherlands) and Drs. N. van Westrhenen (in
South Africa)
General coordinators: Prof. Drs. T. Knijn.
Date: 29 may 2014
Utrecht University
Teddy Bear Clinic
Faculty of Social and Behavioural Sciences
Johannesburg Branch
Heidelberglaan 1
13 Joubert Street
3584 CS Utrecht
Parktown, Johannesburg
The Netherlands
South Africa
Abstract
Introduction: In this research a ‘Creative Expressive Arts Therapy (CEAT)’ is
piloted for sexually abused children in South Africa, at the Teddy Bear Clinic for
abused children. The effect of CEAT on Post Traumatic Stress Disorder (PTSD)
symptoms was evaluated and social support was measured as possible moderator.
Methods: This study included 13 participants in the age from 8 to 12 years, 4
children were on a waiting list and 9 children participated in 10 sessions of CEAT.
PTSD symptoms were measured with the Young Child PTSD Checklist (YCPC) and
the PTSD section of the Kiddie Schedule for Affective Disorders and Schizophrenia
for School-Age Children- Present and Lifetime Version (K-SADS-PL). The perceived
social support was measured with the Multidimensional Scale of Perceived Social
Support (MSPSS). Pre and post CEAT measurements were conducted and compared.
Results: CEAT did not decrease the PTSD symptoms of the children, measured with
the YCPC and K-SADS-PL, and results did not show significant differences between
the therapy and control group. Neither did the analysis show evidence for social
support as moderator between CEAT and PTSD symptoms. The presumption is made
that the results are caused by the amount of methodological constraints. For parents
did indicate to see a difference after CEAT in the children in the therapy group; they
showed a decrease in aggressive behaviour, sadness, loneliness and nightmares.
Conclusion: The results show no statistical evidence of a positive effect of CEAT,
although qualitative data show a positive effect of CEAT on PTSD symptoms. This
supports the use of CEAT with sexually abused children. Besides statistical results,
this research found numerous recommendations for future research in the South
African context.
Keywords: Sexual abuse, Creative Expressive Arts Therapy, PTSD, Social Support,
South Africa.
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Samenvatting
Introductie: Huidig onderzoek is een pilot onderzoek voor de toepassing van
‘Creative Expressive Arts Therapy (CEAT)’ voor seksueel misbruikte kinderen in
Zuid-Afrika, in de ‘Teddy Bear Clinic’ voor misbruikte kinderen. Het effect van de
CEAT, op Post Traumatische Stress Stoornis (PTSS) symptomen, is geëvalueerd en
sociale steun is gemeten als mogelijke moderator. Methode: Aan huidig onderzoek
namen 13 participanten deel in de leeftijd van 8 tot 12 jaar, 4 kinderen stonden op de
wachtlijst en 9 kinderen zaten in de CEAT groep van 10 sessies. PTSS symptomen
zijn gemeten met behulp van de ‘Young Child PTSD Checklist (YCPC) en de PTSS
sectie van de Kiddie Schedule for Affective Disorders and Schizophrenia for SchoolAge Children- Present and Lifetime Version (K-SADS-PL). De ervaren sociale steun
is gemeten door middel van de Multidimensional Scale of Perceived Social Support
(MSPSS). Metingen voor en na de CEAT zijn afgenomen en met elkaar vergeleken.
Resultaten: Het volgen van CEAT verminderde de PTSS symptomen niet, gemeten
op de YCPC en de K-SADS-PL, en er zijn geen verschillen tussen de therapie en
controle groep gevonden. Noch bleek sociale steun te functioneren als moderator
tussen de CEAT en de PTSS symptomen. Het vermoeden bestaat dat het gebrek aan
resultaten het gevolg is van verschillende methodologische beperkingen. Ouders
gaven namelijk aan dat kinderen in de therapie groep wel degelijk verschillen lieten
zien; zij lieten een vermindering in agressief gedrag, bedroefdheid, eenzaamheid en
nachtmerries zien. Conclusie: De resultaten geven geen statistisch bewijs voor een
positief effect van de CEAT, daarentegen wijzen kwalitatieve gegevens wel op
positieve resultaten van de CEAT op PTSS symptomen zien. Dit ondersteunt de
toepassing van CEAT op seksueel misbruikte kinderen, maar geeft ook het belang van
vervolg onderzoek aan. Naast de statistische resultaten verschaft het huidig onderzoek
talrijke aanbevelingen voor toekomstig onderzoek in de Zuid-Afrikaanse context.
Sleutelwoorden: Seksueel misbruik, Creative Expressive Arts Therapy, PTSS, Sociale
Steun, Zuid-Afrika.
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‘The thing no one understands about me is that I have a small heart when I am
scared’
Child during the pre-measurements
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Forword
This thesis is written as an assignment for the master Clinical and Health
Psychology, at the University of Utrecht. The thesis is written about sexually abused
children in South Africa, Johannesburg, and the possible effect of a Creative
Expressive Arts Therapy (CEAT). In February 2014 I arrived in South Africa, an
unknown country to me. Therefore I expected some challenges, as we were in a
different context than we were used to. But still I can say that I underestimated it.
During these four months of research in South Africa, I learned more about the
challenges of research than I could ever have learned in the Netherlands. There where
weeks were we contacted Nadine (our supervisor in South Africa) almost every day,
to discuss the necessary adaptations. Not only my research skills, but also my
patience, flexibility and ‘thinking in solutions’ got refined. And last, but definitely
not least, we got to make a lot of precious contacts with people in the Teddy Bear
Clinic and the lovely children that participated in the research.
I have to thank several persons for their effort and making my time in South
Africa so amazing. First of all Drs. Nadine van Westrhenen, our supervisor in South
Africa, she helped us whenever necessary and made time for us in her already busy
schedule. Not only did she help us with the research, she also took us on trips and
gave us tons of tips. I want to thank Prof. R. Kleber for his useful feedback and the
long distant calls. The Teddy Bear Clinic for opening their doors for us and for letting
us use their files, time, space and help. In particular the help of their social workers
Charles and Ndumiso, who helped us more than we could have wished for. Not only
their help but also their company during our months are so much appreciated. All the
students who helped us conducting the questionnaires, without them we could have
stopped our research in week 3. And many thanks go to the children and caregivers
who participated in this research, it was not always easy to come to therapy, but we
made it! Finally, thanks to everyone who helped us or made our time in South Africa
even better than it already was.
In this research I worked closely with 2 other students; Marloe Leermakers
and Robbe Stolk. Al three of us had the same mean research question, but took a
different sub research question to make our research more individual. Marloe
Leermakers and I both took social support as an extra variable, therefore we worked
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together most of the research and wrote parts together as well. This because of the
great amount of overlap. I took social support as a moderator and Marloe Leermakers
took social support as a mediation, parts about social support are therefore individual.
There was a good distribution in subjects, everything was discussed carefully and
both put in the same amount of effort in the end product. Therefore I want to thank
Marloe Leermakers for the pleasant partnership.
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Contents
1. Abstract English
pp. 2
2. Abstract Dutch
pp. 3
3. Forword
pp. 5
4. Content
pp. 7
5. Case study
pp. 8
6. Introduction
pp. 9
a. Cultural sensitive intervention: CEAT
pp. 10
b. Social support
pp. 12
c. Theoretical framework
pp. 13
d. Goals of this study
pp. 15
7. Method
pp. 15
a. Participants
pp. 15
b. Instruments
pp. 16
c. Procedure
pp. 17
d. Statistical analyses
pp. 18
8. Results
pp. 20
a. Reliability of questionnaires
pp. 20
b. Development of the posttraumatic stress symptoms
pp. 20
of the research group
c. Comparison of the intervention and control group
pp. 21
d. Qualitative findings
pp. 22
e. Social support as a possible moderator
pp. 22
f. The influence of the relation with the perpetrator
pp. 23
on social support
9. Discussion
pp. 23
a. General findings
pp. 23
b. Insights & limitations
pp. 25
i. Measurements of PTSD symptom
pp. 25
ii. Instruments
pp. 27
iii. This research
pp. 29
10. Conclusion
pp. 31
11. References
pp. 32
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Case study
Dembe (pseudonym) is a skinny black boy, 12 years old, who lives in a safe house in
Florida, Johannesburg. He does not know who his father is and he witnessed his mother
die, which had a great impact on him. Therefore, he lived the major part of his life with
foster parents. His foster father seriously abused him physically (beat him up and let him
sleep in the field) and both his foster parents neglected him. For that reason he was put in
a safe house. In the safe house he is abused, several times, by other boys who lived in the
same house. ‘Here the older boys teach the younger boys how to rape.’ When we met
him, he stuttered, did not have many social contacts, felt lonely, he was very aggressive
and had intense nightmares (they had to tie him to the bed to keep him under control).
Therapy
Dembe participated in the Creative Expressive Arts Therapy (CEAT) and was actively
present. He opened up, especially during the music and dance sessions, and he became a
loyal group member. They showed empathy for each other and exchanged stories and
emotions, helping them feeling less lonely. The social worker saw that they assisted each
other through the activities. Dembe did not have to talk during therapy, which was an
advantage for him, as talking was scary since he stuttered. Dembe loved coming to
therapy, he would wait all day at the car so he would not miss it.
Post therapy
Dembe’s housemother told us that after the 10 CEAT sessions Dembe was less
aggressive, which made him more social in a group. He still had nightmares, but instead
of every day, they decreased to 3 nights a week. She noticed that he talked more often,
without hesitation and less fear. She saw a happier child and was very grateful for the
CEAT. Even though the questionnaires still showed PTSD, the CEAT helped Dembe
process his trauma and gave him tools to help him in the future.
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Introduction
Sadly Dembe is not alone; South Africa has the world highest prevalence of
community violence and levels of household abuse (Jewkes et al., 2006). Exposure to
community violence (i.e. robbery, assault in- and outside the home) is associated with
posttraumatic stress disorder (PTSD) symptoms in AIDS orphaned South African
children (Cluver, Gardner & Operario, 2008). Research shows high levels of PTSD
(around 22-25%) amongst poor urban children in South Africa (Seedat, Nyamai,
Njenga, Vythilingum & Stein, 2004). Child sexual abuse (CSA) can be seen as part of
domestic and community violence, and is considered to be a major issue in South
Africa (Jewkes & Abrahams, 2002; Jewkes, Penn-Kekana & Rose-Junius, 2005). A
recent meta-analysis indicated that South Africa has the highest prevalence of CSA
globally (Pereda, Guilera, Forns & Gómez-Benito, 2009). In the context of South
Africa there is not enough help for all the victims, due to a lack of facilities.
Furthermore, not all Western interventions, for example EMDR or Cognitive
Behaviour Therapy, appear to be suitable for South African society. Therefore, this
pilot study will develop and evaluate a cultural sensitive trauma intervention
appropriate for South African society.
The consequences of abuse can be severe and there is evidence that CSA is
related to posttraumatic stress (Estes & Tidwell, 2002; Hall, Mathews & Pearce,
2002). CSA is defined as physical violation of a child’s body or being exposed to
sexually inappropriate stimuli (Piercea & Bozalekb, 2004). CSA is ranked as the most
serious abuse, in comparison with other kinds of abuse (physical maltreatment,
societal abuse and non-physical maltreatment), by South Africans in the social sector
and laypersons (Piercea & Bozalekb, 2004). PTSD can develop after experiencing,
being involved in, or hearing an extreme traumatic stressor (APA, 2000, p.467), like
CSA. PTSD is defined according to criteria as presented in the DSM-IV (APA, 2004).
The DSM-IV is used in current study, as there are no instruments based on the DSM5 yet. One study found that CSA is the strongest predictor for developing PTSD in
South African children, accounting for 25% of the psycho trauma cases (Seedat et al.,
2004). In addition, PTSD among children has only been studied for the past 20 years
and is still developing as a research field (Alisic, Jongmans, van Wesel & Kleber,
2011). Finally, there is a lack of quantitative research in the South African context in
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the field of PTSD. This indicates the need for further research considering PTSD and
interventions for children who experienced CSA.
Cultural sensitive intervention: Creative expressive art therapy
Looking for a cultural sensitive intervention in South Africa, going back to the
roots of the society seems a logic choice. Dance, music and art are strongly embedded
in the South African culture and therefore these activities seem suitable for a cultural
sensitive intervention (Harris, 2009). Arts as a form of healing is probably as old as
human society itself. Using arts as a professional therapy can be seen as a formal
application of human tradition (Malchiodi, 1998). Naumburg (1950/1973) states that
art therapy is a type of psychotherapy that uses art practices and interventions in
combination with talking as a form of treatment. Nowadays, an increasing amount of
evidence supports that creating art is a beneficial way to explore and control emotions
and cognitions (Camic, 2008). The efficiency of creative expressive arts therapy
(CEAT) with children is shown in multiple studies (Carolan, 2001; Douglass, 2001;
Gilroy, 2006; Waller, 2006). However most of the studies concerning art therapy are
case-studies, is qualitative research and have methodological constrains. Moreover,
only one quantitative art therapy intervention study has been conducted in South
Africa, and this study focussed on girls only (Pretorius & Pfeifer, 2010). Most
research has been conducted in Western societies, and can therefore not automatically
be implemented in South Africa. A need for further research that explores the
effectiveness of arts-based methods is recommended by Camic (2008) in previous
studies. Therefore, this study will develop and evaluate an art based trauma
intervention, appropriate for the South African context.
CEAT is a form of therapy used for self-expression and reflection by art. Each
different form of therapy helps people to process their experiences in their own way;
creation of art mediates reflection and personal exploration, dance allows for
experiencing emotions through physical expression, and music has got a soothing
capacity that demonstrates listening skills, and facilitates the increase of
understanding and meaning (Malchiodi, 2008). The positive effect of art based
interventions has been extensively discussed by research with traumatised children
(Coholic, Lougheed & Cadell, 2009; DiSunno, Linton & Bowes, 2011; Kozlowska &
Hanney, 2001; Lev-Wiesel & Liraz, 2007; Robarts, 2006; Rousseau et al., 2007).
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CEAT is used in different styles of practice, from pure artistic expression to
therapeutic tool in psychotherapy (Hogan, 2009). This research will use a ‘groupinteractive approach’, which not only uses art but also includes group interaction.
There is no set protocol for CEAT, most therapists make their own. In this research
the ‘Creative Expressive Arts Therapy Intervention Protocol for Traumatized
Children’ (van Westrhenen, Fritz, Lemont & Oosthuizen, 2014) will be piloted.
Pretorius and Pfeifer (2010) found positive results regarding anxiety and depression
when implementing a group based art therapy intervention for sexually abused girls
from 8 to 11 years old originating from South Africa. Even though most research on
art based interventions is published in journals focussed on art therapy, there are
enough indications to expect a positive effect of CEAT.
While words are usually the strongest way to communicate among humans,
sometimes words cannot describe the amount and complexity of feelings we
experience (Harris, 2009). This is why art therapy can be an alternative way of
expressing emotions and perceived experiences (Edwards, 2004). Expressing through
art therapy gives an opportunity to explore the issues surrounding a traumatic event in
a less threatening, nonverbal way, with some distance and control over disclosure
(Backos & Pagon, 1999). Looking at the diversity of languages in South Africa, a
barrier in communication can often occur. Moreover, cultural rites of art making that
are healing and life enhancing already exist in South African culture (Harris, 2009). In
addition children have difficulty using words as well when talking about feelings and
thoughts (Hanney & Kozlowska, 2002), making CEAT appropriate for the South
African context and for children. Or as seen in the case of Dembe, for children having
trouble talking at all.
Because of a lack of evidence for an appropriate therapy for (sexually) abused
children in South Africa, this pilot study is an important addition to the current body
of literature. The effect of CEAT as an intervention for traumatized children in South
Africa on posttraumatic stress reactions will be explored in this research. The research
question is ‘Does CEAT decrease PTSD symptoms in children who are sexually
abused in South Africa?’ (Q1).
Social support
As stated before, there is a very high prevalence of abuse in South Africa, with
negative psychological effects like PTSD (Carr, 2006). Nevertheless, there are many
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victims of CSA who adapt and therefore function normally and effectively further in
life (Farber & Egeland, 1997 in Hyman, Gold & Cottt, 2003). One factor that
influences this recovery process is social support (Hyman et al., 2003). Social support
is defined as perceived financial, physical, and emotional help from family, friends,
and the community as a whole (Cluver, Fincham & Seedat, 2009). There are
numerous studies that have looked at social support in combination with sexually
abused children or adults (Cluver et al., 2009; Davidson, Inslicht & Baum, 2000;
Runtz & Schallow, 1997) and as a moderator in different types of therapies (apart
from CEAT) (Orgodniczuk, Piper, Joyce, McCallum & Rosie, 2002; Taylor et al.,
2007; Thrasher, Power, Morant, Marks & Dalgleish, 2010). However, not one study
has examined social support as a possible moderator between CEAT and its outcome
in the South African population yet. This study is an attempt to fill this gap in
literature.
Perceived social support is related to a better recovery process and is seen as a
buffering response to extreme stress and trauma (Cluver, et al., 2009; Dirkzwager,
Bramsen, & van der Ploeg, 2003). Runtz and Schallow (1997) found that 55% of the
variance in psychological adjustment in sexually or physically abused male and
female college students could be attributed to social support. This is consistent with
research that has indicated that social support has a significant positive effect on the
recovery process after a traumatic event (Davidson et al., 2000). Family support in
particular has been the focus of studies, showing a positive influence on psychological
well-being after a traumatic event (Cohen & Mannarino, 2000; Grills-Taquechel,
Littletonb & Axsomc, 2011). A lack of social support therefore can place a child at
risk for developing posttraumatic stress symptoms, especially when the perpetrator is
someone known to the child (Jewkes et al., 2005). Studies have shown that this
actually happens in most cases, for instance Collings (2005) found that up to 87% of
the male victims in their study did know their perpetrator. Tremblay, Hebert and Piche
(1999) also found a higher occurrence of internalizing problems (e.g., anxiety,
depression, somatic complaints and withdrawal) when children were abused by a
related adult than by a more distant perpetrator. This indicates that when the
perpetrator is someone the child knows this could harm the child’s perception of
social support, which could predict a negative outcome. In conclusion, social support
is a meaningful factor when it comes to CSA.
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Cluver and colleagues (2009) hypothesized a moderation effect of social
support on the relationship between trauma exposure and PTSD symptoms.
According to Baron and Kenny (1986), a moderator is a variable that specifies if and
under what conditions an independent variable predicts a dependent variable.
Spaccarelli (1994) created a transactional model that indicates that environmental
factors (e.g. family support) moderate relationships between responses of the victim
and abuse stressors. In addition, a moderating role of social support following sexual
abuse on the psychological maladjustment in children and adults was found in several
studies (Hyman et al., 2003; Spaccarelli & Kim, 1995; Tremblay et al., 1999). In
studies on the effect of post-trauma therapies other than CEAT, a positive effect of
social support on the therapy outcome was found, for example in medical treatments
for cancer (Taylor et al., 2007), in exposure therapy for PTSD (Thrasher et al., 2010),
in cognitive restructuring therapy for PTSD (Thrasher et al., 2010) and in interpretive
and supportive group therapy for complicated grief (Orgodniczuk et al., 2002). This
creates the expectation that social support will act as a moderator on the CEAT
outcome (reducing symptoms of PTSD).
In this study the influence of perceived social support on the CEAT outcome
will be measured. To revert to Baron and Kenny (1986), PTSD symptoms post CEAT
is the dependent variable and PTSD symptoms prior CEAT is the independent
variable in this study. The research questions are ‘Does social support function as a
moderator between CEAT (PTSD symptoms prior to CEAT) and PTSD symptoms
(post CEAT)?’ (Q2) and ‘Do children who know their perpetrator experience less
social support than children who do not know their perpetrator?’ (Q3).
Theoretical framework
The theoretical lens in this study is predominantly derived from a neuroscience
perspective. The neuroscience perspective explains the way the brain functions during
and after a traumatic event in support of a creative approach to trauma treatment.
Research shows that abused women with PTSD have a limited verbal declarative
memory in comparison with women with early abuse without PTSD and non-abused
women without PTSD (Bremner, Vermetten, Afzal & Vythilingam, 2004). This could
be explained by research that indicates that the hippocampus, a brain area that is
involved in the learning process and memory, has a lower activation level and a
smaller volume in people who suffer from PTSD (Alastair, 2002; De Bellis, 2001;
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Glaser, 2000). This is also found in abused women (Bremner, 2001) and abused
children (Bremner et al., 2003) with PTSD compared to women and children without
PTSD. Bremner and his colleagues (2003) hypothesized that a smaller and lower
activated hippocampus, after experiencing abuse, can lead to false and fragmented
memories. Although there is a growing body of evidence in favour of the framework,
there is quite a lot of research that did not find differences in hippocampus volume or
memory recall with abused women with PTSD (Pederson et al., 2004).
In addition, research shows growing consensus that traumatic memories are
stored in the right hemisphere of the brain and are nonverbal (Glaser, 2000; Klorer,
2005). Harris (2009) hypothesizes that during the traumatic event activity decreases in
the left hemisphere of the brain, where the language and declarative memory is
located, thereby diminishing verbal processing. This is supported by the findings of
decreased activity in Broca’s area, in patients with PTSD (Alastair, 2002). In addition,
research using Lycra cap (electro cap), PET scans and fMRI found that people with
PTSD have an increased activity in their right hemisphere and a decreased activity in
their left hemisphere in comparison to people without PTSD (Lanius et al., 2004;
Rauch, van der Kolk, Fisler, & Alpert, 1996; Schiffer, Teicher, & Papanicolaou,
1995). These differences in brain activity in PTSD patients may explain the nonverbal
nature of traumatic memories (Klorer, 2005; Lanius et al., 2004).
These neuroscientific findings suggest that using a verbal based therapy may
not be the best approach for people with PTSD. CEAT avoids verbalization and uses
non-linguistic communication and expression (Harris, 2009; Malchiodi, 2003). As
explained above, CEAT includes specific drawing exercises and questions to help the
children after a trauma express their experiences, so the children can reframe their
emotions and negative thoughts without words (Malchiodi, 2003). This can reduce the
symptoms of posttraumatic stress, which makes it a suitable therapy for children who
have experienced a traumatic event.
Goals of this study
The purpose of this study can be divided in two different goals. The first goal is to
improve psychological wellbeing and support positive recovery of children after a
traumatic event, through a creative expressive arts therapy intervention. The second
goal is to add knowledge to the current state of literature on child trauma and
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interventions. This study will explore the implementation of a creative expressive arts
therapy intervention programme and its effects. The hypotheses are:
1. Children who will join the CEAT intervention will experience less
posttraumatic stress symptoms after the intervention compared to prior to the
intervention.
2.
Children who will join the CEAT intervention will experience a greater
decrease of posttraumatic stress after the intervention compared to the control
group (which includes children on the waiting list).
3. Social support functions as a moderator between CEAT and PTSD symptoms,
expecting that children who perceive high social support experience a greater
decrease of posttraumatic stress after the intervention compared to children
who perceive low social support, using the pre measurements of social
support.
4. If the perpetrator is someone the child knows, this will predict less perceived
social support and, it is therefore expected (see H3), less progression through
CEAT.
Method
Participants
The participating children have been selected from files available at the Teddy Bear
Clinic for sexually abused children in South Africa, based on demographic and intake
information available as part of the normal intake procedure in this clinic. Inclusion
criteria were (1) age (8-12 years old), (2) experienced one or multiple events of
sexually abuse between three months and two years, (3) show posttraumatic stress
symptoms, and (4) English speaking. Exclusion criteria were (1) mental retardation,
autistic disorder, and blindness, and (2) already had any form of previous trauma
treatment. 31 children from two different branches of the Teddy Bear Clinic, one
school in Gauteng and a safe house in Florida, Johannesburg, were approached to
participate in this research. 24 children showed up for pre measurements; 11 in the
Soweto branch and 13 in the Krugersdorp branch. When therapy started more children
dropped out, leaving 4 children in the Soweto branch (4 girls, age; M = 11, SD =
0.82) and 5 in the Krugersdorp branch (2 boys and 3 girls, age; M = 10.60, SD =
1.95)). All the children experienced sexual abuse, and additionally two children
indicated that they experienced physical abuse and one child saw his mother die.
15
These children were all participating in CEAT. For the control group, 2 children in
both branches were used (1 boy and 3 girls, age: M = 10, SD = 1.63).
Instruments
PTSD symptoms were measured with the Young Child PTSD Checklist (YCPC)
(Scheeringa, 2010), conducted with parents. This checklist consists of 42 items; 12
items indicate the absence (= 0) or presence (= 1) of several traumatic events during a
lifetime and 30 items who rate the DSM-IV-TR characterized PTSD symptoms in the
last two weeks. The scale uses a 4-point Likert scale, which ranges from ‘not at all’ or
‘hardly ever/none’ (scored 0) to ‘everyday’ (scored 3). Higher scores indicated more
severe PTSD symptoms and more functional impairment due to the symptoms.
The YCPC checklist was derived empirically from a series of studies over the
past 20 years that determined validity of the items with diagnostic interviews
(Scheeringa, 2011; Scheeringa, Zeanah & Cohen, 2011). No psychometric data are
available yet and so far no studies in the South African context have reported to use
this questionnaire. However, a comparable PTSD checklist, the Child PTSD Checklist
(C-PTSD-C) (Amaya-Jackson, McCarthy, Chemey, & Newman, 1995), is used
extensively in South African context (Cluver, Gardner, & Operario, 2007; Cluver et
al., 2008; Fincham, Altes, Stein & Seesat, 2009; Seedat et al., 2004). The C-PTSD-C
shows high reliability (α= 0.93) and the internal consistency is acceptable to good
(Boyes, Cluver & Gardner, 2012). This comparable PTSD checklist was not available
and therefore the YCPC was used in this study.
To be able to diagnose the children, the Kiddie Schedule for Affective
Disorders and Schizophrenia for School-Age Children- Present and Lifetime Version
(K-SADS-PL) (Kaufman et al., 2000) was used, conducted with parents. The KSADS-PL is a standardised clinician administered diagnostic interview, based on the
DSM-IV. The K-SADS-PL consists of 82-items to use as a screening interview, to
assess key symptoms for current and past episodes of 25 different diagnostic areas.
This research only used the PTSD section. The K-SADS-PL has previously been used
in South Africa (Suliman, Kaminer, Seedat & Stein, 2005) and has shown good
reliability and validity (Perrin, Smith & Yule, 2000).
Social support was measured with the Multidimensional Scale of Perceived
Social Support (MSPSS) (Zimet, Dahlem, Zimet & Farley, 1988). This questionnaire
16
has 12 items which measure perceived social support from family, friends, and a
significant other (Zimet et al., 1988). Answers are given on a 7-point Likert-type scale
(‘very strongly disagree’ to ‘very strongly agree’). Respondents’ scores can range
from 12 to 84 points, the higher the score, the higher the level of perceived social
support. The MSPSS has been previously used in South Africa (Bruwer, Emsley,
Kidd, Lochner, & Seedat, 2008; Kuo, Fitzgerald, Operario, Casale, 2012; Myint, &
Mash 2008) and is a psychometrically complete instrument that can be used in South
Africa (Bruwer, et al., 2008). The entire scale has a Cronbach’s alpha of 0.86
(Bruwer, et al., 2008) and has excellent reliability (Zimet, et al.,1988).
Procedure
Participants were selected based on information in files from the clinic. Files with
children matching all inclusion criteria were chosen. Unfortunately not enough
children matched the criteria ‘English speaking’ and therefore children with different
mother languages were included as well (Zulu, Tswana and English). In addition there
was a low turn up of the individually chosen children at one of the two branches
(Krugersdorp), therefore a new group of children was selected by social workers at a
safe house for children in Florida, Johannesburg. Reasons given by the parents who
did not show up were; they did not have money for transport (even though we would
provide them the transport costs), they could not get the day off from work and they
could not leave their other children unattended. For the control group more children
were approached, however, only 2 children showed up. Therefore, 2 children who did
not show up for CEAT were persuaded to come one last time to do postmeasurements. Social workers from the Teddy Bear Clinic made a first appointment
with the children and their parents or caregivers. During the first appointment the
researchers explained what CEAT is, what the goals of the research were and asked
for assent/consent from children and parents or caregivers.
Informed consent was followed by the administration of questionnaires, this
research was part of a larger research project including 6 questionnaires. This research
used 2 questionnaires, one for the children (the MSPSS) and one for the parents (the
YCPC), and an interview (the K-SADS-PL). All questionnaires were conducted in
English, on paper, with no time limit. During the data collection there was a social
worker available the whole time to translate if necessary. Children and parents were
separated while filling in the questionnaires, avoiding influencing each other.
17
Informal interviews were conducted and observations were made to supplement the
quantitative measurements.
Social workers gave the CEAT after they had received a two-day CEAT
training from Lefika, an organisation for creative art therapy. The CEAT included 10
sessions of 1½ hours, twice a week. Due to logistical challenges, the planning differed
from week to week. Each session had its own theme and activities, for a summary of
general outlines of the therapy programme, see table 1. After 10 sessions the children
and parents came in one last time, to repeat the questionnaires, the informal
interviews and the observations.
Table 1.
The general outlines of the CEAT programme.
Week
Phase
Session theme
Activity 1
Activity 2
1
Creating a
Introduction
Group rules
This is me
2
safe space
Psycho-education
Brave Bart
Scribble to music
Safe space
Safety symbols
Mirrored dancing
3
4
Telling the
Emotion identification
Name the feeling
Emotional drama
5
story
Trauma telling
What happened
Bubbles of hope
Emotion regulation
Mask
Powerful/powerless
6
7
Returning to
Strength finder
Hero’s play
My favorite things
8
community
Community support
Music group
Helping hands
9
Meaning making
Past/Present/Future
Group photo shoot
10
Goodbye
Memory box
Certificate ceremony
Statistical analysis
The design of this study was an experimental pretest-posttest control group design,
the two groups existed of children on the waiting list (control group) and children
who participated in CEAT. For the processing and analysis of the research data, the
Statistical Package for Social Sciences (SPSS, version 22.0, 2013) was used. First,
descriptive statistics were used to summarize the demographic data. Thereafter, pre
measurement scores of the YCPC, K-SADS-PL and MSPSS were compared to post
measurement scores to test the effect of CEAT, using a paired-sample t-test. From the
K-SADS-PL only the diagnose (‘PTSD’ or ‘no PTSD’) was used in the analyses. The
18
assumption of normality was analysed with histograms. The variables were not
normally distributed, but the t-test is robust against violations of the assumption of
normal distribution, therefore it was decided to continue and use the test. To compare
the intervention group and the control group scores of the YCPC and K-SADS-PL
were used in an independent sample T-test.
In order to test the moderation effect of social support, as measured with the
MSPSS, linear regression analyses was executed. Although the assumption of
homogeneity was violated and corrections made no significant differences, it was
decided to follow through with the analyses, using regression analyses with
centralised scores. The model used for the moderator analyses is shown in Figure 1,
showing three paths leading to the outcome variable (post CEAT PTSD symptoms
measured with the K-SADS-PL and the YCPC). Path a; prior CEAT PTSD symptoms
as a predictor. Path b; the impact of social support as a moderator. And Path c; the
interaction of these two. Social support functions as a moderator when the interaction
(Path c) is significant (Baron & Kenny, 1986). To test if the relation with the
perpetrator has an influence on perceived social support, a between-subjects design is
used; independent sample t-tests were executed.
For all analysis a p < .05 was significant.
Figure 1. Model of social support as moderator between prior CEAT PTSD symptoms
and post CEAT PTSD symptoms.
19
Results
Reliability of questionnaires
Both the YCPC as the MSPSS showed good reliability (α = .86 and α = .72) at pre
measurements. Additionally a good reliability was found during post measurements
for the YCPC and MSPSS (α =.88 and α = .71).
Development of posttraumatic stress symptoms of the therapy group
The YCPC was completed for all 9 children of the therapy group who received the
intervention. Table 2 shows scores at the YCPC prior and after the intervention as
well as the results of the analyses that reflect the statistical significance of the
changes. As can be seen in table 1 no significant results were found on each scale.
During pre and post measurements the highest mean was found at the avoidance and
numbing scale of the YCPC (M = 4.89, SD = 3.95 and M = 5.56, SD = 5.55). The
effect that can be observed is a slight decrease of the total scale of the YCPC although
not significant.
Table 2: Comparison of scores per scale at the YCPC prior and after the intervention
for the therapy group
N
Pre
Post
measurement
measurement
M
SD
M
SD
t
P
YCPC R
9
3.00
3.50
3.00
3.08
.00
1.000
YCPC AN
9
4.89
3.95
5.56
5.55
-.38
.358
YCPC IA
9
4.11
5.18
3.11
2.57
.56
.297
YCPC T
9
15.56
15.49
14.67
11.99
.21
.420
YCPC FI
9
2.11
2.71
2.44
4.75
-.22
.417
Note. YCPC = Young Child PTSD Checklist: R = Re-experiencing scale, AN = Avoidance and
Numbing scale, IA = Increased Arousal scale, T = Total (R+AN+IA), FI = Functional Impairment.
20
According to the DSM-IV criteria in the K-SADS-PL 6 out of 13 children (therapy
group N = 3 and control group N = 3) were diagnosed with PTSD during premeasurements and 4 out of 13 children showed a PTSD diagnosis during post
measurements (intervention group N=4, and control group N=2). Despite the decrease
of PTSD diagnosis it has to be noted that 4 participants (all therapy group) out of 6
diagnosed with PTSD at pre measurements showed no PTSD diagnose during post
measurements while 2 participants (all intervention group) displayed a PTSD
diagnose only at post measurements.
Comparison of the intervention and control group
Table 3 displays a comparison of results on the YCPC of the intervention and control
group. Scores displayed are difference scores of the post-measurement and premeasurement per scale using an independent sample T-test. A significant result was
found for the functional impairment scale of the YCPC (p = 0.042) with a positive
mean of M = .33 (SD = 4.58) for the intervention group and a negative mean of M = 4.25 (SD = 1.71) for the control group. Meaning that the therapy group experienced
more functional impairment during post measurements and the control group
experienced less functional impairment during post measurements.
Table 3: Comparison of difference scores (post-measurements minus premeasurement score) between intervention and control group
Intervention
Control
N
M
SD
N
M
SD
T
P
R9
.00
2.45
4
4.00
9.49
-.83
.232
YCPC AN
9
.67
5.32
4
-.25
1.50
.33
.373
YCPC IA
9
-1.00
5.39
4
2.25
4.99
-1.02
.164
YCPC T
9
-.89
12.70
4
7.50
15.15
-1.04
.160
YCPC FI
9
.33
4.58
4
-4.25 1.71
1.90
.042*
YCPC
21
Note. YCPC = Young Child PTSD Checklist: R = Re-experiencing scale, AN = Avoidance and
Numbing scale, IA = Increased Arousal scale, T = Total (R+AN+IA), FI = Functional Impairment. * p
< 0.05
Qualitative findings
Although no significant evidence was found in favour of the effectiveness of the
CEAT therapy a few qualitative findings were noticeable. During an informal
interview after post measurements, parents of children indicated that symptoms of the
children had been decreased, namely aggressive behaviour (e.g. less fighting with
other children), sadness (e.g. children were happier), loneliness (e.g. children played
more with other children) and nightmares.
Social support as a possible moderator
Figure 2 displays the results of a moderator analyses, with social support as moderator
between prior CEAT PTSD symptoms and post CEAT PTSD symptoms. A
significant result was found for the first step, prior CEAT PTSD in relation with post
CEAT PTSD symptoms (β = 0.76, p = 0.036). No significant result was found for the
second step, social support in relation with post CEAT PTSD symptoms (β = 0.08, p
= 0.788). And neither for the third step a significant result was found, the interaction
of prior CEAT PTSD symptoms and social support in relation with post CEAT PTSD
symptoms ((β = 0.06, p = 0.845). Therefor social support does not function as a
moderator between prior CEAT PTSD symptoms and post CEAT PTSD symptoms.
22
Figure 2. Results for social support as a moderator between prior CEAT PTSD symptoms and post
CEAT PTSD symptoms. * p < 0.05.
The influence of the relation with the perpetrator on social support
The analysis of the relation between the child and their perpetrator and the possible
influence on social support did not show a significant effect, t (11) = -.50; p = 0.314.
Children who know their perpetrator however did show a higher mean score on the
MSPSS (M = 69.13; SD = 11.53) than children who do not know their perpetrator (M
= 65.20; SD = 17.12). Indicating that children who know their perpetrator experience
more social support than children who do not know their perpetrator.
Discussion
General findings
The purpose of this study was to examine the influences of a creative
expressive art therapy (CEAT) intervention on posttraumatic stress symptoms among
sexually abused South African children aged 8 to 12. PTSD symptoms prior to CEAT
were compared to PTSD symptoms after CEAT. Furthermore this research has
23
focused on social support, expecting it to moderate the effect of CEAT and expecting
it to be an influence, when the child knows the perpetrator.
The results show that there was no significant effect of CEAT on PTSD
symptoms. Therefore the first hypothesis, ‘children who will join the CEAT
intervention will experience less posttraumatic stress symptoms after the intervention
compared to prior to the intervention’, is rejected. In addition there were no
significant differences found in PTSD symptoms after the CEAT between the therapy
and control group. Therefore also the second hypothesis, ‘children who will join the
CEAT intervention will experience a greater decrease of posttraumatic stress
symptoms after the intervention compared to the control group’, is rejected. These
findings are not consistent with recent literature, indicating that CEAT is an effective
therapy for traumatised children (Coholic et al., 2009; DiSunno et al., 2011;
Kozlowska & Hanney, 2001; Lev-Wiesel & Liraz, 2007; Robarts, 2006; Rousseau et
al., 2007). It should be noted that only Rousseau and colleagues (2007) conducted a
quantitative research and they solely found a small effect. The other studies were
qualitative and have methodological constrains. Neither are these results support for
the positive effect of the non-verbal expression during CEAT, which was expected
from a neuroscience point of view (Alastair, 2002; De Bellis, 2001; Glaser, 2000;
Harris, 2009; Klorer, 2005; Malchiodi, 2003). However, the qualitative results that
were found are worth mentioning: caregivers experienced a decrease of aggressive
behaviour, sadness, loneliness and nightmares. During informal conversations with
the children after post measurements, the researchers also noted behavioural changes.
Children seemed happier and were very enthusiastic about the therapy; they did not
want the therapy to stop. Looking at the statistic results and the contradictory
observations, several possible explanations will be discussed in the insight and
limitation section of this article.
Furthermore, results show no moderating role of social support between prior
to CEAT PTSD symptoms and post CEAT PTSD symptoms. Therefore the third
hypothesis, ‘children who perceive high social support experience a greater decrease
of posttraumatic stress after the intervention compared to children who perceive low
social support’, is rejected. Last, results show no influence of the relation between the
child and his/her perpetrator. And therefore also the last hypothesis, ‘children who
know their perpetrator will experience less social support than children who do not
know their perpetrator (and if we had adopted the third hypothesis, therefore
24
experience less progression through CEAT)’, can be rejected. The results even show
an opposite effect; children who know their perpetrator experienced more social
support in comparison with children who did not know their perpetrator. These
findings do not support the current body of literature, indicating that social support
could function as a moderator between CEAT and PTSD symptoms (Cluver et al.,
2008; Davidson et al., 2000; Thrasher et al., 2010), although this was the first study
for moderation using CEAT. Other research that found the influence of the childs’
relation with the perpetrator (Jewkes et al., 2005; Tremblay et al., 1999) is also not
supported by current research. A possible explanation is that children who are brought
to the clinic have a high social support in comparison with children who are not
brought to the clinic. That would mean that this research population is not a good
sample for this research question. Further explanations will be discussed below.
Current research started as a pilot study for the applicability of CEAT for
sexually abused children in South Africa. However during the research another
subject was found which contributes to the existing body of literature, namely
‘conducting research in South Africa’. Several insights were found in how to conduct
or how not to conduct research in the South African context. This insights will be
discussed alongside the limitations of this study.
Insights & limitations
There were several methodological insights and limitations in this study relating to
the diverse cultural context in which this research took place. The two main
limitations, besides the small research population, concerned the sensitivity of PTSD
symptoms in the population under study and the cross-cultural validity of the
instruments used. These two limitations and some other challenges that were
encountered in this project are further discussed below.
Measurement of PTSD symptoms
This research aimed to measure PTSD symptoms in South African children.
Results show low levels of posttraumatic stress, most children (7) did not show
enough symptoms to be diagnosed with PTSD prior to the CEAT, even though they
were exposed to horrific events and their files indicated several symptoms. A first
possible explanation could be that PTSD is a Western cultural construction that has
25
little relevance in traditional societies (Summerfield, 2004), like most black societies
of South Africa. In recent literature, especially as a reaction to the recent published
DSM 5, there is a discussion about the cross-cultural validity of the disorder ‘PTSD’
(Friedman, Resick, Bryant, & Brewin, 2011; Hinton, & Lewis-Fernandez, 2011).
Some research supports the universality of the disorder (Hinton & Lewis-Fernandez,
2011), other research emphasise the cultural insensitivity of the disorder (Herbert &
Sageman, 2004; Renner, Salem & Ottomeyer, 2006; Summerfield, 2004). Hinton and
Lewis-Fernandez (2011) indicate that PTSD is a universal construct, though there are
variabilities in different areas of the construct, like a ‘relative salience of
avoidance/numbing symptoms’. Consistently, current results show that the highest
scores were found in the ‘avoidance & numbing scale’ of the YCPC (table 1). The
findings of this research could be an indication of the cultural insensitivity of the
disorder. Osterman and de Jong (2007) state that there is a need for a model that
includes cultural factors when working with PTSD (culturally competent model of
traumatic stress); this could be the subject of future research.
A second possible explanation of the low levels of posttraumatic stress could
be found in the complexity of trauma in most South African victims, as a result of
early, ongoing and multiple traumas they experience (Friedman et al., 2011).
Symptoms of the multiple traumas could get in the way of typical PTSD symptoms
and give the appearance that PTSD symptoms are less prominent (Herman, 2001 in
Edwards, 2005). Therefore PTSD symptoms could be more difficult to measure in
children who experience ongoing trauma. It could even be questioned if it could be
called PTSD, for the trauma is not over yet (post). Additionally, it is possible that
children in South Africa ‘don’t know better than that it is normal’ due to their frame of
reference and therefore report less symptoms. Most children in this sample
experienced multiple traumatic experiences (like physical abuse, being abandoned by
their parents, or being neglected), than merely a single incidence of sexual abuse. This
emerged from conversations with the children, as they did not show this in the
questionnaires. Several studies promote the use of the term ‘Complex Trauma (CT)’
or ‘Developmental PTSD (DP)’ (Cloitre et al., 2009; Roth, Newman, Pelcovitz, Van
der Kolk & Mandel, 1997; Van der Kolk, 2005), referring to the experience of
multiple, chronic, prolonged, developmentally and early-life onset trauma’s like
physical, emotional, and educational neglect or abuse (Van der Kolk, 2005). Children
26
suffering from CT or DP show different symptoms, in addition to the PTSD
symptoms, like ‘self-regulatory disturbances’ (Cloitre et al., 2009), ‘Loss of
expectancy of protection by others’ and ‘Negative self-attribution’ (Van der Kolk,
2005). This research purely looked at PTSD symptoms instead of CT or DP
symptoms, future research should take these symptoms into consideration.
A third possible explanation for the low PTSD scores could be socially
desirable responses. Social desirability is a personality characteristic which can affect
measurements, and is especially likely to happen when dealing with sensitive issues
as well as when data is collected in a less anonymous way (Johnson & van de Vijver,
2003; Johnson, Shavitt & Holbrook, 2011). In this study there was a high likelihood
for social desirability seeing the sensitivity of the issue at hand and due to resource
constraints, data had to be collected in a public space. An additional complication
included the presence of a perpetrator during pre-measurements in Krugersdorp. Also,
higher social desirability scores were found in Black South Africans compared to
White (Edwards & Riordan, 1994), and current research population consisted entirely
of Black South Africans. Another possible explanation could be that children did not
dare to tell the truth to strangers and therefore answered as what they thought was
desired. Social desirability lowers the validity of this study, which should be taken
into account while interpreting the results as well as in future studies.
Instruments
Apart from the challenges measuring PTSD symptoms in this research
population, another limitation was reliability of the instruments used in this research.
Although numerous studies reported successful application of the selected instruments
in the South African community, and it was therefore expected to be applicable in this
context, several challenges were experienced.
A first limitation jeopardizing the reliability of the instruments was the
language barrier between respondent and researcher in this study, and between
instrument and respondent. Different social workers and students from South Africa
(no trained translators) were used to translate the English instructions and questions of
the questionnaires and interview. Since there are multiple languages in South Africa,
questionnaires and the interview had to be translated in different languages (Zulu and
Tswana), possibly adapting the guidelines and questions slightly. Another difficulty
27
during translation is the use of abstract concepts like feelings (e.g. depression,
motives). Van Eeden and Mantsha (2007) found that it is difficult for translators to
describe words across languages in the same abstract manner. This is consistent with
observations of social workers and students, during testing, that the vocabulary in
different South African languages is not as diverse as the English vocabulary.
Therefore, different English words became the same in the translated language. Also,
control questions used for decreasing social desirability that were formulated slightly
different in English became the same when translated in one of the African languages.
This makes measuring social desirability difficult in other languages. The translation
of questions and guidelines, language capacity and interpretation of words might
cause a bias (Peters & Passchier, 2006; Van de Vijver & Leung, 2011; Van Eeden &
Mantsha, 2007; Wild, Flisher, Bhana & Lombard, 2005), this should be kept in mind
while interpreting the results.
A second observation, made during the use of the instruments, is that children
chose a lot of extreme answers. This could be explained by research that found that
children experience difficulties using Likert-scales (Chambers & Johnston, 2002;
Mellor & Moore, 2014). Chambers and Johnston (2002) reported that children, aged
between 5 to 12 years, had difficulties filling in questions about abstract concepts,
such as their emotional states, using 3-point and 5-point response formats. Consistent
research found that answers of children using a 5-point Likert scale were inconsistent
compared with dichotomous yes/no responses (Mellor & Moore, 2014). Their
research suggested that younger children are more capable using a 5-point Likert
scale when the anchors are meaningful to the child. However, even then the
percentage of children that were able to use the Likert scale successfully remains low
(Mellor & Moore, 2014). For children the easiest is a format that reflects frequency or
behaviours/thoughts (i.e., ‘never’ to ‘always’) (Mellor & Moore, 2014).This is
supported by the findings of this research; children had less difficulty filling in the
Children’s Coping Strategies Checklist-R2 (CCSC-R2), which was conducted for a
larger research. The CCSC-R2 is answered with a 5-point Likert scale from ‘never’ to
‘always’, compared to the questionnaires using a 5-point Likert scale from ‘totally
agree’ to ‘totally disagree’. Therefore the use of abstract answer formats like ‘totally
agree’ to ‘totally disagree’ lowers the reliability of the answers. Nevertheless there is
research supporting the use of Likert-scales with children, children chose the Likert28
scale above the Visual Analogue Scale (VAS) and the numeric VAS (Laerhoven, van
der Zaag-Loonen & Derkx, 2004). During the last round of questionnaires the social
workers made drawings of the scales, big for ‘totally agree’ and small for ‘totally
disagree’, this worked much better. A possible solution would therefore be to use
Likert-scales with meaningful and clear anchors, this should be taken in account in
future research.
The last observation made by the social workers about the use of the
instruments is that children answer the question about recent events instead of the
general past, while most questionnaires ask about the general past. This means, for
example, that if children were asked about their relationship with their family and
there brother or sister gave them a cookie last weekend, they would remember that
and say they have a good relationship. This lowers the reliability and validity of the
questionnaires.
The overall conclusion that can be made on the use of instruments working
with traumatized children in South Africa is that researchers should be aware of risks
that accompany the use of these instruments. Instruments and their interpretation
cannot be seen without the context (Lupele, Mwingi, Kinyanjui, Kimani & Kisamba,
2005). Research strongly advise researchers to include indigenous knowledge in the
design and implementation of questionnaires in Africa (Owusu-Ansah & Mji, 2013).
A start could be to modify current instruments and adapt them to be cultural equal and
cultural sensitive (Friedman, 2011). When the use of a translator is necessary, a
possible bias should be taken into account. Not only cultural differences should be
noted, also working with children and additional necessary adaptions should be an
important focus of future research.
This research
Apart from the sensitivity of PTSD symptoms in the population under study
and the cross-cultural validity of the instruments used, some additional insights were
experienced. These challenges have not been reported in previous studies, and are
important in order to formulate recommendations for future research.
29
One of the observations that was made, was a difference in attitude between
participants in the two branches, in specific between caregivers. In the Soweto branch
caregivers seemed willing to put effort in the healing process of their children, where
in the Krugersdorp branch caregivers were largely dependent on the clinic in terms of
transport arrangements and even to feed their children. Working with the Krugersdorp
branch caregivers was therefore more difficult and there was a lower commitment and
turn up. It is recommended to carefully consider the social and financial status of
participants and its implications when designing a program.
Another observation were challenges with punctuality and time management
between the researchers and the community involved. It was challenging making
appointments with the group, for instance the arrival time could vary from 2 hours too
early to 2 hours too late. Therefore it is recommended in future research to use
participants close to the clinic or use groups (like the safe house) who only need one
person to bring and collect them. Another solution would be to go to a place where all
the children are (i.e. at school), this was not possible during this research due to all the
public holidays.
It was also challenging administering questionnaires with the house parents of
the safe house. Housemothers/fathers were not constantly present to conduct all
questionnaires at the same time and some housemothers only knew the child for a
short while so they could not report on the child before the traumatic event. This
lowered the validity of the questionnaires, as a result of a systematic bias of less
accurate reporting for children in the safe house (Cluver et al., 2009). In addition a
limitation of this study is the use of different caregivers (parents, housemothers,
sisters, etc.). They all knew the child on a different level or in a different way, what
made the comparison biased. Future research should use the same kind of caregivers
for all children in their research.
Another incident with the children from the safe house was that after session 3
in the Krugersdorp branch the researchers found out that one of the children in the
group, who had a very dominant role, had abused at least 2 other children in the
group. This could have happened due to missing information in the files of the
children and lacking knowledge of the house mothers. Future research should conduct
a separate intake with the children, to make sure there is no missing information. This
child was present during the measurements prior to the therapy, influencing other
30
children. In the questionnaires this influence is found, the social desirability was high
in children sitting close to this boy. This makes the results of these children
understandable; questionnaires show no effect of the therapy, for they did not show
symptoms prior to the therapy. This boy was taken out of the therapy and the first
session was focused on the effect of his presents and acts, but the influence of his
company during the first sessions could not be undone.
Not only the children formed a social group, also the researchers became
acquaintances with the children and caregivers. This was especially noticed at post
measurements, children felt less scared to talk about their problems and feelings. This
is probably the reason why some children show more PTSD symptoms after CEAT in
comparison with before CEAT. This expectation corresponds with observations of the
researchers, which show less symptoms instead of more. Future research should try to
make a connection with the children before they conduct the research, so they will
have equal measurements.
The final limitation is that part of the control group (2) existed of children who
were part of pre-measurements but did not show for therapy. This could be explained
by a few factors; it could be that they were not motivated enough, or they had less
symptoms what made them need therapy less than other children, or they had less
social support what made the family not bring them to therapy. The consequence of a
control group that is not randomly assigned is a bias in the results. This should be
taken into account when interpreting the findings.
Conclusion
This study did evaluate the effect of CEAT and social support on PTSD symptoms in
sexually abused children in South Africa. Although no evidence was found in the
questionnaires for improved wellbeing in the children, probably due to the amount of
methodological constraints, observations and feedback from those involved in the
program were very positive. Referring back to the case study of Dembe, positive
changes were seen in is his behavior and feelings. Also, many insights and knowledge
was generated that can contribute to the current state of literature and benefit future
research in this context to a great extent. Future research could for instance focus on
the development of cultural sensitive instruments for the use in South Africa, making
31
use of indigenous knowledge. The most important finding is the serious need of more
research in this context.
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