Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Assessment and the Journal of Clinical Child and Adolescent Psychology's Evidence Base Updates Series: Evaluating the Tools for Gathering Evidence

In 2014, Michael Southam-Gerow and Mitch Prinstein launched the Evidence Base Updates series. As invited contributors, authors of Evidence Base Updates articles offer the field an invaluable resource: regular evaluations of the latest data on tools for addressing the mental health needs of children and adolescents. Until now, authors of Evidence Base Updates articles have focused exclusively on evaluating treatment techniques. In this article, we outline how the Evidence Base Updates series will evolve to also include evaluations of assessment techniques. In our treatment-focused updates, contributors follow strict criteria when evaluating the evidence. Following these criteria allows authors of Evidence Base Updates articles to provide mental health professionals with clear "take-home messages" about the evidence underlying the treatments evaluated. Similarly, we outline the criteria that authors will follow when preparing Evidence Base Updates articles that evaluate assessments. We also highlight the formats of these articles, which will include evaluations of condition-focused measures (e.g., anxiety, conduct problems); transdiagnostic constructs (e.g., parenting, rumination); specific, widely used measures that cut across conditions; and updates on field-wide considerations regarding measurement (e.g., clinical utility, incremental validity).

Mechanisms linking childhood adversity with psychopathology: Learning as an intervention target

Exposure to childhood adversity is common and a powerful risk factor for many forms of psychopathology. In this opinion piece, we argue for greater translation of knowledge about the developmental processes that are influenced by childhood adversity into targeted interventions to prevent the onset of psychopathology. Existing evidence has consistently identified several neurodevelopmental pathways that serve as mechanisms linking adversity with psychopathology. We highlight three domains in which these mechanisms are well-established and point to clear targets for intervention: 1) threat-related social information processing biases; 2) heightened emotional reactivity and difficulties with emotion regulation; and 3) disruptions in reward processing. In contrast to these established pathways, knowledge of how childhood adversity influences emotional learning mechanisms, including fear and reward learning, is remarkably limited. We see the investigation of these mechanisms as a critical next step for the field that will not only advance understanding of developmental pathways linking childhood adversity with psychopathology, but also provide clear targets for behavioral interventions. Knowledge of the mechanisms linking childhood adversity with psychopathology has advanced rapidly, and the time has come to translate that knowledge into clinical interventions to prevent the onset of mental health problems in children who have experienced adversity.

Are Psychotherapies for Young People Growing Stronger? Tracking Trends Over Time for Youth Anxiety, Depression, Attention-Deficit/Hyperactivity Disorder, and Conduct Problems

With the development of empirically supported treatments over the decades, have youth psychotherapies grown stronger? To investigate, we examined changes over time in treatment effects for four frequently treated youth mental-health problems: anxiety, depression, attention-deficit hyperactivity disorder (ADHD), and conduct disorders. We used PubMed and PsycINFO to search for randomized controlled trials (RCTs) that were published between January 1960 and May 2017 involving youths between the ages of 4 and 18 years. We also searched reviews and meta-analyses of youth psychotherapy research, followed reference trails in the reports we identified, and obtained additional studies identified by therapy researchers whom we contacted. We identified 453 RCTs (31,933 participants) spanning 53 years (1963-2016). Effect sizes for the problem-relevant outcome measures were synthesized via multilevel meta-analysis. We tracked temporal trends for each problem domain and then examined multiple study characteristics that might moderate those trends. Mean effect size increased nonsignificantly for anxiety, decreased nonsignificantly for ADHD, and decreased significantly for depression and conduct problems. Moderator analyses involving multiple study subgroups showed only a few exceptions to these surprising patterns. The findings suggest that new approaches to treatment design and intervention science may be needed, especially for depression and conduct problems. We suggest intensifying the search for mechanisms of change, making treatments more transdiagnostic and personalizable, embedding treatments within youth ecosystems, adapting treatments to the social and technological changes that alter youth dysfunction and treatment needs, and resisting old habits that can make treatments unduly skeuomorphic.

Pilot Evaluation of a Tablet-Based Application to Improve Quality of Care in Child Mental Health Treatment

Mental health systems need scalable solutions that can reduce the efficacy-effectiveness gap and improve mental health outcomes in community mental health service settings. Two major challenges to delivery of high-quality care are providers' fidelity to evidence-based treatment models and children's and caregivers' engagement in the treatment process. We developed a novel, tablet-based application designed to enhance via technology the quality of delivery of trauma-focused cognitive-behavioral therapy (TF-CBT). We piloted its use in four community mental health service organizations using a blocked randomized controlled trial to examine the feasibility of implementing tablet-facilitated TF-CBT versus standard TF-CBT with 13 providers and 27 families. Provider fidelity and child engagement in treatment were observationally measured via session audio recording. Parent and child perceptions of the tablet application were assessed using structured interviews and mixed-method analyses. Providers actively and appropriately used tablet TF-CBT to facilitate treatment activities. Providers and families expressed high satisfaction with its use, demonstrating acceptability of this approach. Youth and caregivers in both conditions reported high alliance with their providers. Overall, we found that tablet-facilitated treatment is accepted by providers and families and may be integrated into mental health treatment with minimal training. Further study is needed to examine the extent to which technology-based applications may enhance the reach, quality, and clinical outcomes of mental health treatment delivered to children and families.

Metacognitive Therapy for Posttraumatic Stress Disorder in Youth: A Feasibility Study

Metacognitive therapy (MCT) is an effective treatment for posttraumatic stress disorders (PTSD) in adults. However, there is no evidence for the feasibility, acceptability, and efficacy of MCT for PTSD in youth so far. This study is the first to utilize MCT for children and adolescents with PTSD. Twenty-one children and adolescents (aged 8-19 years) who were consecutively referred to the outpatient trauma clinic were treated with MCT. In all patients, treatment was well accepted and regularly attended. At post-treatment, MCT was associated with significant and large reductions in posttraumatic stress symptoms. Depending on the outcome measure, 95 or 85% of the patients were classified as recovered after treatment. Eighteen patients were included in the calculation of the overall outcome. Effect sizes on primary PTSD measures were large (Cohen's d = 3.42 and d = 1.92) and more than comparable to well-established treatments. Only six patients were available at follow-up, but their improvements were found to be stable. Despite the limitations of this uncontrolled study, the results suggest that MCT may be a feasible and promising treatment for traumatized children and adolescents and they justify a controlled trial evaluating the efficacy of MCT versus an already well-established intervention.

Benefits of Treatment Completion Over Premature Termination: Findings from the National Child Traumatic Stress Network

Objective: To evaluate potential differences in therapeutic outcomes between youths who completed a full course of treatment as planned compared to youths who terminated treatment prematurely. Method: Using longitudinal data from the National Child Traumatic Stress Network (NCTSN) Core Data Set, the present study examined demographic characteristics, trauma history, scores on standardized measures, and ratings of functional impairment and behavior problems in a large clinical sample of children and adolescents exposed to trauma who received treatment at NCTSN centers across the United States. Baseline and follow-up data were used to compare treatment completers (n= 3,108) and noncompleters (n = 4,029). Results: Both treatment completers and noncompleters received benefits from treatment by NCTSN mental health providers in that both groups showed significant decreases in mean scores from baseline to follow-up on all standardized measures. However, compared to noncompleters, treatment completers showed three types of significantly greater benefit at follow-up. These included: (a) greater rates of decline (i.e., steeper slopes) on all outcome measures; (b) greater reductions in the odds of falling within the clinical range on standardized measures; and (c) greater reductions in the odds of exhibiting functional impairment and behavior problems at follow-up. In contrast, compared to treatment completers, noncompleters reported significantly higher rates of lifetime exposure to community violence, psychological maltreatment, physical abuse, neglect, sexual abuse, and sexual assault. Conclusion: These findings underscore the value of incorporating engagement and retention strategies in treatments for traumatized youths to maximize therapeutic benefit and raise the standard of care.

Brief CBT group therapy for Mexican homeless girls

Homeless girls suffer labour and sexual exploitation, abuse, discrimination and social exclusion at a higher rate than the rest of the population. However, worldwide information on homeless girls and intervention programmes for this group are scarce. This study examined the preliminary efficacy of a brief cognitive behavioural group therapy tailored to Mexican homeless girls. The intervention targeted subjective well-being and these determinants: symptoms of anxiety, symptoms of depression, assertive behaviours and functional emotion regulation skills. Results revealed statistically significant differences in symptoms of anxiety and depression, assertiveness, emotion regulation strategies and subjective well-being with treatment effects that ranged from moderate to large. Symptoms of anxiety and depression, and dysfunctional emotion regulation strategies decreased. Assertive skills, functional emotion regulation strategies, and subjective well-being increased. Outcomes were clinically relevant. At 2-month follow-up, participants showed improvement from pre-treatment on all measures. The current study provides unique findings in terms of a promising preliminary intervention that helps restore homeless girls to a healthier social/emotional developmental path especially in the context of Latin American cities. As a result, the clinical implications of this research highlight the urgent need to design effective interventions based on the observed characteristics and identified needs among homeless girls.

Comorbidity of developmental trauma disorder (DTD) and post-traumatic stress disorder: findings from the DTD field trial

Background: Developmental trauma disorder (DTD) has been proposed to describe the biopsychosocial sequelae of exposure to interpersonal victimization in childhood that extend beyond the symptoms of post-traumatic stress disorder (PTSD). Objective: To characterize the psychopathology comorbid with DTD and to determine whether this comorbidity is distinct from, and extends beyond, comorbidities of PTSD. Method: DTD was assessed by structured interview, and probable Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) psychiatric disorders were identified with screening modules on the Kiddie Schedule for Affective Disorders and Schizophrenia, Present/Lifetime version (K-SADS-PL), in a multi-site sample of 236 children (7-18 years old; 50% female) referred by paediatric or mental health providers. Results: DTD (N = 80, 34%) and PTSD (N = 69, 29%) were highly comorbid and shared several DSM-IV internalizing disorder and DSM, 5th Edition (DSM-5) dysregulation disorder comorbidities. However, DTD, but not PTSD, was associated with comorbid panic disorder and disruptive behaviour disorders. On a multivariate basis including all probable DSM-IV disorders and DSM-5 dysregulation disorders, DTD was associated with separation anxiety disorder and attention deficit hyperactivity disorder after controlling for PTSD, while PTSD was associated with major depression and generalized anxiety disorder after controlling for DTD. Conclusions: DTD's comorbidities overlap with but extend beyond those of PTSD to include panic, separation anxiety, and disruptive behaviour disorders. DTD warrants further investigation as a potential diagnosis or a complex variant of PTSD in children, similar to the adult symptoms of disturbances of self-organization in the proposed International Classification of Diseases, 11th revision (ICD-11) complex post-traumatic stress disorder subtype.

Durability of Cognitive Behavioral Therapy Effects for Youth and Adolescents With Anxiety, Depression, or Traumatic Stress:A Meta-Analysis on Long-Term Follow-Ups

Cognitive behavioral therapies (CBT) for youth with anxiety, traumatic stress, and depression have demonstrated strong effects in individual studies and meta-analyses. Relatively more attention has been given to posttreatment effects, though, and assessment of follow-up effects has been limited at the meta-analytic level. The current meta-analysis aimed to (a) examine the effects of youth CBT at posttreatment, 1-month, 3-month, 6-month, 1-year, and long-term (2+ years) follow-up as well as (b) identify research-related variables (e.g., measure respondent type) that relate to effects. Using a random effects model across 110 child and adolescent CBT groups, within-group effect sizes were large at posttreatment (g = 1.24) and from 1-month through long-term follow-up (g = 1.23-1.82), and effect sizes did not significantly differ by treatment target (i.e., anxiety, traumatic stress, depression). However, availability of outcome data for effect sizes diminished across later follow-up assessments. Moreover, effect sizes were significantly associated with outcome respondent type across assessment timing, with outcome measures from caregiver and youth respondents associated with smaller effect sizes (B = -0.97, p < 0.001) relative to outcome measures that were evaluator-reported. Results provide initial support for the durability of treatment effects for youth CBTs and highlight the importance of some confounding variables. Implications for improving treatment research standards and prioritizing assessment of long-term follow-up assessment are discussed.

Implementing evidence-based treatment protocols: Flexibility within fidelity

Efficacious psychological treatments exist for a variety of mental health conditions, but many who could benefit from these treatments do not receive them. Increasing efforts have been made to disseminate effective protocols, and several approaches for implementing such treatments have been proposed, including the use of protocols, principles, practices, and policies. We discuss the relative merits of disseminating protocols, and highlight the importance of employing flexibility within fidelity. We describe the benefits of using protocols, including their empirical support, guidance for decision making, and structure to facilitate training and enhance treatment integrity. We also address several criticisms that have been offered against protocols, citing data that indicates that many of the criticisms are not warranted.

My First Time Hurt: Using Preschool PTSD Treatment to Address PTSD Symptoms in a Young Girl With a History of Pediatric Cancer

This case study followed a 4-year-old Caucasian female in cancer remission who presented with symptoms of posttraumatic stress disorder (PTSD). Given the age of this young girl and the health difficulties that she experienced, the preschool PTSD treatment (PPT) manual was implemented to address her distressing symptoms. In addition, it was important to include this young girl’s primary caregiver at each step of the treatment process. Following treatment, this young girl demonstrated significant improvement in her symptomology, as measured quantitatively and qualitatively. Further, this young girl was able to utilize the skills and techniques that she learned and generalize them to other circumstances that caused discomfort or emotional difficulty for her. This case study also demonstrated that incorporating intensive parental involvement with PPT can further the reduction of PTSD symptoms in young children who have experienced medically related trauma.

AF-CBT for Families Experiencing Physical Aggression or Abuse Served by the Mental Health or Child Welfare System: An Effectiveness Trial

The Partnerships for Families project is a randomized clinical trial to evaluate the effectiveness of Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT), an evidence-based treatment (EBT) for families who are at risk of or have histories of child physical abuse. Across 10 agencies whose programs were supported by referrals from the mental health or child welfare system, individual providers were randomized to receive AF-CBT training ( n = 90) in a 6-month learning community or treatment as usual (TAU; n = 92) which provided trainings per agency routine. We recruited families served by providers in the AF-CBT ( n = 122) and TAU ( n = 73) conditions and collected multiple outcomes at up to four time points (0, 6, 12, and 18 months). Using univariate tests and growth curve models, the analyses revealed that AF-CBT (vs. TAU) showed improvements in both service systems (e.g., abuse risk, family dysfunction) or one service system (e.g., threats of force, child to parent minor assault), with some outcomes showing no improvement (e.g., parental anger). These findings are discussed in relation to AF-CBT, service system, provider, and family characteristics, and training/dissemination methods that affect the delivery of an EBT for this population in community settings.

Implementation Climate and Time Predict Intensity of Supervision Content Related to Evidence Based Treatment

Objective: Children infrequently receive evidence-based treatments (EBTs) for mental health problems due to a science-to-practice implementation gap. Workplace-based clinical supervision, in which supervisors provide oversight, feedback, and training on clinical practice, may be a method to support EBT implementation. Our prior research suggests that the intensity of supervisory focus on EBT (i.e., thoroughness of coverage) during workplace-based supervision varies. This study explores predictors of supervisory EBT intensity.

Methods: Participants were twenty-eight supervisors and 70 clinician supervisees. They completed a baseline survey, and audio recorded supervision sessions over 1 year. Four hundred and thirty eight recordings were coded for supervision content. We chose to explore predictors of two EBT content elements due to their strong evidence for effectiveness and sufficient variance to permit testing. These included a treatment technique (“exposure”) and a method to structure treatment (“assessment”). We also explored predictors of non-EBT content (“other topics”). Mixed-effects models explored predictors at organizational/supervisor, clinician, and session levels.

Results: Positive implementation climate predicted greater intensity of EBT content coverage for assessment (coefficient = 0.82, p = 0.004) and exposure (coefficient = 0.87, p = 0.001). Intensity of exposure coverage was also predicted by more time spent discussing each case (coefficient = 0.04, p < 0.001). Predictors of greater non-EBT content coverage included longer duration of supervision sessions (coefficient = 0.05, p < 0.001) and lower levels of supervisor EBT knowledge (coefficient = −0.17, p = 0.013). No other supervisor- or clinician-level variables were significant predictors in the mixed effects models.

Conclusion: This was the first study to explore multi-level predictors of objectively coded workplace-based supervision content. Results suggest that organizations that expect, support and reward EBT are more likely to have greater intensity of EBT supervision coverage, which in turn may positively impact clinician EBT fidelity and client outcomes. There was evidence that supervisor knowledge of the EBT contributes to greater coverage, although robust supervisor and clinician factors that drive supervision are yet to be identified. Findings highlight the potential effectiveness of implementation strategies that simultaneously address organizational implementation climate and supervisor practices. More research is needed to identify mechanisms that support integration of EBT into supervision.

Mental and sexual health outcomes following sexual assault in adolescents: a prospective cohort study

BACKGROUND

Young people are disproportionately affected by sexual assault, yet longitudinal data are sparse. This paper examines the characteristics of adolescents presenting to sexual assault services and mental and sexual health outcomes after an assault.

METHODS

This was a prospective cohort study in adolescents aged 13-17 years attending the Sexual Assault Referral Centres serving Greater London, UK, over 2 years. Baseline interviews (T0) were done less than 6 weeks after an assault to collect data on sociodemographic and assault characteristics and psychological symptoms, with follow-up interviews (T1) at 4-5 months after the assault. Four psychological symptom questionnaires were used at T0 and T1: The Child Revised Impact of Events Scale, the Short Mood and Feelings Questionnaire, the Screen for Child Anxiety Related Disorders, and the Strengths and Difficulties Questionnaire. The primary outcome was prevalence of any psychiatric disorder at T1, assessed using the Development and Wellbeing Assessment. Secondary outcomes at T1 were pregnancy, sexually transmitted infections, and sexual health screening since the assault.

FINDINGS

Between April 15, 2013, and April 20, 2015, 141 (29%) of 491 eligible young people were recruited to the study (134 females; mean age 15·6 years [SD 1·27]), and 106 (75%) of 141 participants had T1 interviews (99 female). At T0, psychological symptom scores showed that 115 (88%) of 130 females were at risk for depressive disorder, 90 (71%) of 126 were at risk for anxiety disorders, and 116 (91%) of 128 were at risk for post-traumatic stress disorder, with symptoms largely persisting at T1. 68 (80%) of 85 females who had a diagnostic assessment at T1 had a psychiatric disorder, with multiple disorders in 47 (55%) of 85. Anxiety, post-traumatic stress, and major depressive disorders were the commonest diagnoses. Presence of a psychiatric disorder was associated with baseline psychosocial vulnerability (previous social services involvement, mental health service use, self-harm, or sexual abuse), but not assault characteristics. At T1, four (4%) of 105 females had been pregnant since the assault, 14 (12%) of 119 had a sexually transmitted infection diagnosed between T0 and T1, and nine (8%) of 107 reported re-victimisation since the assault.

INTERPRETATION

Vulnerable adolescents have the double disadvantage of being at risk for both sexual assault and associated psychiatric disorders, highlighting the need for comprehensive support after an assault. Feasibility and effectiveness of prevention programmes should be investigated.

FUNDING

National Institute for Health Research Policy Research Programme grant (115/0001).

Supervision in Community Mental Health: Understanding Intensity of EBT Focus

The goal of the present study was to examine clinician, supervisor, and organizational factors that are associated with the intensity of evidence-based treatment (EBT) focus in workplace-based clinical supervision of a specific EBT, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Supervisors (n = 56) and clinicians (n = 207) from mental health organizations across Washington State completed online self-report questionnaires. Multilevel modeling (MLM) analyses were used to examine the relative influence of nested clinician and supervisor factors on the intensity of EBT focus in supervision. We found that 33% of the variance in clinician report of EBT supervision intensity clustered at the supervisor level and implementation climate was the only significant factor associated with EBT supervision intensity. While individual clinician and supervisor factors may play a role in EBT coverage in supervision, our results suggest that an implementation climate that supports EBT may be the most critical factor for improving intensity of EBT coverage. Thus, implementation efforts that address the extent to which EBTs are expected, rewarded, and supported within an organization may be needed to support greater coverage of EBT during workplace-based supervision.

Cost-Effectiveness Analysis of Trauma-Focused Cognitive Behavioral Therapy: A Randomized Control Trial among Norwegian Youth

Traumatic events by young people can adversely affect their psychological and social well-being when left untreated. This can result in high costs for society. In this study, we aimed to evaluate whether trauma-focused cognitive behavioral therapy (TF-CBT) is a cost-effective alternative to therapy as usual (TAU). Individual-level data were collected from 2008 to 2013, as part of a randomized control trial in Norwegian youth, 10-18 years of age, presenting with symptoms of posttraumatic stress (N = 156). Health outcomes, costs, and patient and family characteristics were recorded. Health-related quality of life (HRQoL) was measured with the 16D instrument, and quality-adjusted life-years (QALYs) were derived; total costs included the costs of therapy, and last we calculated the incremental cost-effectiveness ratio (ratio of differences in costs and QALYs gained). We performed nonparametric bootstrapping and used the results to draw a cost-effectiveness acceptability curve depicting the probability that TF-CBT is cost-effective. HRQoL increased in both treatment groups, whereas no significant differences in QALYs were observed. Resource use measured in minutes per session was significantly higher in the TF-CBT group; however, total minutes of therapy and costs were not significantly different between the two groups. In addition, use of resources, such as psychological counseling services, welfare services, and medication, was lower in the TF-CBT group posttreatment. The likelihood of TF-CBT being cost-effective varied from 91% to 96%. TF-CBT is likely to be a cost-effective alternative to standard treatment and should be recommended as the guideline treatment for youth with posttraumatic stress disorder.

Comparative efficacy and acceptability of psychotherapies for post-traumatic stress disorder in children and adolescents: study protocol for a systematic review and network meta-analysis

INTRODUCTION

Post-traumatic stress disorder (PTSD) is common among children and adolescents who are exposed to trauma, and it is often associated with significant negative impacts on their psychosocial functioning and quality of life. Many types of psychotherapies have been found to be effective for PTSD in children and adolescents. However, due to the lack of direct comparisons between different psychotherapies, the hierarchy of treatment efficacy is still unclear. Therefore, we plan to conduct a systematic review and network meta-analysis to evaluate the efficacy and acceptability of various types of psychotherapies for PTSD in children and adolescents.

METHODS AND ANALYSIS

A systematic search will be conducted among eight electronic databases, including PubMed, Cochrane, Embase, Web of Science, PsycINFO, Cumulative Index of Nursing and Allied Health, Published International Literature on Traumatic Stress (PILOTS) and ProQuest Dissertations, from inception to October 2017. Randomised controlled trials, regardless of language, publication year and publication type, comparing any psychotherapies for PTSD to any control condition or alternative treatment in children and adolescents (18 years old or less) diagnosed with full or subclinical PTSD will be included. Study duration and the number of treatment sessions will not be limited. The primary outcome will be PTSD symptom severity at post-treatment as measured by a rating scale reported by the child, parent or a clinician. The secondary outcomes will include: (1) efficacy at follow-up; (2) acceptability (all-cause discontinuation); (3) anxiety symptom severity; (4) depressive symptom severity and (5) quality of life and functional improvement. Bayesian network meta-analyses for all relative outcome measures will be performed. We will conduct subgroup and sensitivity network meta-analyses to determine whether the findings are affected by study characteristics. The quality of the evidence contributing to network estimates of the primary outcome will be evaluated by the Grading of Recommendations, Assessment, Development and Evaluations framework.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. The results will be published in a peer-reviewed journal, which will be disseminated electronically and in print. This network meta-analysis may be updated to inform and guide the clinical management of PTSD in children and adolescents.

PROSPERO REGISTRATION NUMBER

CRD42016051786.

Successful treatment of methotrexate intolerance in juvenile idiopathic arthritis using eye movement desensitization and reprocessing - treatment protocol and preliminary results

BACKGROUND

Methotrexate (MTX), commonly used in juvenile idiopathic arthritis (JIA), frequently has to be discontinued due to intolerance with anticipatory and associative gastrointestinal adverse effects. Eye Movement Desensitization and Reprocessing (EMDR) is a psychological method where dysfunctional experiences and memories are reprocessed by recall combined with bilateral eye movements. The objective of this study was to assess efficacy of EMDR for treatment of MTX intolerance in JIA patients.

METHODS

We performed an open prospective study on consecutive JIA patients with MTX intolerance. Intolerance was determined using the Methotrexate Intolerance Severity Score (MISS) questionnaire prior to treatment, directly after treatment and after four months. Health-related quality of life was determined using the PedsQL prior to and four months after treatment. Patients were treated according to an institutional EMDR protocol with 8 sessions over two weeks. Changes in MISS and PedsQL were analyzed using non-parametric statistics.

RESULTS

Eighteen patients with MTX intolerance (median MISS at inclusion 16.5, IQR = 11.75-20.25) were included. Directly after treatment, MTX intolerance symptoms were significantly improved (median MISS 1 (IQR = 0-2). After four months, median MISS score was at 6.5 (IQR = 2.75-12.25, p = 0.001), with 9/18 patients showing MISS scores ≥6. Median PedsQL after 4 months improved significantly from 77.6% to 85.3% (p = 0.008).

CONCLUSION

MTX intolerance in children with JIA was effectively treated using an EMDR protocol, with lasting effect over a period of 4 months. EMDR treatment can potentially increase quality of life of affected patients and enable continued MTX treatment.

Feasibility and acceptability of two incentive-based implementation strategies for mental health therapists implementing cognitive-behavioral therapy: a pilot study to inform a randomized controlled trial

BACKGROUND

Informed by our prior work indicating that therapists do not feel recognized or rewarded for implementation of evidence-based practices, we tested the feasibility and acceptability of two incentive-based implementation strategies that seek to improve therapist adherence to cognitive-behavioral therapy for youth, an evidence-based practice.

METHODS

This study was conducted over 6 weeks in two community mental health agencies with therapists (n = 11) and leaders (n = 4). Therapists were randomized to receive either a financial or social incentive if they achieved a predetermined criterion on adherence to cognitive-behavioral therapy. In the first intervention period (block 1; 2 weeks), therapists received the reward they were initially randomized to if they achieved criterion. In the second intervention period (block 2; 2 weeks), therapists received both rewards if they achieved criterion. Therapists recorded 41 sessions across 15 unique clients over the project period. Primary outcomes included feasibility and acceptability. Feasibility was assessed quantitatively. Fifteen semi-structured interviews were conducted with therapists and leaders to assess acceptability. Difference in therapist adherence by condition was examined as an exploratory outcome. Adherence ratings were ascertained using an established and validated observational coding system of cognitive-behavioral therapy.

RESULTS

Both implementation strategies were feasible and acceptable-however, modifications to study design for the larger trial will be necessary based on participant feedback. With respect to our exploratory analysis, we found a trend suggesting the financial reward may have had a more robust effect on therapist adherence than the social reward.

CONCLUSIONS

Incentive-based implementation strategies can be feasibly administered in community mental health agencies with good acceptability, although iterative pilot work is essential. Larger, fully powered trials are needed to compare the effectiveness of implementation strategies to incentivize and enhance therapists' adherence to evidence-based practices such as cognitive-behavioral therapy.

Psychiatric Nursing's Role in Child Abuse: Prevention, Recognition, and Treatment

Child abuse affects hundreds of thousands of children in the United States each year. The effects from maltreatment extend beyond the physical injuries-the lasting effects on the child's mental health can be lifelong. Psychiatric nurses have a vital role to play in the prevention, recognition, and treatment of child abuse. [Journal of Psychosocial Nursing and Mental Health Services, 55(11), 16-20.].

The relationship between consumer, clinician, and organizational characteristics and use of evidence-based and non-evidence-based therapy strategies in a public mental health system

We investigated the relationship between consumer, clinician, and organizational factors and clinician use of therapy strategies within a system-wide effort to increase the use of cognitive-behavioral therapy. Data from 247 clinicians in 28 child-serving organizations were collected. Clinicians participating in evidence-based practice training initiatives were more likely to report using cognitive-behavioral therapy when they endorsed more clinical experience, being salaried clinicians, and more openness to evidence-based practice. Clinicians participating in evidence-based practice initiatives were more likely to use psychodynamic techniques when they had older clients, less knowledge about evidence-based practice, more divergent attitudes toward EBP, higher financial strain, and worked in larger organizations. In clinicians not participating in evidence-based training initiatives; depersonalization was associated with higher use of cognitive-behavioral; whereas clinicians with less knowledge of evidence-based practices were more likely to use psychodynamic techniques. This study suggests that clinician characteristics are important when implementing evidence-based practices; and that consumer, clinician, and organizational characteristics are important when de-implementing non evidence-based practices. This work posits potential characteristics at multiple levels to target with implementation and deimplementation strategies.

Changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress symptoms

OBJECTIVE

To understand the meaning of trauma narration, we examined changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy (TF-CBT) and explored the relationship between changes in narratives and in posttraumatic stress.

METHOD

The sample consisted of 12 non-responders and 12 maximum-responders to treatment (M = 14.3, SD = 2.35, range = 10-17; 75% girls). The youth were assessed with the Clinical-Administered PTSD-Scale for Children and Adolescents both pre- and post-treatment. Their first and last narratives were coded according to a standardized coding manual.

RESULTS

For the group as a whole there was an increase in organized thoughts and reports of internal events (e.g., descriptions of thoughts and feelings), while narrative fragmentation decreased. There were no significant narrative changes in external events (e.g., descriptions of actions and dialogues). Max-responders differed significantly from non-responders in developing more organized thoughts. We did not find a significant relationship between changes in narratives and changes in posttraumatic stress symptoms (PTSS).

CONCLUSIONS

Youth receiving TF-CBT develop narratives that contain more organized thoughts and a greater internal focus, which are both thought to be helpful for traumatized youth. However, more coherent and organized trauma narratives were not related to reductions in PTSS. Clinical or methodological significance of this article: This study suggests that trauma-focused cognitive behavioral therapy contributes to more organized and coherent trauma narratives for traumatized youth. Although, this may be important and contribute to meaning making, therapist should be aware that this may not be sufficient in reducing posttraumatic stress symptoms in youth.

Child Trauma Exposure and Psychopathology: Mechanisms of Risk and Resilience

Exposure to trauma in childhood is associated with elevated risk for multiple forms of psychopathology. Here we present a biopsychosocial model outlining the mechanisms that link child trauma with psychopathology and protective factors that can mitigate these risk pathways. We focus on four mechanisms of enhanced threat processing: information processing biases that facilitate rapid identification of environmental threats, disruptions in learning mechanisms underlying the acquisition of fear, heightened emotional responses to potential threats, and difficulty disengaging from negative emotional content. Supportive relationships with caregivers, heightened sensitivity to rewarding and positive stimuli, and mature amygdala-prefrontal circuitry each serve as potential buffers of these risk pathways, highlighting novel directions for interventions aimed at preventing the onset of psychopathology following child trauma.

Differential associations of threat and deprivation with emotion regulation and cognitive control in adolescence

Research on childhood adversity has traditionally focused on single types of adversity, which is limited because of high co-occurrence, or on the total number of adverse experiences, which assumes that diverse experiences influence development similarly. Identifying dimensions of environmental experience that are common to multiple types of adversity may be a more effective strategy. We examined the unique associations of two such dimensions (threat and cognitive deprivation) with automatic emotion regulation and cognitive control using a multivariate approach that simultaneously examined both dimensions of adversity. Data were drawn from a community sample of adolescents (N = 287) with variability in exposure to violence, an indicator of threat, and poverty, which is associated with cognitive deprivation. Adolescents completed tasks measuring automatic emotion regulation and cognitive control in neutral and emotional contexts. Violence was associated with automatic emotion regulation deficits, but not cognitive control; poverty was associated with poor cognitive control, but not automatic emotion regulation. Both violence and poverty predicted poor inhibition in an emotional context. Utilizing an approach focused on either single types of adversity or cumulative risk obscured specificity in the associations of violence and poverty with emotional and cognitive outcomes. These findings suggest that different dimensions of childhood adversity have distinct influences on development and highlight the utility of a differentiated multivariate approach.