Posttraumatic symptoms and cognitions in parents of children and adolescents with PTSD

The therapist role in parent-led cognitive behavioral therapy for children after trauma: treating trauma from a distance

This article examines the therapist experience of their role in providing Stepped Care Cognitive-Behavioral-Therapy for Children after Trauma (SC-CBT-CT), a semi-homebased, parent-led trauma-treatment for children (7-12). Previous research has documented that parent-led, therapist-assisted psychological interventions are an acceptable and effective type of service delivery. Yet, the therapist perspective on their role when providing parent-led treatments has received limited research attention. Attention is therefore directed to the therapist experience of engaging parents, establishing relationships, and working with children's trauma narratives from a distance-through the engagement of parents. The data material consists of semi-structured interviews with SC-CBT-CT therapists. To identify patterns of experience, thought, and viewpoints in the overall data, a stepwise thematic analysis approach was applied. Two core themes emerged: 1) Perceptions of therapeutic control and therapeutic presence when engaging parents to lead their own children through an exposure-based program; 2) Establishment and maintenance of therapeutic alliances with and between parents and children. Although parents are inherently well-positioned to engage with their own children about trauma, the article highlights that treatment adherence, progression, and perseverance is contingent upon systematic therapist guidance, monitoring, and availability for support and problem-solving.

The bidirectional associations between caregiver and child symptoms in the parent-led treatment stepping together for children after trauma

BACKGROUND

An innovative approach to child trauma treatment in which caregivers are allocated treatment tasks has shown promising results, but less is known about the bidirectional associations between caregiver and child symptoms during treatment.

METHODS

Eighty-two child-caregiver dyads who participated in the parent-led therapist-assisted Stepping Together for Children after Trauma (ST-CT) were included (child age: 7-12 years, mean = 9.9 years). Caregivers' emotional reactions and anxiety/depression and children's posttraumatic stress (PTS) and depression were assessed pretreatment, mid-treatment, and posttreatment. We investigated the possible directional associations between caregivers' emotional reactions and anxiety/depression and children's PTS and depression using random intercept cross-lagged panel models.

RESULTS

Symptoms improved in both caregivers and children. Lower levels of caregiver emotional reactions at pretreatment predicted improved child PTS at mid-treatment; lower levels of caregiver emotional reactions at mid-treatment predicted improved child depression at posttreatment; and lower levels of child PTS at mid-treatment predicted improved caregiver emotional reactions at posttreatment.

CONCLUSIONS

These findings suggest that caregivers and children can impact each other's responses to a parent-led child trauma-focused treatment. Notably, children with caregivers who were less affected by their own emotional reactions exhibited greater improvement in both PTS and depression. Supporting the caregivers may benefit both children and caregivers.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862.

Perceived parental depression, intrusive rumination, and internalizing problems: A three-wave longitudinal study in adolescents

Research suggests that perceiving parental depression elicits internalizing problems in adolescents, but certain studies have indicated that adolescents' internalizing problems also increase their perception of parental emotion. To further investigate the inconsistent findings about the nature of this relationship, the current study used longitudinal data to examine the causal association between adolescents' internalizing problems and the parental depression they perceived, as well as the role of intrusive rumination in the relationship. Method: In this longitudinal study, 392 adolescents who experienced the catastrophic Jiuzhaigou earthquake in 2017 were surveyed at three time points after the earthquake: 12 months (T1), 21 months (T2) and 27 months (T3). A cross-lagged panel model was used to carry out the data analysis. Results: Mutual cause-and-effect relationships were found between intrusive rumination and both perceived parental depression and internalizing problems, respectively; a unilateral causal relationship in which internalizing problems positively predicted perceived parental depression was also found. In addition, internalizing problems predicted perceived parental depression via the mediating role of intrusive rumination; similarly, intrusive rumination predicted perceived parental depression via internalizing problems. Conclusions: Internalizing problems were a risk factor for perceived parental depression, and intrusive rumination played an important role in the relationship between internalizing problems and perceived parental depression.

Parent-Led Stepped Care Trauma Treatment: Parents' Experiences With Helping Their Child Recover

Purpose

There is a need for interventions for traumatized children that are easily accessible and effective, and that involve parents directly in the recovery process. To meet this challenge, stepped care trauma-focused cognitive behavioral treatment (SC TF-CBT), which consists of a parent-led therapist-assisted intervention as the first step, was developed. Parent-led trauma-treatment is a promising, but novel approach. The aim of this study was therefore to gain knowledge on how parents experience the model.

Methods

Parents who participated in a SC TF-CBT feasibility study were consecutively recruited and interviewed with semi-structured interviews, which were then analysed using interpretative phenomenological analysis.

Results

The parents described that the intervention gave them insights that led to a sense of parental agency. Through the analysis we identified and labelled four themes: (i) understanding my child: how the trauma has affected my child and our relationship; (ii) understanding myself: how my reactions have stood in the way of helping my child; (iii) gaining competence: how to learn specific tasks that were not part of my normal parenting skills; and (iv) receiving support: how guidance, warmth and encouragement was necessary.

Conclusions

The results from this study show how the shifting of therapeutic tasks to parents may facilitate parental empowerment and improve the parent-child relationship. This knowledge may guide clinicians on how to provide support to parents so they can take a leading role in their child's recovery process after trauma.

Trial registration

ClinicalTrials.gov, NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019), https://clinicaltrials.gov/ct2/show/NCT04073862.

A predictive coding account of value-based learning in PTSD: Implications for precision treatments

While there are a number of recommended first-line interventions for posttraumatic stress disorder (PTSD), treatment efficacy has been less than ideal. Generally, PTSD treatment models explain symptom manifestation via associative learning, treating the individual as a passive organism - acted upon - rather than self as agent. At their core, predictive coding (PC) models introduce the fundamental role of self-conceptualisation and hierarchical processing of one's sensory context in safety learning. This theoretical article outlines how predictive coding models of emotion offer a parsimonious framework to explain PTSD treatment response within a value-based decision-making framework. Our model integrates the predictive coding elements of the perceived: self, world and self-in the world and how they impact upon one or more discrete stages of value-based decision-making: (1) mental representation; (2) emotional valuation; (3) action selection and (4) outcome valuation. We discuss treatment and research implications stemming from our hypotheses.

A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents

This multi-level meta-analysis tested if evidence-based trauma treatment was effective in reducing trauma symptoms and externalizing behavior problems in adolescents. Based on eight independent samples and 75 effect sizes, results indicated that Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization Reprocessing (EMDR) had a large and significant overall effect (d = 0.909) on reducing trauma symptoms and externalizing behavior problems. Trauma treatment significantly decreased trauma symptoms (large effect) and externalizing behavior problems (medium effect). Age and type of control group moderated treatment effects. Treatment was more effective in older adolescents. Trauma treatment for adolescents with externalizing behavior problems had a larger effect compared to no treatment, but not compared to treatment as usual. It seems important to provide a broad treatment offer for adolescents with severe externalizing behavior problems, in which, besides trauma treatment, attention is paid to reducing relevant individual risk factors for behavior problems.

Social phobic beliefs mediate the relationship between post-event processing regarding the worst socially aversive experience and fear of negative evaluation

The experience of socially aversive events is proposed to be a critical etiological factor in the development of social anxiety symptoms even though the experience itself is also common among healthy individuals. Rather than the event itself, accompanying factors such as maladaptive processing might be associated with higher levels of social anxiety symptoms. One-hundred-seventy-four individuals participated in this online-survey comprising questionnaires regarding social anxiety symptoms and retrospective reports concerning maladaptive processing of the worst socially aversive event. Structural equation modelling was used to analyze the hypothesized mediation of maladaptive processing and fear of negative evaluation by intrusive re-experiencing and social phobic beliefs. The positive association between retrospectively evaluated maladaptive processing after the worst socially aversive event and fear of negative evaluation was mediated by social phobic beliefs but not by intrusive re-experiencing. These results point towards the relevance of further investigating processing strategies after socially aversive events as a potential influencing factor for SAD development. Trial registration. The trial was registered at the German Clinical Trial Register (DRKS00021502) on June 3rd, 2020.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12144-022-02805-9.

The Change in Parental Symptoms and Dysfunctional Cognitions in the Course of Trauma-Focused Cognitive-Behavioral Therapy: Sustainability Until One-Year Post-Treatment

Objectives: Symptoms of distress and dysfunctional posttraumatic cognitions (PTCs) have been frequently described in parents of children and adolescents with posttraumatic stress symptoms (PTSS), especially if the parents had experienced traumatic events themselves. The inclusion of non-offending parents in trauma-focused cognitive-behavioral therapy (TF-CBT) for children and adolescents may, thus, help parents to cope with the traumatic experience of their child. The aim of this study is to investigate the effects of TF-CBT on the parents, while taking their own history of traumatic experiences into account. Methods: Parents (N = 57, 84.2% mothers) of children and adolescents who received TF-CBT completed the Posttraumatic Diagnostic Scale, the Beck Depression Inventory, the State-Trait Anxiety Inventory, and the Posttraumatic Cognitions Inventory. Treatment effects and the sustainability at 6- and 12 months post-treatment were tested via repeated-measures analysis of variance, following the intention-to-treat approach. Results:N = 19 (35.2%) of the parents evaluated their child's trauma as the worst event, 18 (33.3%) rated their own experience as their worst event, and 17 (31.5%) indicated that their own worst traumatic experience was the same type as their child's trauma. Significant improvements (p < 0.001) emerged for parental PTSS [F(2, 837) = 8.27; d = 0.30], depression [F(3, 284) = 14.73; d = 0.41], anxiety symptoms [F(3, 185) = 17.44; d = 0.64], and dysfunctional PTCs [F(2, 465) = 13.58; d = 0.46]. Sustainability of these treatment gains remained at both follow-up time points (p < 0.05). There was no interaction between the time and the reference person of the traumatic index event, reported by parents. Conclusion: These results indicate parental benefits from participation in TF-CBT delivered to their child, until 1-year post-treatment and independently from the parental trauma history. The ongoing tendency of improvement might indicate that TF-CBT furnishes children and their parents with skills to further reduce the impact of their traumatic memories. ClinicalTrials.gov NCT01516827.

Post-Traumatic Stress Reactions in Caregivers of Children and Adolescents/Young Adults with Severe Diseases: A Systematic Review of Risk and Protective Factors

Severe illnesses in children and adolescents/young adults (AYAs) may represent a complex burden for patients and their caregivers, including a wide range of mental disorders, particularly post-traumatic stress disorder (PTSD). Few events are as potentially traumatizing as having a son or a daughter diagnosed with a severe, life-threatening, or disabling disease. The presence of PTSD symptoms in caregivers may compromise their efficacy as caregivers and negatively affect the child’s well-being. This systematic review aims at outlining potential risk and protective factors for the development of PTSD symptoms in caregivers of children and AYAs affected by severe acute or chronic illnesses. Thirty-one studies on caregivers of children and AYAs affected by severe, acute, or chronic diseases were included. Socio-demographic and socio-economic characteristics, illness-related distress, psychiatric symptoms, support, and coping styles were found as potential risk/protective factors across studies. It is crucial to consider risk factors affecting caregivers of severely ill young patients, in order to plan focused interventions aimed at preventing an adverse clinical outcome in caregivers and at enhancing caregivers’ coping skills, in order to ultimately improve their quality of life.

Trauma-Focused Cognitive-Behavioral Therapy: The role of caregivers

BACKGROUND

Childhood trauma exposure is unfortunately common and is associated with the development of posttraumatic stress disorder (PTSD) as well as a number of other serious medical and mental and health disorders. After experiencing trauma, children depend on their non-offending parents to believe and support them, reframe the meaning of the trauma, and to keep them safe from future harm. Parents are often negatively impacted by their child's trauma which may contribute to the child's risk for developing PTSD and related problems. Including parents in treatment may enhance child outcomes.

METHODS

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is an evidence-based child and adolescent trauma treatment model that integrally includes non-offending parents or caregivers throughout treatment (hereafter referred to as "caregivers"). This article describes TF-CBT's underlying concepts, principles and core components, as well as the role of caregiver inclusion in this model, and evaluates the extant evidence for caregiver factors in predicting TF-CBT outcomes.

RESULTS

Several studies suggest that inclusion of non-offending caregivers is associated with TF-CBT outcomes, and that this may occur through enhancing caregiver support of the child and/or reducing caregivers' trauma-related maladaptive cognitions.

LIMITATIONS

Few studies have evaluated whether caregiver factors served as formal treatment mediators.

CONCLUSIONS

Including non-offending caregivers in TF-CBT can improve youth outcomes.

Posttraumatic Stress and Parenting Behaviors: The Mediating Role of Emotion Regulation

PURPOSE

Maternal trauma has been linked with problematic parenting, including both harsh and permissive behaviors. However, little is known about mechanisms accounting for this association. The current study examined the potential impact of posttraumatic stress disorder (PTSD) and emotion regulation on dysfunctional parenting behaviors in a sample of community mothers. We hypothesized a mediation model wherein PTSD would be associated with dysfunctional parenting (i.e., lax and overreactive behaviors) indirectly through deficits in maternal emotion regulation.

METHOD

Seventy-eight community mothers of 18- to 36-month-old children were administered the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and 19 mothers met criteria for PTSD. Mothers also completed self-report measures of difficulties with emotion regulation and maternal laxness and overreactivity in parenting.

RESULTS

Results revealed that emotion dysregulation fully mediated relations between PTSD status and lax (but not overreactive) parenting behaviors. Compared to mothers without PTSD, those with PTSD reported greater lax parenting behaviors indirectly through greater emotion dysregulation.

CONCLUSIONS

Mothers with PTSD may struggle to parent assertively when trauma symptoms interfere with emotion regulation abilities. The current study highlights the need to design interventions focused on helping trauma-exposed mothers manage distress, ultimately aiming to enhance parenting effectiveness and improve child outcomes.

Parents' memories and appraisals after paediatric burn injury: a qualitative study

Background: It is well established that a paediatric burn injury can lead to parental post-traumatic stress symptoms. The content of parents' memories and appraisals may reveal the traumatic experiences that need attention. Objective: To inform clinical practice, the aim of this study was to qualitatively examine parents' (intrusive) memories and appraisals, and associated emotions, concerning the injury, the hospitalisation, and its consequences. Method: Approximately three to six months after the burn event, semi-structured interviews were conducted with parents of 18 children (0-16 years old) that had been hospitalised for a burn injury. Thematic analysis was carried out to obtain themes. Results: A central element in parents' memories and appraisals was a sense of external or internal threat. Intrusive memories were predominantly related to the accident and first aid (i.e. threat of the injury), whereas parents' memories about the child's suffering were emotional but not experienced as intrusive. Later appraisals of the burn injury and its consequences included negative appraisals of the child's increased vulnerability, responsibility of self or other, the child's prolonged suffering and (risk of) permanent change, as well as appraisals of positive outcome and recovery. Emotions commonly reported in the context of memories and appraisals were fear, sadness, guilt, and relief. Conclusions: This study offers insight into the traumatic nature of paediatric burn injury from the parent's perspective and provides directions for the delivery of trauma-informed (after)care.

Development and Evaluation of the Thinking About Recovery Scale: Measure of Parent Posttraumatic Cognitions Following Children's Exposure to Trauma

Researchers have recently suggested that parent posttraumatic appraisals potentially contribute to the development of posttraumatic stress in both parents and children following children's exposure to trauma. However, a single-instrument, multidimensional measure of parent posttraumatic cognitions as they relate to their child's recovery has yet to be operationalized. This study described the development and evaluation of a parent-report questionnaire of parent posttraumatic cognitions, designed to be used after a child's exposure to trauma. We generated an initial pool of items in reference to existing theories and subjected this list to an iterative process of item writing and revision. Items were subjected to expert review to maximize construct validity. The 33-item Thinking About Recovery Scale (TARS), which measures three domains (My child has been permanently damaged; The world is dangerous for my child; Parents should always promote avoidance) demonstrated good internal consistency (Cronbach's α = .74-88) and convergent validity (r ² range = .08-.40) when piloted in a sample of 116 parents of children who had been exposed to a serious accidental injury. The TARS augments the available literature by providing a brief measure of parent posttraumatic cognitions, an area which is currently understudied in childhood posttraumatic stress and could have broad clinical and research use.

Change in Parental Depressive Symptoms in Trauma-Focused Cognitive-Behavioral Therapy: Results from a Randomized Controlled Trial

OBJECTIVES

Depressive symptoms are frequently described in parents whose children have been exposed to traumatic events. Hence, including nonoffending parents in trauma-focused cognitive-behavioral therapy (TF-CBT) for children and adolescents may help both children and their parents to cope with the trauma. Up to now, three randomized controlled trials have investigated parental depressive symptoms after TF-CBT. Given the ambiguous results, further effectiveness trials are needed to investigate parental benefit from TF-CBT. The aim of this study is to determine whether TF-CBT is superior to waitlist (WL) regarding change in parental depressive symptoms.

METHODS

Parents, N = 84, whose children (age 6-17 years) were randomly assigned to either 12 sessions of TF-CBT (n = 40) or to WL condition (n = 44) completed the Beck Depression Inventory-Second Edition (BDI-II) for pre-post comparison. The group difference was tested through repeated-measures analyses of variance (ANOVA). The change in parental depressive symptoms was additionally categorized using the reliable change index.

RESULTS

Repeated-measures ANOVA indicated a significant time effect F(1, 82) = 2.55, p = 0.02, and no significant time-group interaction F(1, 82) = 1.09, p = 0.30, suggesting a similar reduction in parental depressive symptoms in both groups. Across both conditions, most of the parents remained unchanged (n = 62), some of them improved (n = 17), and a few deteriorated (n = 5). There was no significant difference between the conditions (χ²(2) = 1.74; p = 0.42).

CONCLUSION

Contrary to findings of several previous studies, our results suggest no superiority of TF-CBT in comparison with WL regarding change in depressive symptoms in parents. This might be due to different types of the child's trauma. Parental benefit from TF-CBT was found in samples of sexually abused, but not in children and adolescents exposed to diverse trauma types.