Developmentally adapted cognitive processing therapy for adolescents suffering from posttraumatic stress disorder after childhood sexual or physical abuse: a pilot study

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

MDMA-assisted psychotherapy for PTSD in adolescents: rationale, potential, risks, and considerations

3,4-Methylenedioxymetamphetamine(MDMA)-assisted psychotherapy (MDMA-AP) is a proposed treatment for posttraumatic stress disorder (PTSD) that may be approved for adults soon. PTSD is also common among trauma-exposed adolescents, and current treatments leave much room for improvement. We present a rationale for considering MDMA-AP for treating PTSD among adolescents. Evidence suggests that as an adjunct to therapy, MDMA may reduce avoidance and enable trauma processing, strengthen therapeutic alliance, enhance extinction learning and trauma-related reappraisal, and hold potential beyond PTSD symptoms. Drawing on existing trauma-focused treatments, we suggest possible adaptations to MDMA-AP for use with adolescents, focusing on (1) reinforcing motivation, (2) the development of a strong therapeutic alliance, (3) additional emotion and behavior management techniques, (4) more directive exposure-based methods during MDMA sessions, (5) more support for concomitant challenges and integrating treatment benefits, and (6) involving family in treatment. We then discuss potential risks particular to adolescents, including physical and psychological side effects, toxicity, misuse potential, and ethical issues. We argue that MDMA-AP holds potential for adolescents suffering from PTSD. Instead of off-label use or extrapolating from adult studies, clinical trials should be carried out to determine whether MDMA-AP is safe and effective for PTSD among adolescents.

Effect of therapeutic competence, adherence, and alliance on treatment outcome in youth with PTSD treated with developmentally adapted cognitive processing therapy

BACKGROUND

Developmentally adapted cognitive processing therapy (D-CPT) is an effective treatment for posttraumatic stress disorder (PTSD) in adolescents and young adults. It is unclear if therapeutic adherence and competence in D-CPT are associated with higher PTSD treatment gains.

OBJECTIVE

To assess if higher therapeutic adherence and competence in D-CPT are associated with higher symptom reduction of PTSD in adolescents and young adults, while controlling for therapeutic alliance.

PARTICIPANTS AND SETTING

Participants were 38 patients (aged 14-21 years; M = 17.61 years, SD = 2.42 years) of a multicenter randomized controlled trial in which the efficacy of D-CPT was compared to a waitlist with treatment advice.

METHODS

Videotaped therapy sessions were rated using validated ratings scales to assess adherence and competence. Therapeutic alliance was assessed via weekly patient ratings. We used hierarchical linear modelling to assess the relationship of adherence and competence on PTSD symptoms being measured by both clinician and patient while controlling for alliance.

RESULTS

Neither adherence nor competence were related to treatment outcomes in clinician or patient rated PTSD symptom severity. Higher alliance was associated with a lower symptom severity at 12 months posttreatment in both clinician and patient rated PTSD symptoms.

CONCLUSIONS

In this study of young adults with PTSD, who were treated with D-CPT by well-trained therapists, therapeutic adherence and competence were not related to treatment outcome. This might be explained by a lack of range in therapist adherence and competence. Therapeutic alliance had a positive effect on PTSD symptom severity.

Long term efficacy of developmentally adapted cognitive processing therapy in youth with abuse related PTSD - Follow-up of a randomized control trial

BACKGROUND

Adolescents and young adults with abuse-related post traumatic stress disorder (PTSD) have been shown to benefit from Developmentally Adapted Cognitive Processing Therapy (D-CPT), yet long-term efficacy of D-CPT has not yet been studied.

OBJECTIVE

To assess the long-term efficacy of D-CPT in a sample of adolescents and young adults (age 14-21 years) with childhood abuse related PTSD.

PARTICIPANTS AND SETTING

Patients of a previously conducted multicenter randomized controlled trial which showed the efficacy of D-CPT compared to a waitlist with treatment advice (WL/TA) were invited for follow-up assessments at 6 and 12 months after the end of treatment.

METHODS

Primary outcome was the PTSD symptom severity, assessed with the Clinician-administered PTSD Scale for Children and Adolescents (CAPS-CA). Secondary outcomes were self-reported PTSD severity, depression, borderline symptom severity, behavior problems, and dissociation.

RESULTS

Of the 44 participants who received D-CPT, 28 (63 %) responded and were assessed at 6-month follow-up. At 12-month follow-up, 22 participants (50 %) responded. The majority of participants in the WL/TA group received D-CPT after the end of the trial and were hence not available for follow-up assessment. In the D-CPT group, treatment gains were maintained at 6- and 12-month follow-up in the CAPS-CA as well as in all secondary outcomes.

CONCLUSIONS

The positive effects of D-CPT were stable in adolescents and young adults with abuse-related PTSD indicating that they can benefit in the long term from a treatment with D-CPT.

Predictors of Clinician-Reported Self-Efficacy in Treating Trauma-Exposed Youth

Clinicians' self-efficacy with regard to delivering evidence-based interventions (EBIs) to youth is an important target for both improving EBI use in the community and mitigating the risk of clinician burnout and turnover. Examining predictors of clinician self-efficacy to treat trauma-exposed youth is, therefore, an important step for informing the design of implementation strategies to enhance the mental health workforce's capacity to deliver EBIs in this population. We examined predictors of clinician self-efficacy in working with trauma-exposed youth in a sample of practicing mental health clinicians (N = 258, M age = 34.4 years, 85.0% female). Clinicians were recruited and surveyed as part of a larger study examining how clients' exposure to potentially traumatic events influences clinician decision-making. Results of regression models indicated that training in any trauma treatment model, being trained via a variety of formats (e.g., in-person training, online, supervision), and training in a variety of treatment models were all associated with higher perceived self-efficacy regarding effectively treating trauma-exposed youth. Of the treatment models and training formats examined, receiving in-person training, R2 = .10, and training in trauma-focused cognitive behavioral therapy, R2 = .10, were the strongest predictors of higher self-efficacy ratings. Clinician discipline, R2 = .04, and clinical practice factors, R2 = .20, were also related to self-efficacy. Collectively, the R2 indicated a large effect, with the predictors explaining 25.4% of the variance in self-efficacy ratings. Implications for designing implementation strategies targeting clinician self-efficacy and future research are discussed.

Mental imagery in adolescent PTSD patients after child abuse: a comparison with matched healthy controls

BACKGROUND

Intrusive mental imagery (MI) plays a crucial role in the maintenance of posttraumatic stress disorder (PTSD) in adults. Evidence on the characteristics of MI in adolescents suffering from PTSD is sparse. The aim of this study was to thoroughly assess MI in an adolescent sample suffering from PTSD after the experience of childhood sexual abuse and/or childhood physical abuse (CA).

METHODS

Thirty-two adolescents with a primary diagnosis of PTSD after CA and 32 adolescents without any mental disorder and without a history of CA, matched for age and gender, completed questionnaires assessing the characteristics of negative and positive MI, as well as images of injury and death that lead to positive emotions (ID-images).

RESULTS

The PTSD group reported significantly more frequent, more vivid, more distressing and more strongly autobiographically linked negative MI compared to the control group. Although positive MI was highly present in both groups (PTSD: 65.6%; controls: 71.9%), no significant differences emerged between the two groups regarding the distinct characteristics of positive MI. The frequency of the ID-images did not significantly differ between the two groups (PTSD: 21.9%; controls: 9.4%), although the ID-images were more vivid in the PTSD group.

DISCUSSION

Negative MI appears to be crucial in adolescent PTSD, whilst positive MI are unexpectedly common in both the PTSD and the control group. The role of positive MI as well as that of ID-images remain unclear. Specific interventions for changing negative MI that are tailored to the developmental challenges in adolescents with PTSD should be developed.

TRIAL REGISTRATION

Some of the PTSD patients in this study were also part of a randomized controlled trial on Developmentally adapted Cognitive Processing Therapy (D-CPT). This trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787 , 18 March 2013.

Suicidal ideation, self-injury, aggressive behavior and substance use during intensive trauma-focused treatment with exposure-based components in adolescent and young adult PTSD patients

BACKGROUND

Multiple traumata such as child sexual and/or physical abuse often result in complex psychopathologies and a range of associated dysfunctional behaviors. Although evidence-based interventions exist, some therapists are concerned that trauma-focused psychotherapy with exposure-based elements may lead to the deterioration of associated dysfunctional behaviors in adolescents and young adults. Therefore, we examined the course of suicidal ideation, self-injury, aggressive behavior and substance use in a group of abuse-related posttraumatic stress disorder (PTSD) patients during phase-based, trauma-focused PTSD treatment.

METHODS

Daily assessments from a randomized controlled trial (RCT) of Developmentally adapted Cognitive Processing Therapy (D-CPT) were analyzed to test for differences in the stated dysfunctional behaviors between the four treatment phases. We conducted multilevel modeling and repeated measure ANOVAs.

RESULTS

We did not find any significant differences between the treatment phases concerning the stated dysfunctional behaviors, either at the level of urge or at the level of actual actions. On the contrary, in some primary outcomes (self-injury, aggressive behavior), as well as secondary outcomes (distress caused by trauma, joy), we observed significant improvements.

DISCUSSION

Overall, during D-CPT, adolescents and young adults showed no deterioration in dysfunctional behaviors, while even showing improvements in some, suggesting that trauma-focused treatment preceded by skills building was not deleterious to this population. Hence, the dissemination of effective interventions such as D-CPT should be fostered, whilst the concerns of the therapists regarding exposure-based components need to be addressed during appropriate training. Nevertheless, further studies with momentary assessment, extended measurement methods, a control group and larger sample sizes are needed to confirm our preliminary findings.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787, 18 March 2013, https://www.drks.de/DRKS00004787 .

Acceptability, Feasibility, and Preliminary Effectiveness of Group Cognitive Processing Therapy with Female Adolescent Survivors of Commercial Sexual Exploitation in Cambodia

Research supports the efficacy of cognitive processing therapy (CPT) for reducing Posttraumatic Stress Disorder (PTSD) and comorbid conditions among survivors of sexual assault and other traumas. To date, there are no known studies using CPT with adolescents exposed to commercial sexual exploitation (CSE). The pilot study implemented a modified version of group CPT to determine the preliminary acceptability and feasibility of this intervention with adolescents who experienced CSE. Thirteen participants living in a residential treatment facility in Cambodia received 10 sessions of modified group CPT. Participants were adolescents ranging in age from 14 to 19. Measures of PTSD, depression symptom severity, and suicidal and non-suicidal ideation and behaviors were obtained at baseline, during the intervention, and 1-week and 3 months posttreatment. Group attendance rates and client satisfaction measures of the intervention were obtained. Client satisfaction with the group intervention was high (mean = 27, SD 2.61) and group attendance was good. There was a significant decline in PTSD symptom severity F(7,24) = 2.60, p = .037 and a significant decline in depression symptom severity over time F(7,12) = 9.67, p < .001. There were no occurrences of suicidal or non-suicidal behavior during the study or at follow-up with one participant reporting suicidal ideation after treatment began. The modified CPT intervention appeared to be feasible and received a high acceptability rating.

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

BACKGROUND

Available evidence on the comparative efficacy and acceptability of psychotherapies for post-traumatic stress disorder (PTSD) in children and adolescents remains uncertain.

OBJECTIVE

We aimed to compare and rank the different types and formats of psychotherapies for PTSD in children and adolescents.

METHODS

We searched eight databases and other international registers up to 31 December 2020. The pairwise meta-analyses and frequentist network meta-analyses estimated pooled standardised mean differences (SMDs) and ORs with random-effects model. Efficacy at post-treatment and follow-up, acceptability, depressive and anxiety symptoms were measured.

FINDINGS

We included 56 randomised controlled trials with 5327 patients comparing 14 different types of psychotherapies and 3 control conditions. For efficacy, cognitive processing therapy (CPT), behavioural therapy (BT), individual trauma-focused cognitive-behavioural therapy (TF-CBT), eye movement desensitisation and reprocessing, and group TF-CBT were significantly superior to all control conditions at post-treatment and follow-up (SMDs between -2.42 and -0.25). Moreover, CPT, BT and individual TF-CBT were more effective than supportive therapy (SMDs between -1.92 and -0.49). Results for depressive and anxiety symptoms were similar to the findings for the primary outcome. Most of the results were rated as 'moderate' to 'very low' in terms of confidence of evidence.

CONCLUSIONS

CPT, BT and individual TF-CBT appear to be the best choices of psychotherapy for PTSD in young patients. Other types and different ways of delivering psychological treatment can be alternative options. Clinicians should consider the importance of each outcome and the patients' preferences in real clinical practice.

Intensive clinical trauma treatment for children and adolescents with mild intellectual disability or borderline intellectual functioning: A pilot study

BACKGROUND

Children and adolescents with mild intellectual disability (MID) or borderline intellectual functioning (BIF) are at increased risk for posttraumatic stress disorder (PTSD) or trauma-related symptoms due to adverse childhood experiences (ACEs). Weekly provided treatment sessions and/or outpatient treatment may not be effective enough.

AIMS

Investigate feasibility, safety and potential effectiveness of an intensive clinical trauma treatment in children and adolescents with MID-BIF and trauma-related symptoms as a result of ACEs or PTSD.

METHODS AND PROCEDURES

Thirty-three participants between 6 and 17 years of age received intensive clinical treatment after experiencing multiple ACEs (most commonly physical abuse, emotional neglect or abuse, sexual abuse, domestic violence and bullying). Treatment lasted 8.4 days on average and consisted of a daily program of prolonged exposure, eye movement desensitisation and reprocessing and physical activation, embedded in a trauma-sensitive environment. Data were collected at intake, first day of treatment, last day of treatment and at follow-up.

OUTCOMES AND RESULTS

There was a significant reduction of trauma-related symptoms and emotional and behavioral problems after treatment. In addition, the number of participants fulfilling the DSM-5 criteria of PTSD decreased from 24 at intake to 8 at the end of treatment. There was no drop out and no adverse events were seen.

CONCLUSIONS AND IMPLICATIONS

The results of this pilot study suggest that an intensive clinical trauma treatment is a potentially effective and safe option for children and adolescents with MID-BIF.

Does attachment predict the outcome of cognitive processing therapy for posttraumatic stress disorder in adolescent patients with interpersonal traumatization?

The attachment has emerged as a significant predictor of psychotherapy outcome. However, studies on trauma-focused treatments and adolescent samples are sparse. We analyzed the data of 43 adolescents and young adults (aged 14-21 years) with clinically relevant abuse-related posttraumatic stress disorder (PTSD) who were undergoing developmentally adapted cognitive processing therapy (D-CPT) within a multicenter, randomized clinical trial (German Clinical Trials Register; identifier: DRKS00004787). Besides clinician-rated posttraumatic stress symptoms (PTSS), attachment-related (AR) anxiety and AR avoidance were assessed using self-reports before and after treatment as well as at three-month and six-month follow-ups. Baseline attachment did not predict any changes in PTSS severity. Averaging across all assessment points, overall higher posttraumatic avoidance was associated with greater baseline AR avoidance in D-CPT. In terms of change in attachment during the trial, a greater reduction of attachment insecurities was associated with a greater reduction of PTSS severity. Results are compared with those of the control group, a wait-list condition with treatment advice (WL/TA; N = 42). AR anxiety was more often a significant variable in the models in WL/TA, whereas AR avoidance was in D-CPT. Our study does furnish initial insights into the role of attachment during trauma-focused treatment with abused adolescents and young adults.Trial registration: German Clinical Trials Register identifier: DRKS00004787.

Treatment Outcomes for Adolescents Versus Adults Receiving Cognitive Processing Therapy for Posttraumatic Stress Disorder During Community Training

Cognitive processing therapy (CPT) is a gold-standard treatment for adults with posttraumatic stress disorder (PTSD). However, adolescents may also benefit from CPT, particularly when existing evidence-based treatments for adolescents are unavailable or not a good fit. In this program evaluation study, community-based therapists participating in training delivered a modular version of CPT to 32 adolescents (age range: 14-17 years) and 174 adults recruited at their sites (overall sample: 81.1% female, 59.7% White, 31.6% Black, 21.6% Hispanic, 2.9% American Indian/Alaskan Native, 1.9% Asian, and 9.7% other race). The same protocol was used for adolescents as adults. Treatment outcomes, including treatment completion status, number of sessions needed, and PTSD and depression symptom change, were compared between groups. In total, 47.1% of adults versus 71.9% of adolescents completed treatment. Among completers, there was no between-group difference in the number of attended sessions, RR = 1.04, 95% CI [0.88, 1.23], p = .576. Overall, in the full intent-to-treat sample (i.e., completers and noncompleters), large symptom reductions were observed for PTSD, b = -3.27, SE = 0.17, p < .001, d = 1.22; and depression, b = -0.82, SE = 0.07, p < .001, d = 0.84. There were no differences in the rate of change for adolescents versus adults regarding PTSD, b = -0.15, SE = 0.48, p = .759; or depression, b = -0.20, SE = 0.14, p = .181. These findings suggest that CPT is a viable treatment option for adolescents, who benefited from treatment and completed treatment at a high rate.

Die einfache und komplexe Posttraumatische Belastungsstörung in der Praxis

Zusammenfassung. Theoretischer Hintergrund: Die ICD-11 enthält reformulierte Kriterien für die Posttraumatische Belastungsstörung (PTBS) und die neue Diagnose komplexe PTBS (kPTBS). Fragestellung: Wie wirken sich die Neuerungen auf die Diagnostik und Behandlung von Kindern und Jugendlichen aus? Methode: In dieser Übersichtsarbeit werden die neuen Kriterien vorgestellt und mit früheren Diagnosemanualen verglichen. Bisherige Forschungsergebnisse zu PTBSICD-11 und kPTBS bei Kindern und Jugendlichen werden zusammengefasst und diskutiert. Ergebnisse: Die PTBSICD-11-Kriterien führen eher zu geringeren Prävalenzraten verglichen mit PTBSICD-10, PTBSDSM-IV und PTBSDSM-5. Erste Studien weisen darauf hin, dass evidenzbasierte traumafokussierte Therapiemanuale auch zur Behandlung der kPTBS geeignet sind. Diskussion und Schlussfolgerung: Die Anwendung neuer Kriterien stellt Praktiker_innen und Forscher_innen vor Herausforderungen. Bisherige Ergebnisse deuten an, dass die kPTBS gut behandelbar ist.

Routineversorgung für Jugendliche und junge Erwachsene mit Posttraumatischer Belastungsstörung nach sexualisierter und physischer Gewalt in Deutschland

Zusammenfassung. Theoretischer Hintergrund: Für die Behandlung der Posttraumatischen Belastungsstörung (PTBS) im Jugend- und jungen Erwachsenenalter liegen diverse evidenzbasierte Interventionen (EBIs) vor. Fragestellung: Inwiefern sind EBIs für Jugendliche und junge Erwachsene mit PTBS nach sexualisierter und physischer Gewalt in Deutschland verfügbar? Methode: Es wurden die Daten von 39 Teilnehmenden einer multizentrischen Behandlungsstudie analysiert, die für die Diagnose einer PTBS ambulante Behandlungsempfehlungen erhalten hatten. Ergebnisse: In den folgenden sieben Monaten erhielten 21 der Teilnehmenden eine Behandlung; bei nur acht wurden in deren Rahmen die traumatischen Erfahrungen adressiert. Alle Teilnehmenden verbesserten sich hinsichtlich der PTBS-Symptomatik unabhängig von der Art der Behandlung. Diskussion und Schlussfolgerung: Die Ergebnisse weisen auf Barrieren für den Zugang zu EBIs in unserer Stichprobe hin. Künftige Forschung sollte die Hintergründe für diese Barrieren fokussieren.

Lost in Transition? Evidence-Based Treatments for Adolescents and Young Adults with Posttraumatic Stress Disorder and Results of an Uncontrolled Feasibility Trial Evaluating Cognitive Processing Therapy

Posttraumatic stress disorder (PTSD) is not uncommon among adolescents and young adults (AYAs). Left untreated, transition to adulthood might be especially challenging and/or prolonged for AYAs. However, it is unclear whether AYAs are adequately represented in current PTSD treatment research and whether they benefit to the same degree as younger or older individuals. In the first part of the paper, we reflect on developmental considerations in the treatment of AYAs and give an overview of current age-specific results in PTSD treatment research. Furthermore, we review individual trauma-focused evidence-based treatments that were examined in AYAs over the last 10 years. In the second part, we present data from an uncontrolled feasibility trial evaluating cognitive processing therapy (CPT) with some age-adapted modifications and an exposure component (written accounts). We treated 17 AYAs (aged 14 to 21) suffering from posttraumatic stress symptoms (PTSS). At posttreatment, participants had improved significantly with respect to clinician-rated PTSS severity (d = 1.32). Treatment gains were maintained throughout the 6-week and 6-month follow-ups. Results indicated that CPT, with only minor adaptations, was feasible and safe in AYAs. The recommendations for future research focus on the inclusion of young adults in trials with adolescents, more refined age reporting in clinical trials, and the encouragement of dismantling studies in youth. To conclude, clinical recommendations for caregiver involvement and the addressing of developmental tasks, motivational issues and emotion regulation problems are discussed.

External locus-of-control partially mediates the association between cumulative trauma exposure and posttraumatic stress symptoms among adolescents from diverse background

Locus of control (LOC) is a modifiable mediator of symptoms of posttraumatic stress disorder (PTSD) among traumatized individuals and a potential target of intervention. Compared with studies involving adults, the potential mediation effect of LOC on PTSD symptoms among trauma-exposed children and adolescents is relatively under-explored. This study, therefore, assessed the mediation effects of LOC on the association between lifetime cumulative trauma and PTSD symptoms among a large cohort of adolescents from different cultural background.

Cross-sectional study.

LOC was determined using the Multi-Dimension Locus of Control Scale; Posttraumatic stress symptoms using the UCLA PTSD Reaction Index; and other significant negative life events using the Life Events Checklist.

Among 3826 adolescents who completed the study, external LOC explained 24% of variance (R² = .24; F_2,3823 = 619.01; p < .01) in PTSD symptoms and had significant indirect effect on the relationship between self-reported cumulative traumatic event exposure and PTSD symptoms (ß = .14; 95% BC CI [.10, .20]). Moderated mediation results showed significant potentiation of the moderation effects among older adolescents; boys; and those from more affluent families.

The study further strengthened the hitherto limited evidence that external LOC partially mediate the relationship between cumulative trauma exposure and PTSD symptoms among adolescents.

Young people's trauma-related cognitions before and after cognitive processing therapy for post-traumatic stress disorder

OBJECTIVES

Cognitive processing therapy (CPT) is a psychotherapy for post-traumatic stress disorder (PTSD) with a broad evidence base. Change in trauma-related cognitions is considered its primary working mechanism. When trying to integrate a traumatic event into existing cognitive schemas, the adaptive mechanism is changing the schema (accommodation). However, PTSD patients frequently either change their schemas too much (over-accommodation), or cognitively distort the event (assimilation). We aimed to test the hypothesized connections between the three types of cognition and symptom load.

DESIGN

This study adds to the literature using 'impact statements', essays on their trauma-related thoughts written by patients at the beginning and end of CPT, to investigate cognitive change and its relationship to symptomatic outcome.

METHODS

We analysed statements written by 31 adolescents and young adults who received developmentally adapted CPT (a longer treatment where CPT is the core component) in a randomized controlled trial.

RESULTS

As expected, post-CPT statements contained more accommodated and fewer over-accommodated and assimilated clauses than pre-CPT statements. Correlations between cognition frequencies and concurrent symptom load were as expected for assimilation, and, in part, over-accommodation and accommodation. Decreased PTSD and depressive symptoms were correlated with increased accommodated thoughts. For over-accommodation and assimilation, however, expected correlations could not be shown.

CONCLUSIONS

Our results support the notion that cognitive change is an important mechanism of change in CPT in a sample of younger, non-English-speaking clients.

Response of young patients with probable ICD-11 complex PTSD to treatment with developmentally adapted cognitive processing therapy

Background: ICD-11 features Complex Posttraumatic Stress Disorder (CPTSD) as a new diagnosis. To date, very few studies have investigated CPTSD in young patients, and there is a need for evidence on effective treatment. Objective: The present study evaluates the applicability of developmentally adapted cognitive processing therapy (D-CPT) for CPTSD in young patients in a secondary analysis of the treatment condition of a randomized controlled trial (RCT) investigating the efficacy of D-CPT. Methods: The D-CPT treatment group in the original study included 44 patients (14-21 years) with DSM-IV PTSD after childhood abuse. We used the ICD-11 algorithm to divide the sample into a probable CPTSD and a non-CPTSD group. We performed multilevel models for interviewer-rated and self-rated PTSD symptoms with fixed effects of group (CPTSD, non-CPTSD) and time (up to 12 months follow-up) and their interaction. Treatment response rates for both groups were calculated. Results: Nineteen (43.2%) patients fulfilled criteria for probable ICD-11 CPTSD while 25 (56.8%) did not. Both CPTSD and non-CPTSD groups showed symptom reduction over time. The CPTSD group reported higher symptom severity before and after treatment. Linear improvement and treatment response rates were similar for both groups. D-CPT reduced symptoms of disturbances in self-regulation in both groups. Discussion: Both, patients with and without probable ICD-11 CPTSD seemed to benefit from D-CPT and the treatment also reduced disturbances in self-regulation. Conclusion: This study presents initial evidence of the applicability of D-CPT in clinical practice for young patients with CPTSD. It remains debatable whether CPTSD implies different treatment needs as opposed to PTSD.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

Get secure soon: attachment in abused adolescents and young adults before and after trauma-focused cognitive processing therapy

Severe posttraumatic stress symptoms (PTSS) are connected to a variety of health-related and interpersonal problems, among them are the insecure attachment orientations. However, psychotherapy seems to improve not only PTSS but also attachment insecurities. In a large multicenter, randomized clinical trial, the attachment characteristics and PTSS of 85 adolescents and young adults (aged 14-21 years) with clinically relevant abuse-related PTSS were assessed at study entry, at the end of treatment, and 3 months after the end of treatment. Participants were randomized either to a developmentally adapted cognitive processing therapy (D-CPT) or to a wait-list with treatment advice (WL/TA). The purpose of the study was to analyze the association between PTSS and attachment at study entry as well as changes in attachment during the trial. We found that attachment-related avoidance (AR avoidance) was positively associated with PTSS from both self-reports and clinician ratings, whereas attachment-related anxiety (AR anxiety) was only related to self-reported PTSS (Pearson correlation coefficients between 0.37 and 0.46). Changes in AR anxiety occurred in both conditions at some point during the study (baseline to 3-month follow-up effect size was d = 0.60 for D-CPT and d = 0.44 for WL/TA) whereas for AR avoidance, only participants in D-CPT improved significantly (baseline to 3-month follow-up effect size was d = 0.75). The results indicate that PTSS and attachment are connected. Positive changes in attachment insecurities brought about by trauma-focused psychotherapy seem possible.Trial registration: German Clinical Trials Register (DRKS); Germanctr.de; identifier: DRKS00004787; date of registration: 18 March 2013.

Psychosexual knowledge and education in autism spectrum disorder individuals

BACKGROUND

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental condition. Autism spectrum disorder individuals are interested in sexual activity and pursuing romantic relationships, yet they often lack psychosexual knowledge and engage in risky sexual behaviors. The special learning needs of ASD individuals influence their exclusion from educational and social settings, resulting in fewer opportunities to acquire sex knowledge from reliable sources.

OBJECTIVES

This review aimed to explore factors influencing sexual knowledge and evaluate outcomes of comprehensive, ASD-tailored psychosexual education.

DATA SOURCES

PubMed, PsychINFO, and EBSCOhost databases were used to locate peer-reviewed articles in English in the 5 years between 2013 and 2018. Keywords included "autism spectrum disorder," "child abuse," "sexual," "sexual offenses," "sexual abuse," and "sexual education."

CONCLUSIONS

Nine articles were included in the review. Compared with neurotypical adults, ASD adults had less sex-related knowledge, more victimization experiences, and obtained sexual information from more nonsocial sources. Knowledge is a partial mediator between ASD diagnosis and sexual victimization. Parents expressed having little support to educate their offspring and provided less sex education to children with intellectual disability and severe symptoms. Psychosexual education programs that are tailored to suit developmental and cognitive differences of ASD individuals increase knowledge and improve parent-child communication, especially for younger adolescents.

IMPLICATIONS FOR PRACTICE

Nurse practitioners who care for ASD individuals should assess knowledge and victimization experiences, assess parent perceptions and concerns, and provide guidance for developmentally and intellectually appropriate sex education. These should be incorporated into practice starting at a young age and continue across the lifespan.

Health-Related Quality of Life and Costs of Posttraumatic Stress Disorder in Adolescents and Young Adults in Germany

BACKGROUND

Posttraumatic stress disorder (PTSD) is one of the psychopathological consequences of sexual and/or physical abuse. The economic burden is assumed to be high, whereas health-related quality of life and education is negatively affected. This study aims to determine health care costs, health-related quality of life, and educational interruption in adolescents and young adults with PTSD after sexual and/or physical abuse in Germany.

METHODS

This analysis used data of 87 participants aged 14-21 years of a randomized controlled trial. Health care utilization, health-related quality of life (EQ-5D-5L), sick leave days, productivity, and delay or failure to achieve educational aims were assessed. Health care costs from a payer perspective were calculated using unit costs for the year 2014.

RESULTS

Mean health care costs for a six-month period were 5,243€ (SE 868€). In particular, costs of inpatient stays in psychiatric hospitals, general hospitals and rehabilitation as well as child welfare institutions were high. In addition, health-related quality of life was lower due to anxiety/depression, resulting in a mean EQ-5D index and EQ-VAS score of 0.70 and 61.0, respectively. Furthermore, participants reported on average 27 sick leave days, a productivity loss of 61%, and a delay in education attainment as well as having been unable to achieve educational aims.

CONCLUSION

PTSD in adolescents and young adults is associated with a high economic burden. Health-related quality of life was substantially reduced. Furthermore, delay and productivity losses in education were observed.

CLINICAL TRIAL REGISTRATION

German Clinical Trials Register identifier: DRKS00004787; date of registration: 18th March 2013; https://www.drks.de.

Challenges in recruiting and retaining adolescents with abuse-related posttraumatic stress disorder: lessons learned from a randomized controlled trial

BACKGROUND

Research on effective recruitment and retention strategies for adolescents and young adults suffering from posttraumatic stress disorder is scarce. The aim of the current study was to provide data on recruitment sources, barriers, and facilitators for participation in a randomized controlled trial for young individuals with histories of sexual and/or physical abuse.

METHODS

Study participants aged 14 to 21 were asked to complete a checklist on individual sources of recruitment, barriers, and facilitators for participation in the trial. Fifty-three out of the 80 study participants who were contacted completed the checklist (66.3%).

RESULTS

Most respondents reported multiple recruitment sources, with online and media advertising search strategies indicated most frequently (45.4% of all mentions), followed by practitioner-referred sources (38.7%). Respondents' reported barriers included additional demands of the trial (60.3%), followed by distress caused by having to talk about painful topics (15.5%). The most frequently indicated facilitators were the organizational setting (55.1%) and monetary incentives (22.2%), followed by social support (12.0%) and non-monetary incentives (10.2%). No significant differences were observed between adolescent and young adult respondents with the exception that adolescents reported significantly more frequently that they had learned about the trial from their caregiver.

CONCLUSIONS

Our findings permit the formulation of recommendations for planning and conducting trials with this clientele. Future research is needed on how specific barriers can be effectively overcome.

Is There an Ace Up Our Sleeve? A Review of Interventions and Strategies for Addressing Behavioral and Neurobiological Effects of Adverse Childhood Experiences in Youth

Exposure to early life adversity (ELA) is a major public health crisis posing as a significant risk of immediate and sustained mental and physical health consequences. While a remarkable body of knowledge has been amassed showing psychological, cognitive, social, developmental, and neurobiological consequences of ELA exposure, little has been done to improve the long-term mental and physical health outcomes for youth exposed to ELA. Furthermore, neurobiological processes underlying poor outcomes in this population have been largely left out of prevention and intervention target efforts. In this review, we first describe ELA-related alterations across psychological and neurobiological systems in children and adolescents. Next, we describe existing evidence-based interventions targeting ELA-related outcomes. We then turn to experimental studies examining individual differences in mechanistic functioning consequent to ELA exposure, and strategies that target these mechanisms and modulate disrupted functioning. Finally, we highlight areas of future research that may be promising in engaging behavioral and neurobiological targets through novel preventive interventions or augmentation of existing interventions, thereby reducing negative mental and physical health outcomes later in life.

Childhood adversity and psychosis in detained inpatients from medium to high secured units: Results from the Scottish census survey

BACKGROUND

There is limited data available regarding the most common forms of psychiatric illness, the occurrence of childhood adversity, and the link between childhood adversity and criminal and psychiatric outcomes amongst forensic inpatients.

AIMS

Using census data for all Scottish forensic inpatients, we investigated the most common primary psychiatric diagnoses in forensic settings, the occurrence of childhood adversity amongst forensic inpatients, and whether childhood adversity experiences significantly predict a range of criminal and psychiatric outcomes.

METHOD

Data for the current study were drawn from 'The Scottish Forensic Network Inpatient Census' (N = 422). The Responsible Medical Officers and other members of the clinical team collected all data from official patient records. All forensic inpatients across high, medium, and low security sites were surveyed.

RESULTS

The majority of patients had a psychotic disorder as their primary diagnosis (86.4%), with schizophrenia being the most common (70.0%). Childhood adversity was highly prevalent (79.2%), with physical abuse being the most common adverse experience (40.1%). Increased levels of childhood adversity were significantly associated with an increased risk of criminal convictions, self-reported abuse of animals, suicidal and self-injurious behaviour, and problematic use of drugs or alcohol.

CONCLUSIONS

Considering the association between adversity and psychosis, trauma informed care is essential for the mental health and forensic needs of this population.

Providing manualized individual trauma-focused CBT to unaccompanied refugee minors with uncertain residence status: a pilot study

BACKGROUND

Unaccompanied refugee minors (URMs) seeking asylum show high rates of posttraumatic stress disorder (PTSD), depression and anxiety. In addition, they experience post-migration stressors like an uncertain residence status. Therefore, psychotherapeutic interventions for URMs are urgently needed but have scarcely been investigated up to now. This study aimed to examine manualized individual trauma-focused cognitive behavioural therapy (TF-CBT) for URMs with PTSD involving their professional caregivers (i.e. social workers in child and adolescent welfare facilities).

METHODS

We conducted an uncontrolled pilot study with three follow-up assessments (post-intervention, 6 weeks, and 6 months). Participants who met the PTSD diagnostic criteria were treated in a university psychotherapeutic outpatient clinic in Germany with a mean of 15 sessions of TF-CBT. All participants (n = 26) were male UM (Mage = 17.1, SD = 1.0), predominately from Afghanistan (n = 19, 73.1%) and did not have a residence permit. The sample was severely traumatized according to the number of traumatic event types reported (M = 11.3, SD = 2.8). The primary outcome was PTSD measured with the Child and Adolescent Trauma Screen (CATS) and the Diagnostic Interview for Mental Disorders in Childhood and Adolescence (Kinder-DIPS). Secondary outcomes were depression, behavioural and somatic symptoms. All but the somatic symptoms were assessed in both self-report and proxy report.

RESULTS

At post-intervention the completer sample (n = 19) showed significantly decreased PTSD symptoms, F(1, 18) = 11.41, p = .003, with a large effect size (d = 1.08). Improvements remained stable after 6 weeks and 6 months. In addition to PTSD symptoms, their caregivers reported significantly decreased depressive and behavioural symptoms in participants. According to the clinical interview, 84% of PTSD cases recovered after TF-CBT treatment. After 6 months, youths whose asylum request had been rejected showed increased PTSD symptoms according to individual trajectories in the Kinder-DIPS. The effect was, however, non-significant.

CONCLUSIONS

Intervention studies are feasible with URMs. This pilot study presents preliminary evidence for the efficacy of an evidence-based intervention like TF-CBT in reducing PTSD symptoms in URMs. Stressors related to asylum proceedings after the end of therapy have the potential to negatively influence psychotherapy outcomes.

Effect of Developmentally Adapted Cognitive Processing Therapy for Youth With Symptoms of Posttraumatic Stress Disorder After Childhood Sexual and Physical Abuse: A Randomized Clinical Trial

IMPORTANCE

Despite the high prevalence, evidence-based treatments for abuse-related posttraumatic stress disorder (PTSD) in adolescents have rarely been studied.

OBJECTIVE

To examine whether developmentally adapted cognitive processing therapy (D-CPT) is more effective than a wait-list condition with treatment advice (WL/TA) among adolescents with PTSD related to childhood abuse.

DESIGN, SETTING, AND PARTICIPANTS

This rater-blinded, multicenter, randomized clinical trial (stratified by center) enrolled treatment-seeking adolescents and young adults (aged 14-21 years) with childhood abuse-related PTSD at 3 university outpatient clinics in Germany from July 2013 to June 2015, with the last follow-up interview conducted by May 2016. Of 194 patients, 88 were eligible for randomization.

INTERVENTIONS

Participants received D-CPT or WL/TA. Cognitive processing therapy was enhanced by a motivational and alliance-building phase, by including emotion regulation and consideration of typical developmental tasks, and by higher session frequency in the trauma-focused core CPT phase. In WL/TA, participants received treatment advice with respective recommendations of clinicians and were offered D-CPT after 7 months.

MAIN OUTCOMES AND MEASURES

All outcomes were assessed before treatment (baseline), approximately 8 weeks after the start of treatment, after the end of treatment (posttreatment), and at the 3-month follow-up. The primary outcome, PTSD symptom severity, was assessed in clinical interview (Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV [CAPS-CA]). Secondary outcomes were self-reported PTSD severity, depression, borderline symptoms, behavior problems, and dissociation.

RESULTS

The 88 participants (75 [85%] female) had a mean age of 18.1 years (95% CI, 17.6-18.6 years). In the intention-to-treat analysis, the 44 participants receiving D-CPT (39 [89%] female) demonstrated greater improvement than the 44 WL/TA participants (36 [82%] female) in terms of PTSD severity (mean CAPS-CA scores, 24.7 [95% CI, 16.6-32.7] vs 47.5 [95% CI, 37.9-57.1]; Hedges g = 0.90). This difference was maintained through the follow-up (mean CAPS-CA scores, 25.9 [95% CI, 16.2-35.6] vs 47.3 [95% CI, 37.8-56.8]; Hedges g = 0.80). Treatment success was greatest during the trauma-focused core phase. The D-CPT participants also showed greater and stable improvement in all secondary outcomes, with between-groups effect sizes ranging from 0.65 to 1.08 at the posttreatment assessment (eg, for borderline symptoms, 14.1 [95% CI, 8.0-20.2] vs 32.0 [95% CI, 23.8-40.2]; Hedges g = 0.91).

CONCLUSIONS AND RELEVANCE

Adolescents and young adults with abuse-related PTSD benefited more from D-CPT than from WL/TA. Treatment success was stable at the follow-up and generalized to borderline symptoms and other comorbidities.

TRIAL REGISTRATION

German Clinical Trials Register identifier: DRKS00004787.

PTSD Symptoms Mediate the Relationship Between Sexual Abuse and Substance Use Risk in Juvenile Justice-Involved Youth

Juvenile justice-involved youth face disproportionate rates of sexual abuse, which increases the risk of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs), both of which are associated with poor long-term outcomes. The present study tested two mediation and moderation models, controlling for age, race, and history of physical abuse, with gender as a moderator, to determine whether PTSD symptoms serve as a risk factor and/or mechanism in the relationship between sexual abuse and substance use. Data were examined for 197 juvenile justice-involved youth (mean age = 15.45, 68.9% non-White, 78.4% male) that completed court-ordered psychological assessments. Results indicated that PTSD symptoms significantly mediated the relationship between sexual abuse and drug (β = 3.44, confidence interval [CI] [0.26, 7.41]; test for indirect effect z = 2.41, p = .02) and alcohol use (β = 1.42, CI [0.20, 3.46]; test for indirect effect z = 2.23, p = .03). PTSD symptoms and gender were not significant moderators. Overall, PTSD symptoms mediate the relationship between sexual abuse and SUDs in juvenile justice-involved youth, which suggests viability of targeting PTSD symptoms as a modifiable risk factor to reduce the effects of sexual abuse on substance use in this high-risk population.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Intensive prolonged exposure treatment for adolescent complex posttraumatic stress disorder: a single-trial design

BACKGROUND

The current study evaluated the effectiveness and safety of intensive prolonged exposure (PE) targeting adolescent patients with complex posttraumatic stress disorder (PTSD) and comorbid disorders following multiple interpersonal trauma.

METHODS

Ten adolescents meeting full diagnostic criteria for PTSD were recruited from a specialized outpatient mental health clinic and offered a standardized intensive PE. The intensive PE consisted of three daily 90-min exposure sessions delivered on five consecutive weekdays, followed by 3 weekly 90-min booster sessions. In a single-trial design, the participants were randomly allocated to one of five baseline lengths (4-8 weeks) before starting the intensive PE. Before, during, and after intensive PE completion, self-reported PTSD symptom severity was assessed weekly as a primary outcome (a total of 21 measurements). Furthermore, clinician-administered PTSD diagnostic status and symptom severity (primary outcome), as well as self-reported comorbid symptoms (secondary outcomes), were assessed at four single time points (baseline-to-6-month follow-up).

RESULTS

Time-series analyses showed that self-reported PTSD symptom severity significantly declined following treatment (p = .002). Pre-postgroup analyses demonstrated significant reductions of clinician-administered PTSD symptom severity and self-reported comorbidity that persisted during the 3- and 6-month follow-ups (all ps < .05), where 80% of adolescents had reached diagnostic remission of PTSD. There was neither treatment dropout nor any adverse events.

CONCLUSIONS

The results of this first proof of concept trial suggest that intensive PE can be effective and safe in an adolescent population with complex PTSD, although the gains achieved need to be confirmed in a randomized controlled trial.

Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client-Centered Therapy on Co-Occurring Emotional and Behavioral Problems

The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.

Does psychotherapy work with school-aged youth? A meta-analytic examination of moderator variables that influence therapeutic outcomes

The present study is a quantitative synthesis of the available literature to investigate the efficacy of psychotherapy for children's mental health outcomes. In particular, this study focuses on potential moderating variables-study design, treatment, client, and therapist characteristics-that may influence therapeutic outcomes for youth but have not been thoroughly accounted for in prior meta-analytic studies. An electronic search of relevant databases resulted in 190 unpublished and published studies that met criteria for inclusion in the analysis. Effect sizes differed by study design. Pre-post-test designs resulted in absolute magnitudes of treatment effects ranging from |-0.02| to |-0.76| while treatment versus control group comparison designs resulted in absolute magnitudes of treatment effects ranging from |-0.14| to |-2.39|. Changes in youth outcomes larger than 20% were found, irrespective of study design, for outcomes focused on psychosomatization (29% reduction), school attendance (25% increase), and stress (48% reduction). The magnitude of changes after psychotherapy ranged from 6% (externalizing problems) to 48% (stress). Several moderator variables significantly influenced psychotherapy treatment effect sizes, including frequency and length of treatment as well as treatment format. However, results did not support the superiority of a single type of intervention for most outcomes. Implications for therapy with school-aged youth and future research are discussed.

Positive and Negative Posttraumatic Change Following Childhood Sexual Abuse Are Associated With Youths' Adjustment

Meanings made of childhood sexual abuse (CSA) experiences are important to psychosocial adjustment. The current study examined adolescents' and young adults' perceptions of posttraumatic change (PTC) in the self, relationships, sexuality, and worldviews attributed to prior CSA experiences. We sought to document the prevalence of positive and negative PTC and examine their unique and joint associations with psychosocial adjustment. Participants included 160 youth with confirmed cases of CSA (73% female; 8-14 years at abuse discovery) who were part of a longitudinal study of the long-term effects of CSA. Six years after discovery, youth were interviewed about their abuse experiences. Interviews were coded for the valence and strength of PTC. The majority of youth reported PTC, and negative changes were more frequent and stronger than positive changes. Controlling for age, gender, abuse severity, and negative PTC, positive PTC was associated with lower abuse stigmatization for all youth. Controlling for age, gender, abuse severity, and positive PTC, negative PTC was associated with greater abuse stigmatization, post-traumatic stress disorder, sexual problems, and dating aggression for all youth. Relations of positive PTC with depression and support from friends and romantic partner were moderated by negative PTC, such that positive PTC was associated with better adjustment for youth with low versus high levels of negative PTC. Results highlight the importance of both negative and positive PTC for understanding meanings made of CSA experiences and their implications for psychosocial adjustment and intervention.

Trauma-focused cognitive behavioral therapy with unaccompanied refugee minors: a case series

BACKGROUND

Unaccompanied refugee minors (URMs) are a group who are vulnerable to developing posttraumatic stress symptoms (PTSS). However, they rarely receive the treatment that is indicated and there are no treatment studies focusing exclusively on this group of adolescents. This case study evaluates the feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) for URMs with PTSS.

METHOD

A health care utilization sample of N = 6 was assessed prior to and after treatment with TF-CBT. Therapists were asked to report differences in treatment application and content in comparison to TF-CBT standard protocol.

RESULTS

We found moderate to high levels of PTSS at baseline and a clinically significant decrease in symptoms at posttest. Some modifications to the TF-CBT protocol were made with regard to affective modulation which required more sessions than usual whereas fewer caregiver sessions were conducted.

CONCLUSION

TF-CBT is feasible in reducing PTSS in severely traumatized URMs. Further research with controlled trials is necessary.

TRIAL REGISTRATION

The trial registration: ClinicalTrials.gov Identifier NCT01516827. Registered 13 December 2011.

[Participation of traumatized children and adolescents affected by provisional safeguards (removal and custody of children ace. to Para. 42 SGB VIII)_]

OBJECTIVE

This study analyzes important variables of settings of children taken into state custody and records trauma exposure.

METHOD

52 children and adolescents with e~periences of removal and custody were questioned online in the social network Facebook. Traumatic stressors before removal and custody were assessed as well as the reasons that lead .to removal and custody and the subsequent burdens.

RESULTS

In more than every other case the children and adolescents reported that they were not involved in important decisions during removal and custody. After termination of the removal and custody process, 50% did not want to return to their parents. Compared to children wanting to return to their parents, children who did not want to return home display signs of severe physical and emotional neglect as well as extreme physical abuse. Even though they have no desire to return, they are often sent back to their parents against their will.

CONCLUSIONS

Children who are removed and put in state custody should be included when deciding important questions. Whether or not they wish to return to their parents should be taken into consideration more strongly. Children who are sent back to theirparents against their will suffer from on going traumatization.

Trauma- und belastungsbezogene Störungen

Mit der Einführung des DSM-5 wurden die Traumafolgestörungen in einem neuen Kapitel „Trauma- und belastungsbezogene Störungen” gruppiert. Außerdem sollte einer Entwicklungsperspektive mehr Rechnung getragen werden, z. B. mit der Einführung spezifischer Kriterien für die posttraumatische Belastungsstörung bei Kindern unter sechs Jahren. Auch in der geplanten elften Auflage der ICD wird es ein derartiges Kapitel geben, wobei hier aller Voraussicht nach neue Diagnosen inkludiert werden, nämlich die komplexe posttraumatische Belastungsstörung und die anhaltende Trauerstörung. Neben der weiteren Adaption dieser Diagnosen auf Kinder und Jugendliche sollten die zukünftigen Forschungsbemühungen verstärkt spezielle Patientengruppen berücksichtigen und die Dissemination der als wirksam evaluierten traumafokussierten Therapieverfahren vorantreiben.

Therapeutic adherence and competence scales for Developmentally Adapted Cognitive Processing Therapy for adolescents with PTSD

Background : The assessment of therapeutic adherence and competence is often neglected in psychotherapy research, particularly in children and adolescents; however, both variables are crucial for the interpretation of treatment effects. Objective : Our aim was to develop, adapt, and pilot two scales to assess therapeutic adherence and competence in a recent innovative program, Developmentally Adapted Cognitive Processing Therapy (D-CPT), for adolescents suffering from posttraumatic stress disorder (PTSD) after childhood abuse. Method : Two independent raters assessed 30 randomly selected sessions involving 12 D-CPT patients (age 13-20 years, M age=16.75, 91.67% female) treated by 11 therapists within the pilot phase of a multicenter study. Results : Three experts confirmed the relevance and appropriateness of each item. All items and total scores for adherence (intraclass correlation coefficients [ICC]=0.76-1.00) and competence (ICC=0.78-0.98) yielded good to excellent inter-rater reliability. Cronbach's alpha was 0.59 for the adherence scale and 0.96 for the competence scale. Conclusions : The scales reliably assess adherence and competence in D-CPT for adolescent PTSD patients. The ratings can be helpful in the interpretation of treatment effects, the assessment of mediator variables, and the identification and training of therapeutic skills that are central to achieving good treatment outcomes. Both adherence and competence will be assessed as possible predictor variables for treatment success in future D-CPT trials.

Reliability, factor structure, and validity of the German version of the Trauma Symptom Checklist for Children in a sample of adolescents

BACKGROUND

The Trauma Symptom Checklist for Children (TSC-C) is the most widely used self-report scale to assess trauma-related symptoms in children and adolescents on six clinical scales. The purpose of the present study was to develop a German version of the TSC-C and to investigate its psychometric properties, such as factor structure, reliability, and validity, in a sample of German adolescents.

METHOD

A normative sample of N=583 and a clinical sample of N=41 adolescents with a history of physical or sexual abuse aged between 13 and 21 years participated in the study.

RESULTS

The Confirmatory Factor Analysis on the six-factor model (anger, anxiety, depression, dissociation, posttraumatic stress, and sexual concerns with the subdimensions preoccupation and distress) revealed acceptable to good fit statistics in the normative sample. One item had to be excluded from the German version of the TSC-C because the factor loading was too low. All clinical scales presented acceptable to good reliability, with Cronbach's α's ranging from .80 to .86 in the normative sample and from .72 to .87 in the clinical sample. Concurrent validity was also demonstrated by the high correlations between the TSC-C scales and instruments measuring similar psychopathology. TSC-C scores reliably differentiated between adolescents with trauma history and those without trauma history, indicating discriminative validity.

CONCLUSIONS

In conclusion, the German version of the TSC-C is a reliable and valid instrument for assessing trauma-related symptoms on six different scales in adolescents aged between 13 and 21 years.

Developmentally adapted cognitive processing therapy for adolescents and young adults with PTSD symptoms after physical and sexual abuse: study protocol for a randomized controlled trial

BACKGROUND

Although childhood sexual and/or physical abuse (CSA/CPA) is known to have severe psychopathological consequences, there is little evidence on psychotherapeutic interventions for adolescents and young adults suffering from post-traumatic stress disorder (PTSD). Equally sparse are data on moderators of treatment response on PTSD-related epigenetic changes, health care costs and loss of productivity, alterations in cognitive processing, and on how successful interventions affect all of these factors. Early treatment may prevent later (co)morbidity. In this paper, we present a study protocol for the evaluation of a newly developed psychotherapeutic manual for PTSD after CSA/CPA in adolescents and young adults - the Developmentally Adapted Cognitive Processing Therapy (D-CPT).

METHODS/DESIGN

In a multicenter randomized controlled trial (RCT) D-CPT is compared to treatment as usual (TAU). A sample of 90 adolescent outpatients aged 14 to 21 years will be randomized to one of these conditions. Four assessments will be carried out at baseline, at end of treatment, and 3 and 6 months after end of therapy. Each time, patients will be assessed via clinical interviews and a wide range of questionnaires. In addition to PTSD symptoms and comorbidities, we will evaluate moderators of treatment response, epigenetic profiles, direct and indirect costs of this disorder, and neurophysiological processing of threat cues in PTSD and their respective changes in the course of these two treatments (D-CPT and TAU).

DISCUSSION

The study will provide new insights in the understudied field of PTSD in adolescents and young adults. A newly developed intervention will be evaluated in this therapeutically underserved population. Results will provide data on treatment efficacy, direct and indirect treatment costs, as well as on associations of treatment outcome and PTSD intensity both to epigenetic profiles and to the neurobiological processing of threat cues. Besides, they will help to learn more about the psychopathology and possible new objective correlates of PTSD.

TRIAL REGISTRATION

Germanctr.de identifier: DRKS00004787.