The Role of Caregiver Psychopathology in the Treatment of Childhood Trauma with Trauma-Focused Cognitive Behavioral Therapy: A Systematic Review

Identifying effective moderators of cognitive behavioural trauma treatment with caregiver involvement for youth with PTSD: a meta-analysis

Children can develop post-traumatic stress disorder (PTSD) and mental health symptoms after traumatic events. This meta-analysis evaluated the influence of moderators of cognitive behavioural trauma treatment (CBTT) with caregiver involvement in traumatized children. A total of 28 studies were included, with 23 independent samples and 332 effect sizes, representing the data of 1931 children (M age = 11.10 years, SD = 2.36). Results showed a significant medium overall effect (d = 0.55, t = 2.478, p = 0.014), indicating CBTT with caregiver involvement was effective in treating PTSD (d = 0.70), with somewhat smaller effect sizes for internalizing, externalizing, social, cognitive and total problems (0.35 < d > 0.48). The positive treatment effect was robust; we found somewhat smaller effect sizes at follow-up (d = 0.49) compared to post-test (d = 0.57) assessments. Furthermore, several sample (i.e. child's age, gender, and trauma event), programme (i.e. the duration of treatment, number of sessions), study (i.e. control condition, type of instrument, informant, type of sample), and publication (i.e. publication year and impact factor) characteristics moderated the treatment outcomes of the child. In sum, the results of our meta-analysis might help to improve the effectiveness of cognitive behavioural trauma treatment for youth with PTSD, and guide the development of innovative trauma interventions that involve caregivers. Implications for theory and practice are discussed.

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.

Bidirectional effects of parental and adolescent symptom change in trauma-focused cognitive behavioral therapy

OBJECTIVE

The current study examines dynamic, bidirectional associations between parent and adolescent symptom improvement in response to children's therapy for posttraumatic stress disorder (PTSD).

METHOD

Data were collected from a racially and ethnically heterogeneous sample of 1,807 adolescents (age 13-18 years old; 69% female) and a parent participating in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) at a community outpatient behavioral health clinic. Parents self-reported their depressive symptoms and youth self-reported their PTSD and depressive symptoms at the onset of treatment and every three months for up to nine months. Using a bivariate dual change score model (BDCSM) we examine: (a) individual dyad members' change in symptoms and (b) the bidirectional associations between changes in the parent's and youth's symptoms across treatment.

RESULTS

Parents' and adolescents' symptoms at the start of treatment were correlated and both parents' and adolescents' symptoms decreased over the course of treatment. Parents' elevated depressive symptoms at each time point contributed to smaller decreases in their children's PTSD and depressive symptoms at the subsequent time point. Adolescents' elevated symptoms at each time point contributed to greater decreases in their parents' symptoms at the subsequent time point.

CONCLUSIONS

These findings highlight the impact that parents and children have on each other's response to children's trauma-focused psychotherapy. Notably, parents' depressive symptoms appeared to slow their children's progress in treatment, suggesting that attending to parents' symptoms and providing them with supportive services may be an important adjunct to children's interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Parent-led stepped care for traumatised children: parental factors that predict treatment completion and response

Background: Stepped care cognitive behavioural therapy for children after trauma (SC-CBT-CT; aged 7-12 years) can help to increase access to evidence-based trauma treatments for children. SC-CBT-CT consists of a parent-led therapist-assisted component (Step One) with an option to step up to standard therapist-led treatment (Step Two). Studies have shown that SC-CBT-CT is effective; however, less is known about what parent variables are associated with outcome of Step One.Objective: To examine parent factors and their relationship with completion and response among children receiving Step One.Method: Children (n = 82) aged 7-12 (M = 9.91) received Step One delivered by their parents (n = 82) under the guidance of SC-CBT-CT therapists. Logistic regression analyses were used to investigate whether the following factors were associated with non-completion or non-response: the parents' sociodemographic variables, anxiety and depression, stressful life experiences and post-traumatic symptoms, negative emotional reactions to their children's trauma, parenting stress, lower perceived social support, and practical barriers to treatment at baseline.Results: Lower level of educational achievement among parents was related to non-completion. Higher levels of emotional reactions to their child's trauma and greater perceived social support were related to non-response.Conclusions: The children seemed to profit from the parent-led Step One despite their parents` mental health challenges, stress, and practical barriers. The association between greater perceived social support and non-response was unexpected and warrants further investigation. To further increase treatment completion and response rates among children, parents with lower education may need more assistance on how to perform the interventions, while parents who are very upset about their child's trauma may need more emotional support and assurance from the therapist.Trial registration: ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019).

A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents

BACKGROUND

Among minors, posttraumatic stress symptoms (PTSS) are a common consequence of traumatic events requiring trauma-focused treatment.

OBJECTIVE

This meta-analysis quantified treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) with PTSS as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes.

PARTICIPANTS AND SETTING

Inclusion criteria for individual settings: (1) patients aged between 3 and 21, (2) at least one traumatic event, (3) minimum 8 sessions of (4) TF-CBT according to Cohen, Mannarino and Deblinger (2006, 2017), (5) a quantitative PTSS measure at pre- and post-treatment, (6) original research only. Inclusion criteria for group settings: had to involve (1) psychoeducation, (2) coping strategies, (3) exposure, (4) cognitive processing/restructuring, (5) contain some reference to the manual and no minimum session number was required.

METHODS

Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey.

RESULTS

4523 participants from 28 RCTs and 33 uncontrolled studies were included. TF-CBT showed large improvements across all outcomes from pre- to post-treatment (PTSS: g = 1.14, CI 0.97-1.30) and favorable results compared to any control condition including wait-list, treatment as usual, and active treatment at post-treatment (PTSS: g = 0.52, CI 0.31-0.73). Effects were more pronounced for group settings. We give pooled estimates adjusted for risk of bias and publication bias, which initially limited the quality of the analyzed data.

CONCLUSIONS

TF-CBT is an effective treatment for pediatric PTSS as well as for depressive, anxiety, and grief symptoms. It is superior to control conditions, supporting international guidelines recommending it as a first-line treatment.

Outcomes of Parent-Child Interaction Therapy (PCIT) for families presenting with child maltreatment: A systematic review

BACKGROUND

The developmental consequences of childhood trauma for young children are extensive and impact a diverse range of areas. Young children require treatments that consider their developmental stage and are inclusive of caregiver involvement. Parent-Child Interaction Therapy (PCIT), with its dyadic focus and developmental sensitivity, is uniquely positioned to offer therapeutic support to young children and their families.

AIM

The current study aimed to conduct a systematic review of the current literature on PCIT and trauma and determine treatment outcomes for children and caregivers.

METHOD

A systematic review of five electronic databases was undertaken. Studies that utilized PCIT to treat a population who had experienced trauma were included in the review regardless of study design.

RESULTS

PCIT was used to treat a population who had experienced trauma in 40 studies. PCIT was an effective treatment in improving a variety of child and parent outcomes in this population including reduced parenting stress, child behavior problems, child trauma symptoms, parental mental health concerns, negative parenting strategies, and reducing potential risk of recidivism of abuse and neglect. These findings should be taken with caution given attrition rates and potential for bias in the study samples.

DISCUSSION

Clinicians should consider PCIT as a potential treatment for children who have experienced trauma and their families. Future research should incorporate corroborative sources of information, assessment of caregiver and child trauma symptoms, examination of permanency outcomes, and consider standardization of PCIT modifications for child trauma to determine treatment in this population of children.

Child and parent secondary outcomes in stepped care versus standard care treatment for childhood trauma

INTRODUCTION

Stepped care trauma-focused cognitive behavioral therapy (SC-TF-CBT) is comparable in efficacy to standard TF-CBT for child posttraumatic stress symptoms (PTSS), but less is known about the effectiveness of SC-TF-CBT on child and parent secondary outcomes. The aim of this community-based randomized clinical trial was to compare child- and caregiver-secondary outcomes among SC-TF-CBT versus TF-CBT participants.

METHODS

Children (ages 4 to 12) with PTSS and their caregivers were randomly assigned to either SC-TF-CBT (n = 91) or TF-CBT (n = 92). Secondary child (internalizing and externalizing behavior problems, anger outburst and sleep disturbances) and parent outcomes (PTSS, depression symptoms, and parenting stress) were measured at baseline, post-treatment and 6- and 12-month follow-up.

RESULTS

There were comparable changes at all-time points in child and caregiver secondary outcomes. Non-inferiority tests indicated that for completers and intent-to-treat samples, SC-TF-CBT was non-inferior to TF-CBT for all outcomes except parenting stress at 6-months. The analysis with completers did not support non-inferiority at post-treatment for internalizing and externalizing problems and at 6- and 12-month follow-up assessments for externalizing problems, but the intent-to-treat analysis did support non-inferiority.

LIMITATIONS

Limitations included modest rates of attrition, excluding in vivo component for standard TF-CBT, parent-only assessments, and no control condition.

CONCLUSIONS

SC-TF-CBT is an effective alternative treatment method although parents with high stress may need more support and children with externalizing problems may need more standard TF-CBT sessions.

Caregiver Behaviors and Child Distress in Trauma Narration and Processing Sessions of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an effective treatment for children impacted by trauma, and non-offending caregivers play an important role in this treatment. This study aims to identify correlates of four caregiver variables that have been identified as predictors of child outcomes in TF-CBT: support, cognitive-emotional processing, avoidance, and blame/criticism. Audio recorded sessions were coded from a community effectiveness trial of TF-CBT that included 71 child-caregiver dyads participating in the trauma narration and processing phase of treatment. Regression analyses were conducted to examine caregiver trauma history and child baseline symptoms (internalizing, externalizing, and posttraumatic stress disorder [PTSD] symptoms) as predictors of caregiver behavior during the trauma processing sessions. Caregivers who reported exposure to more trauma types exhibited more in-session avoidance and also processing during the trauma processing phase of treatment. Child symptoms at baseline did not predict caregiver in-session behaviors. Bivariate correlations were used to investigate concurrent associations between mean levels of in-session caregiver behaviors and in-session child distress (negative emotion, hopelessness, negative behaviors). More caregiver blame/criticism was associated with more in-session child distress on all three measures. Caregiver avoidance was associated with more child negative emotion and hopelessness. Findings may help identify therapeutic targets when working with caregivers to promote change and enhance TF-CBT outcomes.

A Systematic Review Focusing on Psychotherapeutic Interventions that Impact Parental Psychopathology, Child Psychopathology and Parenting Behavior

Given the high rates of co-occurrence of psychopathology within families, it is important to identify and characterize interventions that simultaneously reduce both parent and child symptoms, and improve parenting quality. This is needed as intervention development is increasingly moving toward integrated interventions that target some combination of parent and child mental health, and parenting behavior. Even so, much remains unknown regarding which treatment components provide maximum benefit for parent symptoms, child symptoms, and parenting behavior. This systematic review identified and characterized psychotherapeutic interventions that report improvements in each of three outcomes: parent symptoms, child symptoms and parenting behavior. Fifty-six unique interventions were eligible for review, of which 25 reported improvements in all three outcomes. All 25 of these interventions directly intervened on parenting behavior, often as the sole target of the intervention. Few interventions improved all three outcomes in samples in which parents, children or both met clinical-level thresholds of psychopathology. Additional research is needed to better understand the bi-directional and transactional influences of treatment on family members, and to better inform the development of interventions for dually disordered parent-child dyads across a range of diagnostic profiles.

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.

Posttraumatic Stress Disorder and the Developing Adolescent Brain

Posttraumatic stress disorder (PTSD) in adolescents is common and debilitating. In contrast to adult PTSD, relatively little is known about the neurobiology of adolescent PTSD, nor about how current treatments may alter adolescent neurodevelopment to allow recovery from PTSD. Improving our understanding of biological mechanisms of adolescent PTSD, taken in the context of neurodevelopment, is crucial for developing novel and personalized treatment approaches. In this review, we highlight prevailing constructs of PTSD and current findings on these domains in adolescent PTSD. Notably, little data exist in adolescent PTSD for prominent adult PTSD constructs, including threat learning and attentional threat bias. Most work to date has examined general threat processing, emotion regulation, and their neural substrates. These studies suggest that adolescent PTSD, while phenomenologically similar to adult PTSD, shows unique neurodevelopmental substrates that may impair recovery but could also be targeted in the context of adolescent neuroplasticity to improve outcomes. Both cross-sectional and longitudinal data suggest abnormal frontolimbic development compared with typically developing youths, a pattern that may differ from resilient youths. Whether current treatments such as trauma-focused psychotherapy engage these targets and restore healthy neurodevelopment remains an open question. We end our review by highlighting emerging areas and knowledge gaps that could be addressed to better characterize the biology underlying adolescent PTSD. Emerging studies in computational modeling of decision making, caregiver-related transmission of traumatic stress, and other areas may offer new targets that could harness adolescent neurobehavioral plasticity to improve resilience and recovery for some of our most vulnerable youths.