A Follow-Up Study from a Multisite, Randomized Controlled Trial for Traumatized Children Receiving TF-CBT

A community-based study of the impact of trauma exposure on school-aged children's self-concept and improvements following TF-CBT

BACKGROUND

Experiencing trauma in childhood has been associated with more severe psychopathology and a greater risk of engaging in harmful behavior later in life. Traumatic exposure can also erode a child's self-concept. Negative self-concept has been associated with shame, self-doubt, and helplessness in the face of adverse experiences. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based model for children; however, research on its effectiveness in improving children's self-concept is limited.

OBJECTIVE

To investigate the impact of trauma on school-aged children's self-concept and improvements following TF-CBT.

PARTICIPANTS AND SETTING

A demographically diverse sample of trauma-exposed school-aged children referred to community-based agencies in Canada and a normative sample of school-aged children randomly selected from the general population in the United States.

METHOD

A longitudinal design was used to assess trauma-exposed children's self-reported self-concept using the short-form Tennessee Self-Concept Scale - Second Edition (TSCS:2; Fitts & Warren, 1996) prior to and following TF-CBT.

RESULTS

Trauma-exposed children had a significantly more negative mean self-concept compared to that of the normative sample. Improvements following TF-CBT - and not the passage of time alone - were found with gains maintained six months post-therapy.

CONCLUSIONS

School-aged children awaiting treatment at community-based agencies are likely to hold clinically concerning negative views of themselves. TF-CBT was effective in significantly improving their self-concept with continued and lasting improvements observed after the therapy had been completed.

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.

Are Differences Evident in the Ways Boys and Girls Appraise and Interpret Their Traumatic Experiences? A Qualitative Analysis of Youth Trauma Narratives

The purpose of this study was to explore potential similarities and differences in the ways boys and girls appraise and interpret their traumatic experiences, and better understand how gender roles, performance, and socialization processes may impact trauma experiences, appraisals, and narratives within the context of trauma-focused treatment. We used thematic analysis to analyze the trauma narratives of youth (N = 16) ages 8-16 who had experienced multiple types (M = 5.38) of child maltreatment and who were receiving Trauma-focused Cognitive Behavioral Therapy to address clinically elevated posttraumatic stress symptoms. Four themes emerged: variations in the content of negative cognitions, differences in relational emotion, adoption of socially prescribed gender roles, and symptom differences. Although many similarities existed in youth's trauma narratives, differences emerged that point to the importance of social context and the ways gender role expectations and socialization processes influence youth's appraisal of and responses to traumatic events. Findings indicate the importance of considering distress tolerance, relational emotion, gender identity development, and role socialization within the treatment milieu.

Stability of Treatment Effects and Caregiver-Reported Outcomes: A Meta-Analysis of Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents

The efficacy of trauma-focused treatments for children and adolescents is well researched. However, less is known about the long-term and caregiver-reported effects. Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey. Treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) were computed at 12-month follow-up with posttraumatic stress symptoms (PTSS) as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes. Concordance between participant and caregiver ratings were investigated. TF-CBT showed large improvements across all outcomes from pre-treatment to 12-month follow-up (PTSS: g = 1.71, CI 1.27-2.15) and favorable results compared to active treatments and treatment as usual at 12-month follow-up (PTSS: g = .35, CI .13-.56). More pronounced effects were found in group settings. No significant differences were detected between participant and caregiver ratings with high reliability across almost all outcomes and assessment points. TF-CBT is a reliable treatment for pediatric PTSS and secondary symptoms with stable results at 12-month follow-up.

Trauma and Resilience in Adolescents and Young Adults With Opioid Use and Eating Disorders

Substance use disorders and feeding and eating disorders (FEDs) often manifest in early adolescence, are difficult to treat, and tend to co-occur. Despite their co-occurrence, little is known about their shared risk factors. A cross-sectional study was conducted to compare standardized measures of adverse childhood experiences (ACEs) and protective factors among 90 adolescents and young adults seeking outpatient treatment for either opioid use disorder (OUD) or an FED. These were assessed using the Modified Adverse Childhood Experience Survey and Southern Kennebec Healthy Start Resilience Survey. Reported ACEs were high in both groups compared with the national average, and those with OUD were more likely to endorse ≥4 resilience factors. Meanwhile, the prevalence of emotional neglect, household mental illness, and peer victimization/isolation/rejection was similar between groups. Opioid use disorder patients were also less likely to endorse ≥9 resilience factors. Health providers should be mindful to assess for trauma and resiliency in both these populations.

Examining the Feasibility of Telehealth Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) with Young People in Foster Care

Purpose: Despite the high rate of trauma exposure among young people with child welfare involvement, various systematic and patient barriers exist that inhibit utilization of evidence-based trauma treatments. One strategy for alleviating barriers to such treatments is using telehealth. A few studies have found that the clinical outcomes of telehealth TF-CBT are comparable to those found from clinic-based, in-person treatment administration. Studies have yet to examine the feasibility of telehealth TF-CBT with young people in care. The current study sought to address this gap by examining outcomes for patients who received telehealth TF-CBT, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care. Methods: Patient data were collected retrospectively from the electronic health records of 46 patients who received telehealth TF-CBT between March 2020 and April 2021, and feedback was sought via focus group from 7 of the clinic's mental health providers. A paired-sample t-test was conducted to evaluate the impact of the intervention for the 14 patients who completed treatment. Results: Responses from the Child and Adolescent Trauma Screen showed a significant decrease in posttraumatic stress symptoms when comparing pre-treatment scores (M = 25.64, SD = 7.85) to post-treatment scores (13.57, SD = 5.30), t(13) = 7.50, p < .001. The mean decrease in scores was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Themes emerging from the focus group centered on home environment, caregiver participation, and systemic topics. Conclusions: Findings suggest that telehealth TF-CBT with young people in care is feasible but relatively low completion rates suggest that barriers to treatment completion remain.

Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: a randomized controlled trial

Background

Improving children's access to mental health services need more innovative solutions, especially in low- and middle-income countries. School-based psychosocial interventions delivered by lay counselors may be an efficient way to improve children's access to mental health services. But few studies were conducted to examine the effectiveness of these interventions. Therefore, this study is to evaluate the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) in a group format delivered by lay counselors to children with trauma-related symptoms in China.

Methods

A total of 234 children (aged 9-12 years) with full or subthreshold posttraumatic stress disorder (PTSD) were randomly assigned to group-based TF-CBT or treatment as usual (TAU). In the intervention group, 118 children received 10-12 sessions of group-based TF-CBT delivered by lay counselors for 9 consecutive weeks. In the TAU group, 116 children received the usual school services provided by psychology teachers. The primary outcome was the reduction in PTSD severity, which was assessed with the UCLA PTSD reaction index for DSM-5 (PTSD-RI-5). The secondary outcomes included the reduction in PTSD severity and the remission of PTSD, both of which were measured with the PTSD checklist-5 (PCL-5). Secondary outcomes also included the reduction in depression severity and the reduction in generalized anxiety severity. Blinded assessments were collected at baseline, posttreatment (primary endpoint), and 3-month follow-up. This trial is registered with Chinese Clinical Trial Registry, ChiCTR1900027131.

Findings

At posttreatment, the intervention group scored significantly lower than the TAU group on PTSD-RI-5 PTSD (30.98 vs. 39.22; adjusted mean difference [AMD], -7.35; 95% CI, -11.66 to -3.04), PCL-5 PTSD (28.78 vs. 38.04; AMD, -8.49; 95% CI, -13.23 to -3.75), depression (5.52 vs. 7.96; AMD, -1.63; 95% CI, -2.50 to -0.76), and generalized anxiety (7.23 vs. 8.64; AMD, -1.21; 95% CI, -2.20 to -0.23). The remission of PCL-5 PTSD was also significantly higher in the intervention group (42.86% vs. 13.54%, χ ²  = 13.10, P < 0.001). These two groups showed a similar level of symptoms at the 3-month follow-up.

Interpretation

The group-based TF-CBT can significantly alleviate PTSD, depression, and generalized anxiety right after treatment in Chinese children who suffer from different types of trauma. But the long-term effects of this intervention need to be further tested. This intervention can be delivered by trained lay counselors in low- and middle-income countries.

Funding

None.

Review: Unaccompanied refugee minors' perception of mental health services and professionals: a systematic review of qualitative studies

BACKGROUND

Unaccompanied refugee minors (URMs) are a population at risk of mental health problems and a population with whom the therapeutic alliance can be difficult to set up. The therapeutic alliance's quality can impact the result and effectiveness of psychotherapeutic interventions. The aim of the present study was to gather URMs' points of view about mental health services and mental health professionals (MHP) in the host country. A summary of interviews conducted with URMs will allow a better understanding of their perception and expectations.

METHODS

Seven databases were searched with English and French keywords. In the end, nine studies were selected.

RESULTS

The review of the interviews shows that URMs do not have a clear perception of MHP - it seems difficult for them to trust MHP, but also to understand the value of sharing past painful experiences to reduce current symptoms. They can have a negative perception of mental health and consider that this is not a priority. URMs prefer to focus on day-to-day problems, do activity-based interventions and do group sessions to value social interactions.

CONCLUSIONS

Clinical and methodological implications are discussed. The development of an instrument to evaluate therapeutic care for URMs could be interesting for future research and for clinicians.

Therapists' Perceived Competence in Trauma-Focused Cognitive Behavioral Therapy and Client Outcomes: Findings From a Community-Based Learning Collaborative

This study examined therapists' perceived competence in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and its association with youth treatment outcomes (posttraumatic stress and depression). Participants included 99 community therapists enrolled in a TF-CBT-focused Learning Collaborative (LC), along with one of their randomly selected TF-CBT training cases. Analyzed data included: 1) caregiver/youth-reported posttraumatic stress and depressive symptoms, pre- and post-treatment, and 2) therapist-perceived competence with TF-CBT components across treatment delivery. Youth- and caregiver-reports indicated large, significant pre- to post-treatment decreases in youth posttraumatic stress (ds = 1.10-1.30, ps < .001) and depressive symptoms (d = 1.01, p < .001). Higher therapist-perceived competence with TF-CBT predicted positive treatment responses for posttraumatic stress (ds = 0.38-0.39, ps = .03) and depression (d = 0.25), though only the former association was significant (ps = .03 vs. p = .15). Findings highlight the need to monitor and improve therapists' competencies to enhance clinical outcomes for trauma-exposed youth and suggest that LCs may be an effective training/implementation model to help achieve those critical goals.

Cognitive behavioral therapy for children and adolescents with post-traumatic stress disorder: meta-analysis

BACKGROUND

Children and adolescents who experience traumatic events may develop post-traumatic stress disorder (PTSD), which is often associated with other psychiatric disorders, including depression and anxiety. Cognitive behavioral therapy (CBT) is widely used in psychotherapy to treat PTSD in children and adolescents. This meta-analysis evaluated previous studies on the effectiveness of CBT in the treatment of PTSD in children and adolescents.

METHODS

Randomized controlled trials (RCTs) published before July 25, 2021, were retrieved from seven databases. All RCTs of CBT compared to control, including conventional treatment or other treatments, in children or adolescents with PTSD. Random effect models were employed for all outcomes. Risk of bias was performed by Cochrane Collaboration's tool. The publication bias was evaluated using the Egger's regression analysis.

RESULTS

Nineteen RCTs were included in the meta-analysis. Compared with control, CBT was effective in reducing the symptoms of PTSD in children and adolescents, with a variety of scales used to measure the overall PTSD symptoms: CAPS (SMD = -0.41, 95%CI [-0.71, -0.12]), CPSS (SMD = -0.88, 95%CI [-1.42, -0.34]) and UCLA-PTSD RI (SMD = -1.70, 95%CI [-2.98, -0.42]). Furthermore, CBT also improved the comorbidities of depression (SMD = -0.43, 95%CI [-0.70, -0.17]) and anxiety (SMD = -0.29, 95%CI [-0.56, -0.03]) associated with PTSD. However, CBT was not effective in reducing avoidance symptoms (SMD = 0.38, 95%CI [-0.55, 1.31]).

CONCLUSION

CBT can reduce the severity of PTSD in children and adolescents and improve the symptoms of depression and anxiety, as evident in the treatment of PTSD victims of sexual abuse and war and in patients aged more than 7 years.

Examining the 8-Year Trajectory of Posttraumatic Stress Symptoms in Children Exposed to Intimate Partner Violence

Millions of children witness intimate partner violence (IPV) each year, and the effects of these experiences are substantial. One of the more common sequelae of exposure to IPV is the development of posttraumatic stress symptoms (PTSS). Given the chronic nature of both IPV and PTSS, there is a need for prospective research on long-term mental health outcomes following IPV exposure in childhood. This study prospectively examines trajectories of PTSS over an 8-year period, beginning from the preschool period. This study also investigates factors that may be associated with these trajectories, including intervention participation, continued IPV exposure, and the caregiving environment. A total of 120 mother-child dyads participated in four study waves over an 8-year period, beginning when children were between the ages of 4 and 6. Mothers and children participated in an intervention between baseline and Time 2. At the onset of the study, all mothers reported experiencing IPV over the previous year. Findings demonstrate that, in general, children experienced worsening of their PTSS over the 8-year trajectory, and few factors were significantly associated with this trajectory. There were no associations between intervention participation, parenting behaviors, and long-term child PTSS outcomes; however, there were significant associations between amount of IPV exposure, mother's level of PTSS, and children's PTSS outcomes. These results underscore the need to better understand the impact of early-life exposure to IPV, as well as the need for interventions tailored to this developmental period. Furthermore, these findings highlight the long-term negative associations between chronic exposure to IPV and child well-being, as well as the significant connections between caregiver and child mental health.

Application of Evidence-Based Treatment in Community Mental Health Settings: Examining EBT Delivery Duration and Client Discharge

Characterizing community mental health (CMH) treatment duration and discharge is an important step toward understanding how to better meet client needs. This report describes patterns of treatment duration and discharge among clinicians participating in a state-funded evidence-based treatment (EBT) training initiative. After training and consultation, clinicians (N = 376) reported on treatment duration and discharge for their "most complete case." On average, clinicians delivered 12.4 sessions (SD = 5.1) of the treatment. After completing treatment, half of clinicians (58.7%) continued with regularly scheduled therapy, either using EBT elements or switching to supportive therapy. Clinicians who continued with regularly scheduled therapy delivered treatment in approximately the same number of sessions. Results revealed that CMH clinicians often do not discontinue therapy after completing a treatment protocol. These findings suggest it may be essential to better understand clinician decision-making around applying EBTs to their caseloads.

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.

Effectiveness of trauma-focused cognitive behavioral therapy for Japanese children and adolescents in community settings: a multisite randomized controlled trial

BACKGROUND

Trauma-focused cognitive behavioural therapy (TF-CBT) is an efficacious treatment model for children and adolescents with trauma-related disorders. However, few studies have been conducted in community settings, and there have been no randomized controlled trials in Asian countries.

OBJECTIVE

To evaluate the effectiveness of TF-CBT in regular community settings in Japan through comparison with a waitlist with minimal services control condition.

METHOD

Thirty Japanese children and adolescents with posttraumatic stress disorder symptoms (22 females, eight males, mean age = 13.90, range = 6-18) were randomly assigned to 12 sessions of TF-CBT or the waitlist control condition. The primary outcome measure was the Kiddie Schedule for Affective Disorders and Schizophrenia score assessed by blinded evaluators one month later.

RESULTS

The mean number of sessions was 12 (range: 11-13) in the TF-CBT group and 4.87 (range: 3-7) in the control group. Intention to treat analysis showed that the TF-CBT group achieved significantly greater symptom reduction than did the control group. The effect size (Cohen's d) between the TF-CBT and control groups was 0.96 (p =.014) for posttraumatic symptoms and 1.15 (p =.004) for depressive symptoms. However, the TF-CBT group did not show better results than the control group with regard to improvements in anxiety symptoms, psychosocial functioning, and behavioural problems.

CONCLUSIONS

The findings provided preliminary evidence of the effectiveness of TF-CBT for treating youth with trauma in community mental health facilities. TF-CBT in the Japanese context proved identical to the original, demonstrating that it is also suitable for use with children and adolescents in non-Western settings.

Sociodemographic characteristics of youth in a trauma focused-cognitive behavioral therapy effectiveness trial in the city of Philadelphia

While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder, TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study-drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia-we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants' addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p > .05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.

Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial

IMPORTANCE

Approximately 140 million children worldwide have experienced the death of one or both parents. These children, mostly in low- and middle-income countries, have higher rates of mental health problems than those who have not experienced parental death. Cognitive behavioral therapy (CBT) may improve the well-being of these children, but to our knowledge there have been no randomized clinical trials specifically focused on this population.

OBJECTIVES

To test the effectiveness of trauma-focused CBT (TF-CBT) for improving posttraumatic stress (PTS) in children in Kenya and Tanzania who have experienced parental death, to test the effects of TF-CBT on other mental health symptoms, and to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as trainers and supervisors.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial conducted in urban and rural areas of Tanzania and Kenya compared TF-CBT and usual care (UC) for 640 children aged 7 to 13 years who were recruited from February 13, 2013, to July 24, 2015. All children had experienced the death of one or both parents and had elevated PTS and/or prolonged grief. Interviewers were masked to study condition. Participants were followed up for 12 months after the randomized clinical trial. Statistical analysis was performed from February 3, 2017, to August 26, 2019. All analyses were on an intent-to-treat basis.

INTERVENTIONS

In the intervention condition, 320 children received 12 weeks of group TF-CBT delivered by lay counselors who were supervised weekly. In the UC condition, 320 children received community services typically offered to this population.

MAIN OUTCOMES AND MEASURES

The primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured.

RESULTS

A total of 640 children (320 girls and 320 boys; mean [SD] age, 10.6 [1.6] years) were included in the study. Trauma-focused CBT was more effective than UC for PTS in 3 of 4 sites after treatment (end of 3-month randomized clinical trial): rural Kenya (Cohen d = 1.04 [95% CI, 0.72-1.36]), urban Kenya (Cohen d = 0.56 [95% CI, 0.29-0.83]), and urban Tanzania (Cohen d = 0.45 [95% CI, 0.10-0.80]). At 12-month follow-up, TF-CBT remained more effective than UC in both rural (Cohen d = 0.86 [95% CI, 0.64-1.07]) and urban (Cohen d = 0.99 [95% CI, 0.75-1.23]) Kenya. At 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement (rural Tanzania, Cohen d = 0.09 [95% CI, -0.08 to 0.26]; urban Tanzania, Cohen d = 0.11 [95% CI, -0.09 to 0.31]). A similar pattern was seen for secondary outcomes, with stronger effects observed in Kenya, where children experienced greater stress and adversity (eg, more food scarcity, poorer guardian health, and greater exposure to traumatic events).

CONCLUSIONS AND RELEVANCE

This study found that TF-CBT was more effective than UC in reducing PTS among children who experienced parental death in 3 of 4 sites in Kenya and Tanzania. At 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural and urban Kenya.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01822366.

Is high-quality of trials associated with lower treatment efficacy? A meta-analysis on the association between study quality and effect sizes of psychological interventions for pediatric PTSD

This meta-analysis aimed at providing an up-to-date estimate on the efficacy of psychological interventions for pediatric PTSD and to analyze the association between treatment efficacy and study quality. We systematically searched PsycINFO, Medline and recent meta-analyses for randomized controlled trials (RCTs). RCTs were eligible if a) they included at least 10 participants per group, b) compared a psychological intervention to a control condition or another psychological intervention and c) mean age was below 19 years. Study quality was assessed independently by both authors on the basis of eight quality criteria. We explored the potential associations between study quality and effect sizes in three ways. Firstly, we compared effect-sizes of high-quality vs. lower-quality studies. Secondly, we analyzed study quality as a continuous predictor of effect sizes. And thirdly, we examined the relationship between the eight individual quality criteria and effect sizes. A total of 46 eligible RCTs were included in the meta-analysis. Psychological interventions produced a large effect size when compared to waitlist (g = 1.07, k = 23, NNT = 1.81) and a medium effect size when compared to active control conditions (g = 0.60, k = 15, NNT = 3.03) at post-treatment. Overall, study quality was moderate. Comparisons of high-quality trials (k = 16) with lower-quality trials (k = 30) produced only non-significant findings in main-analyses as well as moderator sub-analyses. Study quality as a continuous variable was also not found to be related to effect sizes in any of the main analyses, nor was any of the eight individual quality criteria. The summary of the available literature strongly suggests that psychological interventions are effective in treating PTSD in children and adolescents. No significant associations between study quality and treatment efficacy were observed.

Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents

Important advances in understanding traumatic stress reactions in children and young people have been made in recent years. The aim of this review was to synthesise selected recent research findings, with a focus on their relevance to clinical practice. We therefore address: findings on the epidemiology of trauma exposure and Posttraumatic Stress Disorder (PTSD); recent changes to diagnostic classification; implications for screening and assessment of traumatic stress reactions; and treatment outcome studies including interventions for acute and chronic PTSD, dissemination of effective treatments into community settings, and early interventions. We conclude with recommendations for clinical practice and suggestions for future areas of research.

Trauma-focused group intervention for unaccompanied young refugees: "Mein Weg"-predictors of treatment outcomes and sustainability of treatment effects

BACKGROUND

Current research on treatment predictors and long-term effects of trauma-focused interventions for (unaccompanied) refugee minors is limited. This secondary analysis of a recent randomised controlled trial (RCT), evaluating the trauma-focused group intervention "Mein Weg" (English "My Way") compared to usual care, investigated several refugee-specific factors such as treatment predictors and sustainability of treatment gains.

METHODS

In total N = 50 participants (M _age = 17.00, 94% male) were included in this analysis. Evaluation of 3-month follow-up data included: posttraumatic stress symptoms [(PTSS) CATS-Self, CATS-Care], depression (PHQ-8), and dysfunctional posttraumatic cognitions (CPTCI-S). Baseline symptom severity of the above-mentioned measures, trauma load and socio-demographic factors were investigated as the treatment predictors.

RESULTS

Intention-to-treat-analyses (ITT) revealed the sustainability of treatment effects in self-reported PTSS (pre to post change: 6.48 ± 1.60, d = 0.62, p < 0.001; post to 3-month follow-up change: 1.41 ± 1.96, d = 0.11, p = 0.47) and depression (pre to post change: 7.82 ± 2.09, d = 0.64, p < 0.001; post to 3-month follow-up change: 1.35 ± 2.17, d = 0.05, p = 0.54). Country of origin alone was a significant predictor of the change in PTSS (b = - 8.22 ± 3.53, t(30) = - 2.33, p = 0.027), and baseline levels of depression were a significant predictor of the change in depression (b = 0.83 ± 0.19, t(33) = 4.46, p < 0.001).

CONCLUSION

This group intervention can serve as a valuable component in a stepped care approach with promising long-term effects for young refugees.Trial registration DRKS, #DRKS00010915. Registered 15 September 2016, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010915.

Victimization and traumatic stress: Pathways to depressive symptoms among low-income, African-American girls

Socioeconomic disadvantage is associated with increased exposure to victimization and traumatic stress. The present study evaluates longitudinal pathways linking victimization and trauma to depressive symptoms in a socioeconomically disadvantaged sample of African-American adolescent girls seeking mental health services (N = 177, 12-16 years old at baseline). Girls completed four assessments over the course of three years (T1-T4). Depressive symptoms were assessed at T1-T3 using clinical interviews and questionnaires. At T4, lifetime history of victimization and traumatic stressors was evaluated with in-person interviews. Separate structural equation models tested longitudinal pathways from stressor frequency, severity, and duration to depressive symptoms. In all three models, higher levels of victimization and traumatic stressors were associated with significantly higher levels of depressive symptoms. More frequent stressors prior to T1 directly predicted depressive symptoms at T1 and indirectly predicted depressive symptoms at T2, which, in turn, predicted depressive symptoms at T3. A similar pattern emerged in the stressor severity and duration models. Findings support the idea that victimization and traumatic stressors are associated with higher levels of depressive symptoms and that, among treatment-seeking low-income adolescent girls, these effects occur through both direct and indirect paths. Implications of these findings are discussed in the context of the stress-generation and stress proliferation models of psychopathology.

Development and implementation of a group based mental health intervention for unaccompanied minors

Unaccompanied refugee minors (UMs) are at significant risk to experience severe mental health symptoms (Derluyn, Broekaert & Schuyten). Trauma-focused treatments have been found to be effective for traumatized refugees (Slobodin & de Jong). However, trauma-focused mental health services are seldom available, and treatment fails when UMs lack trust in service providers (Majumder, O'Reilly, Karim & Vostanis). In order to address this gap, a 10-session group based mental health intervention for UMs was developed and then pilot tested in 3 accommodation units for UMs in Finland. The implementation and effectiveness of the intervention was studied by qualitative and quantitative methods. The process was completed by 18 UMs. Symptom measures showed no statistically significant changes on the mental health variables studied. However, staff members and UMs reported increased trust and communication, and participating staff members felt empowered to facilitate groups independently. The group model promoted social interaction and built trust in the accommodation units. Further studies are required to UMs.

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

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

Treatment Features Associated with Youth Cognitive Behavioral Therapy Follow-Up Effects for Internalizing Disorders: A Meta-Analysis

Our aim was to investigate whether four treatment features (i.e., the inclusion of parental involvement, goal-setting strategies, maintenance/relapse prevention sessions, the addition of booster sessions) were associated with posttreatment and follow-up effect size of youth cognitive behavioral therapies (yCBTs) for anxiety, depression, posttraumatic stress disorder, and obsessive-compulsive disorder in age groups spanning young children to adolescents. We conducted a random-effects meta-analysis of 106 yCBTs tested in 76 randomized clinical trials from the PracticeWise Database to examine average effects of yCBTs posttreatment and at a later follow-up assessment. We coded the use of parental involvement, goal setting, booster sessions, and maintenance/relapse prevention in each yCBT and conducted random-effects meta-regression analyses to investigate whether these treatment features were associated with yCBT effects at posttreatment as well as at follow-up. Overall, yCBTs produced large pre- to posttreatment effects (d = 1.05), 95% confidence interval [0.94, 1.15], and larger pre- to follow-up effects (d = 1.29), 95% confidence interval [1.18, 1.40]. Metaregression results indicated that parental involvement was significantly associated with larger pre- to posttreatment effect sizes as well as pre- to follow-up effect sizes. Booster sessions, goal setting, and maintenance/relapse prevention were not significantly related to effect sizes at posttreatment or follow-up. Parental involvement may be helpful for maximizing long-term effectiveness of yCBT. Future studies should investigate for whom and under what conditions inclusion of yCBT treatment features is related to the durability of treatment gains.