Evidence-based treatments for traumatized children and adolescents

A pragmatic feasibility trial of the Primary Care Intervention for PTSD: A health service delivery model to reduce health disparities for low-income and BIPOC youth

OBJECTIVE

This study is a non-randomized pragmatic trial to assess the feasibility and acceptability of the Primary Care Intervention for Posttraumatic stress disorder (PCIP) (Srivastava et al., 2021), an Integrated Behavioral Health Care treatment for PTSD in adolescents.

METHOD

Following routine clinic procedures, youth who were suspected of having trauma-related mental health symptoms were referred by their primary care providers to integrated care social workers for evaluation. The integrated care social workers referred the first 23 youth whom they suspected of having PTSD to the research study. Twenty youth consented to the study and 19 completed the pre-assessment (17 female; mean age = 19.32, SD = 2.11; range 14-22 years). More than 40% identified as Black and a third as Hispanic/Latinx. PCIP mechanisms and clinical outcomes were assessed pre- and post-treatment, and at one-month follow-up. Participants and therapists completed post-treatment qualitative interviews to assess feasibility and acceptability, and treatment sessions were audio recorded to assess fidelity.

RESULTS

Findings suggest high acceptability, satisfaction, and feasibility of the PCIP delivered in "real-life" safety net pediatric primary care. Integrated care social workers had high treatment fidelity. Despite the small sample size, there was significant improvement in symptom scores of anxiety (g = 0.68, p = 0.02) and substance use (g = 0.36, p = 0.04) from pre to post, and depression symptoms (g = 0.38, p = 0.04) from pre to follow-up. Qualitative data from patients who completed exit interviews and integrated social workers indicated high satisfaction with the treatment, with some participants reporting that the integrated intervention was more acceptable and less stigmatizing than seeking mental health care outside of primary care.

CONCLUSIONS

The PCIP may improve treatment engagement and access for vulnerable youth. Promising findings of high acceptability, feasibility, and initial clinical effectiveness suggest that PCIP warrants larger-scale study as part of routine care in pediatric integrated care.

Systematic Review on the Application of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Preschool-Aged Children

Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the most widely studied and disseminated treatments for posttraumatic stress disorder (PTSD) and other comorbid conditions, and has been identified as a "level one" or "well-established" intervention for school-aged children and adolescents. The present systematic review examined the literature on the application of TF-CBT within a preschool-aged population (i.e., children ages three to six), as well as the developmental literature that could increase the efficacy of TF-CBT for preschool-aged children. Information on the use of TF-CBT with preschool-aged children was extracted from randomized controlled trials, case studies, meta-analyses, and other forms of empirical evidence, as part of the evidence-based practice in psychology framework. In comparison to research with school-aged children and adolescents, fewer studies have directly assessed the efficacy of TF-CBT for preschool-aged children who have been exposed to trauma. Given the few studies published to date and difference in treatment protocols for TF-CBT used with preschool-age children, TF-CBT appears to meet criteria as a "level two" or "probably efficacious" intervention for preschool-aged children specifically. According to the available literature, language and cognitive abilities, family context, culture, and clinician expertise are considered as potential variables to address when contemplating the use of TF-CBT for preschool-aged children with symptoms of post-traumatic stress.

Care use and its intensity in children with complex problems are related to varying child and family factors: A follow-up study

Background

There is little evidence on the child and family factors that affect the intensity of care use by children with complex problems. We therefore wished to identify changes in these factors associated with changes in care service use and its intensity, for care use in general and psychosocial care in particular.

Methods

Parents of 272 children with problems in several life domains completed questionnaires at baseline (response 69.1%) and after 12 months. Negative binominal Hurdle analyses enabled us to distinguish between using care services (yes/ no) and its intensity, i.e. number of contacts when using care.

Results

Change in care use was more likely if the burden of adverse life events (ALE) decreased (odds ratio, OR = 0.94, 95% confidence interval, CI = 0.90–0.99) and if parenting concerns increased (OR = 1.29, CI = 1.11–1.51). Psychosocial care use became more likely for school-age children (vs. pre-school) (OR = 1.99, CI = 1.09–3.63) if ALE decreased (OR = 0.93, CI = 0.89–0.97) and if parenting concerns increased (OR = 1.26, CI = 1.10–1.45). Intensity of use (>0 contacts) of any care decreased when ALE decreased (relative risk, RR = 0.95, CI = 0.92–0.98) and when psychosocial problems became less severe (RR = 0.38, CI = 0.20–0.73). Intensity of psychosocial care also decreased when severe psychosocial problems became less severe (RR = 0.39, CI = 0.18–0.84).

Conclusions

Changes in care-service use (vs. no use) and its intensity (>0 contacts) are explained by background characteristics and changes in a child’s problems. Care use is related to factors other than changes in its intensity, indicating that care use and its intensity have different drivers. ALE in particular contribute to intensity of any care use.

A Meta-Analysis of Parenting Practices and Child Psychosocial Outcomes in Trauma-Informed Parenting Interventions after Violence Exposure

Over half of all youth are exposed to violence, which a growing body of literature suggests is associated with a broad range of negative developmental outcomes over the life course. However, best practices for supporting parenting are not widely applied to parents with children exposed to violence-related trauma. This meta-analyses seeks to synthesize the literature base of trauma-informed parenting interventions to better understand their potential impact on parenting and child outcomes. Specifically, 21 trauma-informed parenting interventions were identified that quantitatively assessed intervention effects on parenting and child outcomes. Six meta-analyses were conducted to assess intervention effects on (1) positive parenting practices, (2) negative parenting practices, (3) parenting stress, (4) children's internalizing problems, (5) children's externalizing problems, and (6) trauma symptoms, respectively. Moderate to large effect sizes were found for positive parenting practices (d = 0.62) as well as child internalizing problems, externalizing problems, and trauma symptoms (d = 0.48-0.59). Validity tests indicated robust findings for positive parenting and for all child outcomes. Additional moderator analyses support the importance of informed intervention design, showing differential findings by trauma type as well as by duration of the intervention. These findings indicate the value of evidence-based parenting interventions for violence-related trauma and support models of trauma-informed care that situate treatment in the broader social context, particularly the family. Results are discussed with respect to which parenting practices hold the most promise for supporting children exposed to violence-related trauma.

What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review

The long-term consequences of exposure to firearm injury-including suicide, assault, and mass shootings-on children's mental and physical health is unknown. Using PRISMA-ScR guidelines, we conducted a scoping review of four databases (PubMed, Scopus, PsychINFO, and CJ abstract) between January 1, 1985 and April 2, 2018 for articles describing long-term outcomes of child or adolescent firearm injury exposure (n = 3582). Among included studies (n = 31), most used retrospective cohorts or cross-sectional studies to describe the correlation between firearm injury and post-traumatic stress. A disproportionate number of studies examined the effect of mass shootings, although few of these studies were conducted in the United States and none described the impact of social media. Despite methodologic limitations, youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury. Evidence is lacking on best practices for prevention of mental health and behavioral sequelae among youth exposed to firearm injury. Future research should use rigorous methods to identify prevalence, correlates, and intervention strategies for these at-risk youth.

Parental Experiences of Supporting Children with Clinically Significant Post-Traumatic Distress: a Qualitative Study of Families Accessing Psychological Services

The aim of this study was to investigate the experiences of parents in providing support to their child following trauma exposure in cases where children are experiencing clinically significant levels of post-traumatic distress. Qualitative interviews were conducted with parents whose child was exposed to a trauma and referred for psychological treatment. Parents reported considerable anxiety in coping with their child's post-traumatic distress. Avoidance of trauma-related discussions was encouraged due to concerns that non-avoidant approaches may worsen children's post-trauma difficulties. Nonetheless, parents were often sensitive to their child's distress and offered reassurance and other forms of support. Many barriers existed to accessing psychological treatment, and perceptions of inadequate guidance from therapists on supporting child adjustment contributed to parental distress. The results illustrate the strategies used by parents in supporting their child post-trauma and may assist mental health professionals in providing acceptable guidance to parents following child trauma.

A trauma-informed approach supports health and development in children and youth with spina bifida

Children with developmental disabilities may be at greater risk for experiencing maltreatment and traumatic events, threats to their physical and psychological safety and well-being. Young children and youth with spina bifida benefit from being considered in light of this risk, and may be especially vulnerable given the complexity of their neurodevelopmental condition. A trauma-informed approach brings together evidence from the neurosciences, epidemiology and psychology to promote improved developmental, behavioral, physical and mental health status. Incorporating a trauma-informed approach strengthens a longitudinal, interdisciplinary and developmentally-oriented care model for children and youth with spina bifida. A case example further illustrates how using a trauma-informed approach and evidence-based interventions can foster the development and well-being of youth with spina bifida who have been impacted by a traumatic event.

Addressing the Needs of Children With Disabilities Experiencing Disaster or Terrorism

PURPOSE OF REVIEW

This paper reviews the empirical literature on psychosocial factors relating to children with disabilities in the context of disaster or terrorism.

RECENT FINDINGS

Research indicates adults with disabilities experience increased exposure to hazards due to existing social disparities and barriers associated with disability status. However, studies on the psychological effects of disaster/terrorism on children with pre-existing disabilities are exceedingly few and empirical evidence of the effectiveness of trauma-focused therapies for this population is limited. Secondary adversities, including social stigma and health concerns, also compromise the recovery of these children post-disaster/terrorism. Schools and teachers appear to be particularly important in the recovery of children with disabilities from disaster. Disasters, terrorism, and war all contribute to increased incidence of disability, as well as disproportionately affect children with pre-existing disabilities. Disaster preparedness interventions and societal changes are needed to decrease the disproportionate environmental and social vulnerability of children with disabilities to disaster and terrorism.

The effects of parental components in a trauma-focused cognitive behavioral based therapy for children exposed to interparental violence: study protocol for a randomized controlled trial

BACKGROUND

Interparental violence is both common and harmful and impacts children's lives directly and indirectly. Direct effects refer to affective, behavioral, and cognitive responses to interparental violence and psychosocial adjustment. Indirect effects refer to deteriorated parental availability and parent-child interaction. Standard Trauma Focused Cognitive Behavioral Therapy may be insufficient for children traumatized by exposure to interparental violence, given the pervasive impact of interparental violence on the family system. HORIZON is a trauma focused cognitive behavioral therapy based group program with the added component of a preparatory parenting program aimed at improving parental availability; and the added component of parent-child sessions to improve parent-child interaction.

METHODS/DESIGN

This is a multicenter, multi-informant and multi-method randomized clinical trial study with a 2 by 2 factorial experimental design. Participants (N = 100) are children (4-12 years), and their parents, who have been exposed to interparental violence. The main aim of the study is to test the effects of two parental components as an addition to a trauma focused cognitive behavioral based group therapy for reducing children's symptoms. Primary outcome measures are posttraumatic stress symptoms, and internalizing and externalizing problems in children. The secondary aim of the study is to test the effect of the two added components on adjustment problems in children and to test whether enhanced effects can be explained by changes in children's responses towards experienced violence, in parental availability, and in quality of parent-child interaction. To address this secondary aim, the main parameters are observational and questionnaire measures of parental availability, parent-child relationship variables, children's adjustment problems and children's responses to interparental violence. Data are collected three times: before and after the program and six months later. Both intention-to-treat and completer analyses will be done.

DISCUSSION

The current study will enhance our understanding of the efficacy interparental violence-related parental components added to trauma focused cognitive behavioral group program for children who have been exposed to IPV. It will illuminate mechanisms underlying change by considering multiple dimensions of child responses, parenting variables and identify selection criteria for participation in treatment.

TRIAL REGISTRATION

Netherlands Trial Register NTR4015 . Registered 4th of June, 2013.