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Park EJ, Lee MS, Bae SM, Kim HS, Hong M, Kim E, Lee SK, Kim J, Bhang SY. Promising Effect of the Children in Disaster: Evaluation and Recovery Intervention on Trauma Symptoms and Quality of Life for Children and Adolescents: A Controlled Study. Psychiatry Investig 2024; 21:123-132. [PMID: 38321890 PMCID: PMC10910171 DOI: 10.30773/pi.2023.0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 02/08/2024] Open
Abstract
OBJECTIVE The Children in Disaster: Evaluation and Recovery (CIDER) program in Korea was developed to treat children and adolescents exposed to trauma. This study aimed to demonstrate the effectiveness of the CIDER through a comparison with controls. METHODS A total of 85 participants consisted of the intervention group (n=41) and control group (n=44). We assessed the changes in trauma-related symptoms, depression, anxiety, and improvements in quality of life before and after the intervention. RESULTS In total, bullying and school violence (44.7%) were the most common trauma, followed by sexual abuse (17.6%). Acute stress disorder and post-traumatic stress disorder (PTSD) accounted for 41.2%, and attention-deficit/hyperactivity disorder (ADHD) and developmental disorder were the most common comorbidities (51.8%). The symptoms of trauma, depression, anxiety, and quality of life improved significantly in the intervention group, while the control group did not show significant changes. CONCLUSION Compared with the control group, the CIDER improved symptoms and quality of life in children and adolescents who had experienced trauma. The CIDER program was practical and easy to apply, even for different ages, types of traumas, and comorbidities.
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Affiliation(s)
- Eun Jin Park
- Jinny Mental Health Clinic, Goyang, Republic of Korea
| | - Mi-Sun Lee
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Eulji Psychiatry and Medical Science Center, Eulji University, Seongnam, Republic of Korea
| | - Seung Min Bae
- Department of Psychiatry, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hyun Soo Kim
- Department of Psychiatry, Hanyang University College of Medicine, Myongji Hospital, Goyang, Republic of Korea
| | - Minha Hong
- Department of Psychiatry, Hanyang University College of Medicine, Myongji Hospital, Goyang, Republic of Korea
| | - Eunji Kim
- Maumtodak Psychiatry Clinic, Ansan, Republic of Korea
| | - Seul Ki Lee
- Department of Psychiatry, Gil Hospital, Incheon, Republic of Korea
| | - Jiyoun Kim
- Goodmind Psychiatry Clinic, Suwon, Republic of Korea
| | - Soo-Young Bhang
- Eulji Psychiatry and Medical Science Center, Eulji University, Seongnam, Republic of Korea
- Department of Psychiatry, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
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Shayani DR, Canale CA, Sloan DM, Hayes AM. Predictors of dropout in cognitive processing therapy for PTSD: An examination of in-session treatment processes. Behav Res Ther 2023; 171:104428. [PMID: 37952284 PMCID: PMC10826797 DOI: 10.1016/j.brat.2023.104428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
Dropout rates for treatments for adult posttraumatic stress disorder (PTSD) are high. Process research can reveal client factors during treatment that predict dropout. An observational coding system was used to code client processes in audio-recorded early sessions of cognitive processing therapy (CPT), a gold-standard treatment for PTSD. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET), with higher rates of dropout in CPT than WET (39.7% vs. 6.4%). Participants in this study were 53 treatment-seeking adults with PTSD who were in the CPT arm of the trial and completed the CAPS-5 at pretreatment and at least one session. Of these, 15 (28.3%) dropped out of CPT early (completing ≤9 sessions) and 38 (71.7%) completed treatment. Sessions were coded with an observational coding system on a four-point scale (0 = absent to 3 = high) for maladaptive trauma-related responses (overgeneralized beliefs, ruminative processing, avoidance), affective engagement (negative emotions, physiological distress), and adaptive processing (cognitive emotional processing). Binary logistic regressions showed that more physiological distress and cognitive emotional processing predicted lower dropout, whereas more avoidance predicted higher dropout. Negative emotion, ruminative processing, and overgeneralization were not significant predictors. These findings highlight potential early indicators of treatment engagement that could be targeted to reduce dropout and perhaps facilitate further therapeutic change.
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Affiliation(s)
- Danielle R Shayani
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA.
| | - Caroline A Canale
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Adele M Hayes
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA
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3
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Jin J, Al-Shamali H, Smith-MacDonald L, Reeson M, Polzin W, Wei Y, Pazderka H, Silverstone PH, Greenshaw AJ. Access to therapy for child sexual abuse survivors: Preliminary dialogue of barriers and facilitators between caregivers. PLoS One 2023; 18:e0294686. [PMID: 37976247 PMCID: PMC10655970 DOI: 10.1371/journal.pone.0294686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Difficulties in access to therapy were highlighted by COVID-19 measures restricting in-person gatherings. Additional challenges arise when focusing on caregivers of child sexual abuse (CSA) survivors in particular, which are a population that has been historically difficult to engage with due to issues of stigma and confidentiality. OBJECTIVES To present preliminary qualitative results from caregivers of CSA survivors. METHODS This study was conducted with caregivers of CSA survivors. Two hybrid webinar/focus groups were conducted using a video conferencing platform in fall of 2021 with two groups of stakeholders (11 caregivers and 5 moderators/clinical staff at Little Warriors, an intensive episodic treatment facility). Sessions were recorded, transcribed, and thematically-analyzed using standard qualitative methodology. RESULTS A total of 11 caregivers contributed to the data. Themes include: (1) Challenges of starting and maintaining treatment (i.e., emotional impact of intake day, challenges of enrolling), (2) Therapeutic benefits of specialized treatment (i.e., feeling safe and supported and the importance of trauma-informed care), and (3) Barriers and facilitators of treatment (i.e., avenues to scale-up and self-care). CONCLUSION The importance of a strong therapeutic alliance was highlighted by both caregivers/clinical staff and further support is needed for families post-treatment. The present hybrid webinar/focus group also achieved engagement goals in a population that is typically difficult to reach. Overall, the response rate (12%) was equivalent to reported registrant attendance rates for general business to consumer webinars and the recommended focus group size. This preliminary approach warrants replication in other populations outside our clinical context.
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Affiliation(s)
- Jonathan Jin
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Huda Al-Shamali
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Reeson
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Wanda Polzin
- Little Warriors Be Brave Ranch, Edmonton, Alberta, Canada
| | - Yifeng Wei
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Hannah Pazderka
- Department of Psychiatry, University of Alberta, Edmonton, Canada
- Little Warriors Be Brave Ranch, Edmonton, Alberta, Canada
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Kangaslampi S, Zijlmans J. MDMA-assisted psychotherapy for PTSD in adolescents: rationale, potential, risks, and considerations. Eur Child Adolesc Psychiatry 2023:10.1007/s00787-023-02310-9. [PMID: 37814082 DOI: 10.1007/s00787-023-02310-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
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.
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Affiliation(s)
- Samuli Kangaslampi
- Faculty of Social Sciences/Psychology, Tampere University, Tampere, Finland.
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands.
| | - Josjan Zijlmans
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam University Medical Center, Mental Health, Amsterdam, The Netherlands
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van der Hoeven ML, Assink M, Stams GJJM, Daams JG, Lindauer RJL, Hein IM. Victims of Child Abuse Dropping Out of Trauma-Focused Treatment: A Meta-Analysis of Risk Factors. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2023; 16:269-283. [PMID: 37234839 PMCID: PMC10205941 DOI: 10.1007/s40653-022-00500-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 05/27/2023]
Abstract
A substantial number of children who experienced child maltreatment drop out of evidence-based trauma-focused treatments (TF-CBT). Identifying child, family, and treatment-related factors associated with treatment dropout is important to be able to prevent this from happening and to effectively treat children's trauma-related symptoms. Methods: A quantitative review was performed based on a systematic synthesis of the literature on potential risk factors for dropout of trauma-focused treatment in maltreated children. Results: Eight studies were included, that examined TF-CBT, reporting on 139 effects of potential risk factors for dropout. Each factor was classified into one of ten domains. Small but significant effects were found for the "Demographic and Family" risk domain (r = .121), with factors including being male, child protective services involvement or placement, and minority status, and for the "Youth Alliance" risk domain (r = .207), with factors including low therapist-child support and low youth perception of parental approval. Moderator analyses suggested that family income and parental education may better predict the risk for TF-CBT dropout than other variables in the "Demographic and Family" domain. Conclusions: Our results provide a first overview of risk factors for dropout of trauma-focused treatments (TF-CBT) after child maltreatment, and highlight the role of the therapeutic relationship in this. Supplementary Information The online version contains supplementary material available at 10.1007/s40653-022-00500-2.
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Affiliation(s)
- Mara L. van der Hoeven
- Amsterdam UMC, Department of Child and Adolescent Psychiatry, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, the Netherlands
| | - Mark Assink
- Research Institute of Child Development and Education, University of Amsterdam, Nieuwe Achtergracht 127, 1018 WS Amsterdam, the Netherlands
| | - Geert-Jan J. M. Stams
- Research Institute of Child Development and Education, University of Amsterdam, Nieuwe Achtergracht 127, 1018 WS Amsterdam, the Netherlands
| | - Joost G. Daams
- Medical Library, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Ramón J. L. Lindauer
- Amsterdam UMC, Department of Child and Adolescent Psychiatry, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, the Netherlands
- Levvel, Academic Center for Child and Adolescent Psychiatry, Meibergdreef 5, 1105 AZ Amsterdam, the Netherlands
| | - Irma M. Hein
- Amsterdam UMC, Department of Child and Adolescent Psychiatry, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, the Netherlands
- Levvel, Academic Center for Child and Adolescent Psychiatry, Meibergdreef 5, 1105 AZ Amsterdam, the Netherlands
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6
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Eslinger J, Sprang G, Jodts J. Keeping children and youth in trauma treatment: Examination of an alliance building dropout management program. Clin Child Psychol Psychiatry 2023; 28:721-733. [PMID: 35762135 DOI: 10.1177/13591045221111849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Evidence-based treatments exist to address traumatic stress related symptoms for children, however dropout from trauma-focused treatment remains a concern. This study examined use of an alliance building dropout management program for a group of children ages 3-17 who received an evidence-based trauma-focused treatment. Logistic regression analysis was conducted to examine the relationships between child gender, race, ethnicity, age, guardianship, externalizing behaviors, participation in a dropout management program and the dose of treatment received. The final model was significant and participation in the dropout management program as well as a child's placement in foster care were significant individual correlates with full completion of treatment. Use of an Alliance Building Dropout Management program may help decrease overall dropout over and above the contribution of other variables known to impact treatment completion.
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Affiliation(s)
- Jessica Eslinger
- Department of Psychiatry, 12252University of Kentucky, Lexington, KY, USA.,Center on Trauma and Children, 4530University of Kentucky, Lexington, KY, USA
| | - Ginny Sprang
- Department of Psychiatry, 12252University of Kentucky, Lexington, KY, USA.,Center on Trauma and Children, 4530University of Kentucky, Lexington, KY, USA
| | - Jenna Jodts
- Center on Trauma and Children, 4530University of Kentucky, Lexington, KY, USA
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Ng LC, Miller AN, Bowers G, Cheng Y, Brigham R, Him Tai M, Smith AM, Mueser KT, Fortuna LR, Coles M. 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. Behav Res Ther 2023; 165:104310. [PMID: 37040669 DOI: 10.1016/j.brat.2023.104310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 04/09/2023]
Abstract
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.
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8
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de Soet R, Vermeiren RRJM, Bansema CH, van Ewijk H, Nijland L, Nooteboom LA. Drop-out and ineffective treatment in youth with severe and enduring mental health problems: a systematic review. Eur Child Adolesc Psychiatry 2023:10.1007/s00787-023-02182-z. [PMID: 36882638 DOI: 10.1007/s00787-023-02182-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
Youth with severe and enduring mental health problems (SEMHP) tend to drop out of treatment or insufficiently profit from treatment in child and adolescent psychiatry (CAP). Knowledge about factors related to treatment failure in this group is scarce. Therefore, the aim of this systematic review was to thematically explore factors associated with dropout and ineffective treatment among youth with SEMHP. After including 36 studies, a descriptive thematic analysis was conducted. Themes were divided into three main categories: client, treatment, and organizational factors. The strongest evidence was found for the association between treatment failure and the following subthemes: type of treatment, engagement, transparency and communication, goodness of fit and, perspective of practitioner. However, most other themes showed limited evidence and little research has been done on organizational factors. To prevent treatment failure, attention should be paid to a good match between youth and both the treatment and the practitioner. Practitioners need to be aware of their own perceptions of youth's perspectives, and transparent communication with youth contributes to regaining their trust.
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Affiliation(s)
- R de Soet
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands.
| | - R R J M Vermeiren
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
- Youz, Parnassia Group, The Hague, The Netherlands
| | - C H Bansema
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
| | - H van Ewijk
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
| | - L Nijland
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
| | - L A Nooteboom
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
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Kagan R, Pressley J, Espinoza R, Lanktree C, Henry J, Knoverek A, Duffy S, Labruna V, Habib M, Blaustein ME, Spinazzola J. Development of a Differential Assessment Guide to Improve Engagement with Youths & Families Living with Chronic Trauma. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2023; 16:145-159. [PMID: 36776636 PMCID: PMC9908809 DOI: 10.1007/s40653-022-00479-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 06/18/2023]
Abstract
Youths and parents/caregivers who have experienced multiple forms of severe interpersonal trauma may demonstrate severe and persistent symptoms of complex trauma including high-risk behaviors. Engagement, and sustaining engagement, of these youths and parents/caregivers in evidence-supported trauma treatment is a critical challenge, especially when youths or parents/caregivers have experienced chronic traumas that may be expected to continue into the foreseeable future. An extensive literature review was conducted leading to development of an assessment framework that could increase engagement of youths and parents/caregivers in trauma treatment based on research on chronic trauma, complex trauma, Developmental Trauma Disorder (DTD), and factors that promote engagement. A multi-dimensional assessment guide was developed to enable clinicians to differentiate types of chronic trauma based on a continuum of past, current and expected exposure over time and then to use this guide collaboratively with youths and parents/caregivers to develop priorities for treatment and service planning that matches their needs and strengths. The assessment guide incorporates exposure to intra-familial and community forms of interpersonal trauma, attachment disruptions, established symptoms of PTSD, Complex PTSD and DTD, as well as social-emotional development. The assessment and treatment planning guides proposed in this article expand applicability of evidence-supported trauma-informed therapy to youths and families who have not been engaged by programs offering treatments that are focused on past or single incident traumas or do not address disrupted attachments, multi-generational experiences of adversity, discrimination and community violence, life-threatening dangers or the impact of chronic trauma on youth, parent/caregiver and family development.
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Affiliation(s)
- Richard Kagan
- Training Programs on Traumatic Stress, Family Treatment Center Foundation, The Institute for Adolescent Trauma Treatment and Training at Adelphi University, Garden City, USA
| | - Jana Pressley
- The Foundation Trust, Richmont Graduate University, Chattanooga, USA
| | - Rosa Espinoza
- The Foundation Trust, Children’s Hospital Los Angeles/USC UCEDD, Los Angeles, USA
| | - Cheryl Lanktree
- Department of Psychiatry & Behavioral Sciences, Keck Medical School, University of Southern California Adolescent Trauma Training Center, University of Southern California, Los Angeles, USA
| | - Jim Henry
- School of Social Work and Children’s Trauma Assessment Center, Western Michigan University, Kalamazoo, USA
| | - Angel Knoverek
- School of Counselor Education, Culver-Stockton College, Adams State University, Alamosa, USA
| | | | - Victor Labruna
- The Institute for Adolescent Trauma Treatment and Training at Adelphi University, Garden City, USA
| | - Mandy Habib
- The Institute for Adolescent Trauma Treatment and Training at Adelphi University, Garden City, USA
| | | | - Joseph Spinazzola
- The Foundation Trust, Richmont Graduate University, Chattanooga, USA
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Becker KD, Chorpita BF. Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:284-309. [PMID: 36787342 DOI: 10.1080/15374416.2023.2169926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.
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11
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Wamser-Nanney R, Walker HE. Attrition from pediatric trauma-focused cognitive behavioral therapy: A meta-analysis. J Trauma Stress 2023; 36:17-30. [PMID: 36320164 DOI: 10.1002/jts.22890] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022]
Abstract
Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the leading interventions for trauma-exposed children and adolescents and is associated with significant improvements in a variety of trauma-related symptoms. Nonetheless, attrition from TF-CBT is quite common, and children who do not receive the full intervention may continue to suffer from trauma-related symptoms. Rates of premature termination have varied across studies, and to date, no meta-analyses have been conducted regarding dropout from TF-CBT. The objective of the present study was to conduct a meta-analysis of the rates of attrition from TF-CBT, as well as review factors related to premature termination from this intervention. A total of 22 studies were available for inclusion in this meta-analysis. The prevalence of attrition was 33.9% (95% CI [26.2%, 42.5%]) from 2,059 children receiving TF-CBT. Clinician-rated attrition was 38.5%, and 17.5% did not receive an adequate dose of TF-CBT (e.g., 12+ sessions). Further, the study type was related to differing rates of dropout, with randomized controlled trials having a much lower attrition rate. Regarding risk factors for premature termination, the emerging literature suggests that a child's age, racial-ethnic minority status, and symptom levels may evince some ties to attrition. Caregiver, family, therapist, and treatment factors remain underexplored in relation to premature termination; however, preliminary work suggests that lack of caregiver attendance and difficulty in the child-therapist relationship may be related to attrition. A substantial number of children prematurely terminate from TF-CBT, underscoring the need to better prevent dropout.
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Affiliation(s)
- Rachel Wamser-Nanney
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, Missouri, USA
| | - Hannah E Walker
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, Missouri, USA
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12
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Skar AMS, Braathu N, Jensen TK, Ormhaug SM. Predictors of nonresponse and drop-out among children and adolescents receiving TF-CBT: investigation of client-, therapist-, and implementation factors. BMC Health Serv Res 2022; 22:1212. [PMID: 36175864 PMCID: PMC9521876 DOI: 10.1186/s12913-022-08497-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background There is a paucity of evidence about effective implementation strategies to increase treatment response and prevent drop-out among children receiving evidence-based treatment. This study examines patient, therapist, and implementation factors and their association to nonresponse and drop-out among youth receiving Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Methods Youth (n = 1240) aged 6–18 (M = 14.6) received TF-CBT delivered by 382 TF-CBT therapists at 66 clinics. Odds ratio analyses were used to investigate whether pretreatment child (age, gender, number of trauma experiences, post-traumatic stress symptoms (PTSS), therapist (education), and implementation strategy factors (high-low, low-low, low–high intensity therapist and leadership training respectively) or tele-mental health training during the Covid-19 pandemic are associated with nonresponse (above clinical PTSS level post-treatment) and drop-out (therapist-defined early termination). Fidelity checks were conducted to ensure that TF-CBT was used consistently. Results One fourth of the children (24.4%) were nonresponders and 13.3 percent dropped out. Exposure to three or more traumatic experiences were related to nonresponse and drop-out. Higher baseline PTSS was related to a higher probability of nonresponse. There was no effect of therapist education or child gender on nonresponse and drop-out, whereas children over 15 years had a higher likelihood of both. After controlling for baseline PTSS, the effect of age on nonresponse was no longer significant. Drop-out was related to fewer sessions, and most dropped out during the first two phases of TF-CBT. Fidelity was high throughout the different implementation phases. High-intensity therapist training was related to a lower probability of both nonresponse and drop-out, whereas low therapist and leadership training were related to a higher likelihood of both. Multivariate analysis revealed higher child age and higher PTSS baseline scores as significant predictors of nonresponse, and number of trauma experiences (> = 3) at baseline as the only predictor of drop-out. Conclusions High-intensity therapist training seem key to prevent patient nonresponse and drop-out. Leadership training might positively affect both, although not enough to compensate for less intensive therapist training. More complex cases (higher PTSS and exposure to more traumas) predict nonresponse and drop-out respectively, which underscores the importance of symptom assessment to tailor the treatment. The lack of predictive effect of therapist education increases the utilization of TF-CBT. Trial registration Retrospectively registered in ClinicalTrials, ref. nr. NCT05248971.
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Affiliation(s)
- Ane-Marthe Solheim Skar
- Norwegian Center for Violence and Traumatic Stress Studies, Gullhaugveien 1-3, 0484, Oslo, Norway. .,Department of Psychology, University of Oslo, Forskningsveien 3A, Oslo, Norway.
| | - Nora Braathu
- Norwegian Center for Violence and Traumatic Stress Studies, Gullhaugveien 1-3, 0484, Oslo, Norway
| | - Tine K Jensen
- Norwegian Center for Violence and Traumatic Stress Studies, Gullhaugveien 1-3, 0484, Oslo, Norway.,Department of Psychology, University of Oslo, Forskningsveien 3A, Oslo, Norway
| | - Silje Mørup Ormhaug
- Norwegian Center for Violence and Traumatic Stress Studies, Gullhaugveien 1-3, 0484, Oslo, Norway
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13
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Aitchison KA, McFerran KS. Young peoples' lived experiences of multidisciplinary mental health assessment in an intensive day program. Australas Psychiatry 2022; 30:330-333. [PMID: 35465732 DOI: 10.1177/10398562221089498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to explore young peoples' lived experiences of multidisciplinary mental health assessment in an intensive mental health day program. METHOD Interpretative phenomenological analysis (IPA) was applied to data from semi-structured interviews with six males, aged 13-16 years. Member-checking interviews were conducted to ensure the trustworthiness of findings. RESULTS Analysis revealed three themes, 'therapy fatigue', '360 supports' and 'experiential assessment'. Participants had either attended many years of psychological therapy without significant change or had failed to engage with therapy. Participants' attitudes changed at the day program with intensive support and their own determination. Participants valued experiential elements of assessment such as music therapy and art therapy which helped them understand the service, get to know others and experience positive emotions. CONCLUSIONS Unsuccessful psychological treatment can leave young people feeling jaded and reluctant to engage with services. The potential for iatrogenic harm should be monitored and alternative approaches, such as intensive, multidisciplinary treatment including music therapy and art therapy considered to help young people overcome therapy fatigue, regain hope and reengage with mental health services.
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Affiliation(s)
- Kate A Aitchison
- 94273Children's Health Queensland, Child and Youth Mental Health Service, Australia.,Faculty of Fine Arts and Music, 94273The University of Melbourne, Parkville, VIC, Australia
| | - Katrina S McFerran
- Faculty of Fine Arts and Music, 94273The University of Melbourne, Parkville, VIC, Australia
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14
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Zilberstein K. Trauma in Context: an Integrative Treatment Model. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2022; 15:487-500. [PMID: 35600523 PMCID: PMC9120280 DOI: 10.1007/s40653-021-00416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 06/03/2023]
Abstract
Evidenced based trauma treatments benefit children, but they rarely suffice for youth with multiple and complex comorbidities. After the completion of standard treatments, many children continue to show residual social, behavioral, and emotional difficulties. Part of the difficulty is that while the literature on trauma describes numerous facets that contribute to the severity, expression, and outcomes of trauma exposure, clinical assessments and interventions do not sufficiently reflect that literature. Clinicians thus have little guidance on how to integrate the intricacies of client's circumstances into a trauma-informed framework. To expand the scope and efficacy of treatments and guide clinicians in selecting appropriate interventions, this paper explores factors associated with pretreatment traumatic responses and proposes an integrative treatment model that includes the trauma experience, itself, combined with pre- and post-trauma factors that are both internal and external to the child and family. Pre-trauma experiences influence the severity of traumatic responses, while post-trauma factors impact a person's ability to cope and recover. Both are important targets for direct intervention.
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15
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Hoogsteder LM, Ten Thije L, Schippers EE, Stams GJJM. A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2022; 66:735-757. [PMID: 33899551 DOI: 10.1177/0306624x211010290] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This multi-level meta-analysis tested if evidence-based trauma treatment was effective in reducing trauma symptoms and externalizing behavior problems in adolescents. Based on eight independent samples and 75 effect sizes, results indicated that Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization Reprocessing (EMDR) had a large and significant overall effect (d = 0.909) on reducing trauma symptoms and externalizing behavior problems. Trauma treatment significantly decreased trauma symptoms (large effect) and externalizing behavior problems (medium effect). Age and type of control group moderated treatment effects. Treatment was more effective in older adolescents. Trauma treatment for adolescents with externalizing behavior problems had a larger effect compared to no treatment, but not compared to treatment as usual. It seems important to provide a broad treatment offer for adolescents with severe externalizing behavior problems, in which, besides trauma treatment, attention is paid to reducing relevant individual risk factors for behavior problems.
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16
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Canale CA, Hayes AM, Yasinski C, Grasso DJ, Webb C, Deblinger E. Caregiver Behaviors and Child Distress in Trauma Narration and Processing Sessions of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Behav Ther 2022; 53:64-79. [PMID: 35027159 PMCID: PMC8765780 DOI: 10.1016/j.beth.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
| | - Adele M. Hayes
- University of Delaware, Department of Psychological and Brain Sciences
| | | | - Damion J. Grasso
- University of Connecticut School of Medicine, Department of Psychiatry
| | - Charles Webb
- State of Delaware Division of Prevention and Behavioral Health Services
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17
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Wamser-Nanney R. Child-reported posttraumatic stress symptoms and attrition from therapy. CHILD ABUSE & NEGLECT 2021; 121:105266. [PMID: 34479132 DOI: 10.1016/j.chiabu.2021.105266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/26/2021] [Accepted: 08/08/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND High rates of attrition from child trauma-focused treatment are a significant barrier to mitigating children's trauma-related difficulties. Nonetheless, to date, only one study has investigated child-reported posttraumatic stress symptoms (PTSS) in relation to dropout from trauma-focused therapy and the posttraumatic stress disorder (PTSD) symptom clusters remain unexamined. OBJECTIVE The present study sought to determine whether higher levels of child-reported PTSS, as well as the specific DSM-IV PTSD symptom clusters, predicted attrition from trauma-focused cognitive behavioral therapy (TF-CBT). PARTICIPANTS/SETTING/METHOD One hundred and seventy one children ages 7-18 (M = 11.76, SD = 2.71; 67.4% female; 55.8% Black) were included in the study from an archival database. Dropout was investigated by two operational definitions: 1) clinician-rated dropout, and 2) whether the child received an adequate dose of treatment (i.e., 12 or more sessions). RESULTS Sixty eight percent (68.4%) of the children prematurely terminated treatment per their clinician, yet 70.2% received an adequate treatment dose. Child's age and income were related to clinician-rated attrition, but PTSS did not correspond with either attrition definition. None of the PTSD symptom clusters were associated with clinician-rated dropout; however, higher levels of avoidance symptoms were tied to increased likelihood of the child receiving an adequate dose of treatment. CONCLUSION From a public health perspective, it is encouraging that children who are reporting higher levels of PTSS may not be at greater risk for attrition.
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Affiliation(s)
- Rachel Wamser-Nanney
- Psychological Sciences, University of Missouri, St. Louis, MO 63121, United States of America.
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18
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Wamser-Nanney R. Maternal Support and Attrition from Child Trauma-Focused Therapy. J Trauma Stress 2021; 34:840-850. [PMID: 34057745 DOI: 10.1002/jts.22698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 11/07/2022]
Abstract
Many children prematurely terminate from trauma-focused therapy (TFT), and attrition is a critical barrier in addressing the impacts of childhood sexual abuse (CSA). The field's knowledge of risk factors for dropout is growing; however, one aspect of the child's environment that remains unexamined is maternal support following the CSA disclosure/discovery. Maternal support has been theorized to play a valuable role in influencing children's outcomes after CSA and may be relevant in understanding attrition. The objective of the current study was to investigate the associations between children's symptoms, relationship to the perpetrator, and maternal support in relation to premature termination from TFT among 186 sexually abused children (Mage = 9.24 years, SD = 3.72, 67.3% female). Two operational definitions of attrition were used: (a) clinician-rated dropout (i.e., clinician's ratings of whether the child completed treatment) and (b) whether the child received an adequate treatment dose treatment (i.e., ≥12 sessions). Maternal marital status was the only factor associated with clinician-rated treatment dropout, OR = 2.35, whereas maternal support and blame/doubt were unrelated. Living farther from the clinic was tied to an increased risk of receiving an inadequate treatment dose, OR = 0.96. Replication of these findings is needed, particularly using a clinician-administered measure of caregiver support; yet, maternal emotional support and blame/doubt may not evince strong ties to dropout from TFT among sexually abused children. Additional work is needed to discern if there are key subgroups for whom support is more strongly related to the risk of premature termination following CSA.
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Affiliation(s)
- Rachel Wamser-Nanney
- Department of Psychological Sciences, University of Missouri St. Louis, St. Louis, Missouri, USA
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19
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Francis JKR, Andresen JA, Guzman A, McLeigh JD, Kloster HM, Rosenthal SL. Research Participation of Minor Adolescents in Foster Care. J Pediatr Adolesc Gynecol 2021; 34:190-195. [PMID: 33333259 PMCID: PMC8005475 DOI: 10.1016/j.jpag.2020.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/02/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE In this study we evaluated published studies about foster care to: (1) determine the types of data used; (2) describe the degree to which a sexual/reproductive health topic was addressed; and (3) describe the consent process. DESIGN Analysis of published literature. SETTING PubMed was searched using "foster care" for English articles published between January 1, 2017 and September 4, 2019. PARTICIPANTS None. INTERVENTIONS None. MAIN OUTCOME MEASURES Articles were coded into 4 data source categories: primary, secondary, peripheral, or perspective data. Articles with a primary data source were coded for participant ages: only 9 years old and younger, 10- to 17-year-olds (minor adolescents), and only 18 years old and older. Articles using a secondary data source were coded for the source of the data registry. All articles were coded for presence of a sexual/reproductive health outcome. The primary data articles that included minor adolescents were coded for the study topic and consent process. RESULTS Of the 176 articles about foster care, 72/176 (41%) used primary data, 53/176 (30%) used secondary data, and 51/176 (29%) used peripheral/perspective data. Forty-eight of the primary data articles included minor adolescents. Secondary data sources included few national research surveys. Sexual/reproductive health outcomes were measured in 17 articles, 4 of which used primary data. The consent process for minor adolescents varied and had no consistent pattern across studies. CONCLUSION Research on best practices for consent processes and use of registries could be developed to increase research on sexual/reproductive health outcomes among adolescents in foster care.
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Affiliation(s)
- Jenny K R Francis
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
| | - Jane A Andresen
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Alexis Guzman
- Department of Pediatrics, Stanford Medicine, Stanford, California
| | | | - Heidi M Kloster
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Susan L Rosenthal
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York; NewYork-Presbyterian Hospital, New York, New York; Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
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20
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Tiwari A, Smith S, Wekerle C, Kimber M, Jack SM, MacMillan H, Gonzalez A. Trauma services for youth victims of sexual abuse- does one size fit all? A qualitative study among service providers in Ontario, Canada. CHILD ABUSE & NEGLECT 2021; 112:104903. [PMID: 33412414 DOI: 10.1016/j.chiabu.2020.104903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Despite a range of interventions available to treat mental health symptoms experienced by youth with a history of child sexual abuse (CSA), limited empirical work has examined practitioner delivery of these interventions in real-world practice. OBJECTIVE This paper aimed to qualitatively explore the delivery of trauma-based interventions in community settings in Ontario, Canada. PARTICIPANTS AND SETTINGS Using qualitative description, a purposeful sample of service providers (N = 51; 92 % female) were recruited from nine community-based organizations located in Southern Ontario, Canada providing psychotherapeutic trauma-based interventions to youth with a history of child sexual abuse. METHODS Semi-structured one-on-one (n = 17), joint (n = 3) and focus group (n = 5) interviews elicited provider descriptions of their strategies and approaches for addressing trauma-related symptoms in this population. Data were interpreted using conventional content analyses. RESULTS Eclectic delivery of interventions and multifactorial decision-making processes were identified as core elements of treatment planning and intervention delivery among providers. Eclectic treatment was described to involve the consideration of four core elements (provider judgement; youth voice; youth characteristics; and clinical team discussion) of intervention and three key principles (meeting youth needs; providing client-centered care; addressing safety and stability). CONCLUSIONS Research capable of characterizing the efficacy of client-centered, eclectic approaches to treat symptoms experienced by youth with a history of CSA is needed.
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Affiliation(s)
- Ashwini Tiwari
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, West 5th Campus, Administration, B3, 100 West 5th, Hamilton, ON L8N 3K7 Canada.
| | - Savanah Smith
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada.
| | - Christine Wekerle
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada.
| | - Melissa Kimber
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, West 5th Campus, Administration, B3, 100 West 5th, Hamilton, ON L8N 3K7 Canada.
| | - Susan M Jack
- School of Nursing, McMaster University 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada.
| | - Harriet MacMillan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, West 5th Campus, Administration, B3, 100 West 5th, Hamilton, ON L8N 3K7 Canada.
| | - Andrea Gonzalez
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, West 5th Campus, Administration, B3, 100 West 5th, Hamilton, ON L8N 3K7 Canada.
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21
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Eastwood O, Peters W, Cohen J, Murray L, Rice S, Alvarez-Jimenez M, Bendall S. "Like a huge weight lifted off my shoulders": Exploring young peoples' experiences of treatment in a pilot trial of trauma-focused cognitive behavioral therapy. Psychother Res 2020; 31:737-751. [PMID: 33283674 DOI: 10.1080/10503307.2020.1851794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Background: The efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) is well-established, yet little work has been done to understand how young people experience this intervention.Method: Semi-structured interviews were conducted with 13 young people aged 17-25 years (M = 20.0, SD = 2.61) who received TF-CBT as part of a pilot trial. Transcripts were analyzed via interpretative phenomenological analysis.Results: Four super-ordinate themes were identified: (i) experience of authentic care, (ii) personal role in therapy and recovery, (iii) talking about trauma is difficult but important, and (iv), transformative change. Young people described authenticity on behalf of the therapist, which seemed to foster emotional connection and comfort discussing trauma. They emphasized the importance of retaining autonomy and control during therapy, and a degree of personal responsibility in their recovery. Talking about trauma was described as difficult and potentially distressing, but also as critical for recovery. Transformative life changes were noted, which had a significant impact on young peoples' future outlook and self-perception.Conclusions: This study suggests that therapists should be attuned to the interpersonal needs of clients, attempt to foster self-determination throughout therapy, and simultaneously recognize the difficulty and importance of trauma work for young people when delivering TF-CBT.
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Affiliation(s)
- Oliver Eastwood
- Orygen, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Wilma Peters
- Orygen, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Judith Cohen
- Department of Psychiatry, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Laura Murray
- Department of International Health, John Hopkins University, Baltimore, MD, USA
| | - Simon Rice
- Orygen, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Mario Alvarez-Jimenez
- Orygen, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sarah Bendall
- Orygen, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
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22
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Brown EJ, Cohen JA, Mannarino AP. Trauma-Focused Cognitive-Behavioral Therapy: The role of caregivers. J Affect Disord 2020; 277:39-45. [PMID: 32791391 DOI: 10.1016/j.jad.2020.07.123] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/06/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Childhood trauma exposure is unfortunately common and is associated with the development of posttraumatic stress disorder (PTSD) as well as a number of other serious medical and mental and health disorders. After experiencing trauma, children depend on their non-offending parents to believe and support them, reframe the meaning of the trauma, and to keep them safe from future harm. Parents are often negatively impacted by their child's trauma which may contribute to the child's risk for developing PTSD and related problems. Including parents in treatment may enhance child outcomes. METHODS Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is an evidence-based child and adolescent trauma treatment model that integrally includes non-offending parents or caregivers throughout treatment (hereafter referred to as "caregivers"). This article describes TF-CBT's underlying concepts, principles and core components, as well as the role of caregiver inclusion in this model, and evaluates the extant evidence for caregiver factors in predicting TF-CBT outcomes. RESULTS Several studies suggest that inclusion of non-offending caregivers is associated with TF-CBT outcomes, and that this may occur through enhancing caregiver support of the child and/or reducing caregivers' trauma-related maladaptive cognitions. LIMITATIONS Few studies have evaluated whether caregiver factors served as formal treatment mediators. CONCLUSIONS Including non-offending caregivers in TF-CBT can improve youth outcomes.
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Affiliation(s)
- Elissa J Brown
- Professor of Psychology, St. John's University, 8000 Utopia Parkway, Queens, NY 11439, United States.
| | - Judith A Cohen
- Professor of Psychiatry, Drexel University College of Medicine, Allegheny Health Network/Allegheny General Hospital, 4 Allegheny Center, 8th Floor, Pittsburgh, PA 15212, United States.
| | - Anthony P Mannarino
- Professor and Vice ChairDepartment of Psychiatry, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, 4 Allegheny Center, 8th Floor, Pittsburgh, PA 15212, United States.
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23
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Wamser-Nanney R. Sexual Behavior Problems and Premature Termination From Pediatric Trauma-Focused Treatment Among Sexually Abused Children. J Trauma Stress 2020; 33:835-842. [PMID: 32479696 DOI: 10.1002/jts.22518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 11/02/2019] [Accepted: 11/13/2019] [Indexed: 11/07/2022]
Abstract
Premature termination from child trauma-focused treatment is common; however, the role of children's level of symptoms as a risk factor for attrition remains uncertain. In particular, children's sexual behavior problems (SBPs) have received scant attention in the prior attrition literature, and no known studies to date have thoroughly examined SBPs in relation to premature treatment termination. The current study investigated whether higher levels of children's SBPs were associated with increased risk for attrition from trauma-focused treatment in a sample of 242 sexually abused children aged 2-12 years (M = 7.48 years, SD = 2.68; 64.5% female, 54.1% White). To assess the potential associations between SBPs and treatment dropout more thoroughly, two definitions of attrition were utilized: (a) clinician-rated dropout and (b) whether the child received an adequate dose of treatment (i.e., 12 or more sessions). Whereas only 34.3% of the children completed treatment per their clinician, 69.4% received an adequate dose of treatment. In contrast to the study hypotheses, neither development-related nor sexual abuse-specific SBPs were associated with either clinician-rated dropout or adequate dose status, ORs = 0.99-1.00. Sexual acting-out behaviors in sexually abused children may not correspond with attrition from trauma-focused treatment at multiple points of treatment. Given the heterogeneity of SBPs, further assessment of whether attrition patterns differ across subgroups of children who exhibit SBPs is needed.
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Affiliation(s)
- Rachel Wamser-Nanney
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, Missouri, USA
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24
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Alpert E, Hayes AM, Barnes JB, Sloan DM. Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content. Behav Ther 2020; 51:774-788. [PMID: 32800305 PMCID: PMC7431675 DOI: 10.1016/j.beth.2019.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 12/30/2022]
Abstract
Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients' written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.
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Affiliation(s)
| | - Adele M. Hayes
- University of Delaware, Department of Psychological and Brain Sciences
| | - J. Ben Barnes
- University of Delaware, Department of Psychological and Brain Sciences
| | - Denise M. Sloan
- VA Boston Healthcare System, National Center for PTSD,Boston University School of Medicine
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Wamser-Nanney R. Predictors of Attrition Among Young Children Receiving Trauma-Focused Therapy. J Trauma Stress 2020; 33:564-574. [PMID: 32479708 DOI: 10.1002/jts.22513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 11/06/2022]
Abstract
Findings from studies of predominately school-aged children indicate that few children complete trauma-focused treatment; however, researchers have not specifically examined risk factors for dropout among young trauma-exposed children. The purpose of the present study was to investigate risk factors for attrition among young children receiving trauma-focused therapy. Study participants were 189 treatment-seeking children aged 3-5 years (M = 4.86 years, SD = 0.71; 54.1% female, 47.7% White) and their nonoffending legal guardian(s). Child and family characteristics, number of traumatic events, and pretreatment posttraumatic stress symptoms (PTSS) were examined in relation to two attrition definitions: (a) clinician-rated dropout and (b) whether the child received an adequate treatment dose (i.e., 12 or more sessions). Although 70.3% of children prematurely terminated therapy per their clinician, a nearly equivalent portion (67.4%) received an adequate treatment dose. Family characteristics were largely not associated with attrition, although residing farther from the clinic was related to clinician-rated treatment dropout, OR = 0.96. As expected, higher levels of externalizing symptoms were associated with clinician-rated dropout and inadequate dose status, ORs = .95 and .96, respectively, whereas lower levels of trauma-related anger were related to clinician-rated treatment completion, OR = 1.03, and lower levels of PTSS and sexual concerns corresponded with an increased likelihood the child received an inadequate treatment dose, ORs = 1.03 and 1.02, respectively. Thus, child and family factors appear to play a small role in predicting attrition; however, higher levels of externalizing problems and lower levels of PTSS may increase the risk for dropout.
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Affiliation(s)
- Rachel Wamser-Nanney
- Department of Psychological Sciences, University of Missouri-St. Louis, Louis, Missouri, USA
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Barca TB, Moltu C, Veseth M, Fjellheim G, Stige SH. The nature of youth in the eyes of mental-health care workers: therapists' conceptualization of adolescents coming to therapy at others' initiative. Int J Ment Health Syst 2020; 14:31. [PMID: 32391078 PMCID: PMC7201627 DOI: 10.1186/s13033-020-00363-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 04/25/2020] [Indexed: 02/07/2023] Open
Abstract
Background Adolescent clients often come to therapy at the initiative of others and show a higher drop-out rate compared to adult clients. Therapeutic relationships are critical for preventing drop-outs and attaining good outcomes, yet few empirical studies have investigated how therapists conceptualize and meet adolescent clients who come reluctantly to therapy. Methods We conducted ten focus-group interviews in this study with a total of 51 therapists at different Norwegian specialist outpatient clinics for children and adolescents with mental-health problems to explore how therapists view and understand adolescents who come to therapy at the initiative of someone else. We used a reflexive approach to thematic analysis to analyze the transcripts. Results We found five main themes, expressing variations in participants’ understanding: The hurt and distrustful adolescent; The adolescent lacking hope for the future; The adolescent engulfed in the burden of mental-health suffering; The adolescent as something more than a psychiatric patient; and The adolescent meeting a system with varying flexibility and space for engagement. Conclusions Several conceptualizations of the adolescent client coexist within and between clinics, resulting in variability of services for adolescents even within the frames of a strong welfare system.
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Affiliation(s)
- Tonje Børseth Barca
- Finnmark Hospital Trust, District Psychiatric Centre, Po.Box 1294, 9505 Alta, Norway
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Wamser-Nanney R. Risk Factors for Attrition From Pediatric Trauma-Focused Treatment. CHILD MALTREATMENT 2020; 25:172-181. [PMID: 31510772 DOI: 10.1177/1077559519874406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Rates of attrition from pediatric trauma-focused treatments are high, yet few studies have examined predictors of dropout. The aim of the study was to investigate whether higher levels of caregiver- and child-reported pretreatment difficulties predicted attrition from trauma-focused therapy. One hundred seventy-two children aged 6-18 (M = 10.53, SD = 3.36; 64% female, 64% Black) and their caregivers were included in the study. Two operational definitions of attrition were utilized: (1) clinician-rated dropout and (2) whether the child received an adequate dose of treatment (i.e., 12 or more sessions). Rates of clinician-rated attrition were high (76.2%); however, 73.8% received an adequate dose. Despite expectations, higher levels of rule-breaking and aggressive behavior were related to clinician-rated dropout (d = 0.59, .63, respectively) but were not significant predictors in a logistic regression model. Child-reported symptoms were unrelated to clinician-rated attrition. Higher levels of caregiver-reported anxiety/depression, somatic complaints, and trauma-related difficulties corresponded with adequate dose (ds = 0.52-1.06). Yet only caregiver-reported sexual concerns predicted adequate dose in a regression model (OR = 1.09). Caregiver- and child-reported symptoms may be unrelated to clinician-rated treatment completion and appear to play a small role in understanding whether the child received an adequate dose of treatment.
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Steinberg AM, Layne CM, Briggs EC, Liang LJ, Brymer MJ, Belin TR, Fairbank JA, Pynoos RS. Benefits of Treatment Completion Over Premature Termination: Findings from the National Child Traumatic Stress Network. Psychiatry 2019; 82:113-127. [PMID: 30735480 PMCID: PMC8324311 DOI: 10.1080/00332747.2018.1560584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To evaluate potential differences in therapeutic outcomes between youths who completed a full course of treatment as planned compared to youths who terminated treatment prematurely. Method: Using longitudinal data from the National Child Traumatic Stress Network (NCTSN) Core Data Set, the present study examined demographic characteristics, trauma history, scores on standardized measures, and ratings of functional impairment and behavior problems in a large clinical sample of children and adolescents exposed to trauma who received treatment at NCTSN centers across the United States. Baseline and follow-up data were used to compare treatment completers (n= 3,108) and noncompleters (n = 4,029). Results: Both treatment completers and noncompleters received benefits from treatment by NCTSN mental health providers in that both groups showed significant decreases in mean scores from baseline to follow-up on all standardized measures. However, compared to noncompleters, treatment completers showed three types of significantly greater benefit at follow-up. These included: (a) greater rates of decline (i.e., steeper slopes) on all outcome measures; (b) greater reductions in the odds of falling within the clinical range on standardized measures; and (c) greater reductions in the odds of exhibiting functional impairment and behavior problems at follow-up. In contrast, compared to treatment completers, noncompleters reported significantly higher rates of lifetime exposure to community violence, psychological maltreatment, physical abuse, neglect, sexual abuse, and sexual assault. Conclusion: These findings underscore the value of incorporating engagement and retention strategies in treatments for traumatized youths to maximize therapeutic benefit and raise the standard of care.
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