Treatment research for children and youth exposed to traumatic events: moving beyond efficacy to amp up public health impact

Evaluation of an Early Intervention Model for Child and Adolescent Victims of Interpersonal Violence

Only the minority of youth exposed to traumatic events receive mental health care, as trauma-informed clinical services are lacking or are poorly accessible. In order to bridge this gap, the Outpatient Trauma Clinic (OTC) was founded, an easily accessible early, short-time intervention, with onward referral to follow-up treatment. This report presents the OTC's interventional approach and first outcome data. Using a retrospective naturalistic design, we analyzed trauma- and intervention-related data of the sample (n = 377, 55.4% female, mean age 10.95, SD = 4.69). Following drop-out analyses, predictors for treatment outcome were identified by logistic regression. The majority (81.9%) was suffering from posttraumatic stress disorder (PTSD) or adjustment disorders. Around one forth dropped out of treatment; these cases showed higher avoidance symptoms at presentation. In 91%, psychological symptoms improved. Experience of multiple traumatic events was the strongest predictor for poor treatment outcome (B = -0.823, SE = 0.313, OR = 0.439, 95% CI 0.238-0.811). Around two thirds were connected to follow-up treatment. The OTC realized a high retention rate, initial improvement of symptoms and referral to subsequent longer-term psychotherapeutic treatment in the majority. Further dissemination of comparable early intervention models is needed, in order to improve mental health care for this vulnerable group.

Factors Influencing Implementation of Evidence-Based Mental Health Interventions for Infants and Young Children

Large-scale efforts have been made to adopt evidence-based practices (EBPs) for young children within community mental health settings. The current study investigated the implementation of Parent-Child Interaction Therapy and Child-Parent Psychotherapy using an online survey of 20 program managers representing 16 birth-to-five mental health agencies serving an ethnically diverse Medicaid population throughout a large urban county. Survey questions addressed intake and referral processes, training and supervision in EBPs, treatment fidelity, and patient outcomes/satisfaction. Results indicated that both clinical judgment and established decision-trees were used to select treatment approaches and that supervision, consultation, and fidelity monitoring were used to support fidelity to the models. Participants cited intensive EBP training processes, staff turnover, and patient attrition as barriers to sustainability. Implications regarding implementation of EBPs for infants and young children are discussed, including issues related to patient care, training and supervision, treatment fidelity, program sustainability, and barriers to system change.

Therapeutic intervention and parenting style of abusive parents

Background:

Victims of abuse comprise a significant proportion of all child psychiatric admissions, with an estimated 30% incidence of lifetime of physical and sexual abuse among child and adolescent outpatients, and as high as 55% among psychiatric inpatients.

Objectives:

The present study was conducted to examine the effects of therapeutic intervention and parent management training on parenting skill of abusive parents.

Patients and Methods:

The study population consisted of all children who were referred to Child Psychiatric and Pediatric Departments of Imam Hossein Hospital, Tehran, IR Iran diagnosed with child abuse. Children and their families were visited by a psychiatrist for psychiatric problems. Later, the necessary interventions were taken for the children. To study the effect of intervention, parents completed ‘Being a Parent and Parenting Scale’ before intervention, and then again, in the third and sixth months following the intervention. The interventions included 8 weekly parent management training sessions for all of the involved parents and additional pharmacologic and psychological interventions according to the subjects’ needs.

Results:

Participants included 73 children with the mean age of 6.9 ± 4.3 year, while the mean age of parents was 31.76 ± 6.52 year for the mothers and 38.07 ± 8.45 year for the fathers. General anxiety disorder (30.1%) and depression (27.4%) were the most common psychiatric disorders among mothers. In parenting scale, there were significant differences between the zero and third month in all subscales (P = 0.008), but there was no significant difference in verbosity and overreactivity after 6 months. Laxness showed significant changes over the period (P = 0.03). In viewing the ‘Being a Parent Scale’, there was no significant difference in satisfaction and competency subscales before and after the intervention.

Conclusions:

Therapeutic intervention and parent management training improves parenting skill of abusive parents, and this might lead to fewer incidents of abuse or neglect.

A Framework for Enhancing the Value of Research for Dissemination and Implementation

A comprehensive guide that identifies critical evaluation and reporting elements necessary to move research into practice is needed. We propose a framework that highlights the domains required to enhance the value of dissemination and implementation research for end users. We emphasize the importance of transparent reporting on the planning phase of research in addition to delivery, evaluation, and long-term outcomes. We highlight key topics for which well-established reporting and assessment tools are underused (e.g., cost of intervention, implementation strategy, adoption) and where such tools are inadequate or lacking (e.g., context, sustainability, evolution) within the context of existing reporting guidelines. Consistent evaluation of and reporting on these issues with standardized approaches would enhance the value of research for practitioners and decision-makers.

Trauma-Focused Cognitive Behavioral Therapy for Youth: Effectiveness in a Community Setting

OBJECTIVE

The current investigation examined the effectiveness of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in treating child traumatic stress when implemented in community settings on a state-wide level.

METHOD

Seventy-two youths (ages 7-16 years) with a history of documented trauma (sexual or physical abuse, traumatic loss, domestic or community violence) and symptoms of Posttraumatic Stress Disorder (PTSD) received an average of 10 sessions delivered in a state-contracted mental health agency. PTSD symptoms and internalizing and externalizing behavior problems were assessed at pre-treatment and then at 3-, 6-, 9-, and 12-months after intake.

RESULTS

Piecewise hierarchical linear modeling revealed that symptoms of PTSD, as well as internalizing and externalizing problems, decreased significantly over the six months after intake (pretreatment, 3-month, 6-month assessments), and these gains were maintained over the next 6 months (6, 9, and 12 month assessments). Symptoms of externalizing symptoms increased somewhat during the follow-up period, but this change was not statistically significant.

CONCLUSIONS

These findings suggest that TF-CBT can be implemented effectively in community settings. Treatment outcomes were similar to those reported in efficacy trials of TF-CBT delivered in specialty clinic settings. Improvements in PTSD symptoms and internalizing and externalizing problems were maintained up to one year after treatment began, although the changes in externalizing symptoms were the least stable.

Evaluation and treatment of childhood physical abuse and neglect: a review

According to 2010 CDC estimates, 1 in 5 US children have experienced maltreatment. Risk factors for child maltreatment include child characteristics such as non-compliance and diagnostic conditions that increase caregiver burden. Parent characteristic risk factors include parental mental illness and low social support. New developments in radiologic evaluation of child maltreatment will be reviewed. New findings in evidence based psychotherapies for childhood maltreatment will be discussed. A review of the role of pharmacotherapy in child maltreatment cases will also be presented. New evidence from prevention models targeting young mothers and families are also reviewed.

A Pilot Study of Computer-Assisted Cognitive Behavioral Therapy for Childhood Anxiety in Community Mental Health Centers

Anxiety disorders among children are common, disabling, and run a chronic course without treatment. Cognitive behavioral therapy (CBT) has shown robust efficacy for childhood anxiety. However, dissemination of CBT into community mental health centers (CMHCs) is limited. Computer-assisted CBT (CCBT) programs have been developed to improve dissemination by providing a structured treatment format that allows therapists to reliably deliver evidence-based treatments with fidelity. In this pilot study involving therapists with limited CBT experience, the effectiveness, feasibility, and acceptability of a CCBT program, Camp Cope-A-Lot (Khanna & Kendall, 2008b), were examined in three CMHCs. Seventeen youth ages 7–13 years and diagnosed with a primary anxiety disorder were enrolled. Assessments were conducted by a rater not involved in treatment at baseline and posttreatment. Significant reductions in anxiety severity and impairment were demonstrated at the posttreatment assessment. High levels of family satisfaction were reported. These results provide preliminary support for the effectiveness of a computer-assisted treatment into CMHCs and warrant replication in a controlled setting.

Implementation of AF-CBT by community practitioners serving child welfare and mental health: a randomized trial

The Partnerships for Families project is a randomized clinical trial designed to evaluate the implementation of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT), an evidence-based treatment for family conflict, coercion, and aggression, including child physical abuse. To evaluate the effectiveness of a training program in this model, 182 community practitioners from 10 agencies were randomized to receive AF-CBT training (n = 90) using a learning community model (workshops, consultation visits) or Training as Usual (TAU; n = 92) which provided trainings per agency routine. Practitioners completed self-report measures at four time points (0, 6, 12, and 18 months following baseline). Of those assigned to AF-CBT, 89% participated in at least one training activity and 68% met a "training completion" definition. A total of 80 (44%) practitioners were still active clinicians in the study by 18-month assessment in that they had not met our staff turnover or study withdrawal criteria. Using an intent-to-train design, hierarchical linear modeling analyses revealed significantly greater initial improvements for those in the AF-CBT training condition (vs. TAU condition) in CBT-related knowledge and use of AF-CBT teaching processes, abuse-specific skills, and general psychological skills. In addition, practitioners in both groups reported significantly more negative perceptions of organizational climate through the intervention phase. These significant, albeit modest, findings are discussed in the context of treatment training, research, and work force issues as they relate to the diverse backgrounds, settings, and populations served by community practitioners.

Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers

BACKGROUND

Recent global mental health research suggests that mental health interventions can be adapted for use across cultures and in low resource environments. As evidence for the feasibility and effectiveness of certain specific interventions begins to accumulate, guidelines are needed for how to train, supervise, and ideally sustain mental health treatment delivery by local providers in low- and middle-income countries (LMIC). MODEL AND CASE PRESENTATIONS: This paper presents an apprenticeship model for lay counselor training and supervision in mental health treatments in LMIC, developed and used by the authors in a range of mental health intervention studies conducted over the last decade in various low-resource settings. We describe the elements of this approach, the underlying logic, and provide examples drawn from our experiences working in 12 countries, with over 100 lay counselors.

EVALUATION

We review the challenges experienced with this model, and propose some possible solutions.

DISCUSSION

We describe and discuss how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature.

CONCLUSION

In our experience, the apprenticeship model provides a useful framework for implementation of mental health interventions in LMIC. Our goal in this paper is to provide sufficient details about the apprenticeship model to guide other training efforts in mental health interventions.

Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center

This paper examines the sustainability and outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as delivered by practitioners in a community-based child protection program who had received training in the model several years earlier. Formerly described as Abuse-Focused CBT, AF-CBT is an evidence-based treatment (EBT) for child physical abuse and family aggression/conflict that was included in the National Child Traumatic Stress Network's initial EBT dissemination efforts in 2002. Seven practitioners participated in a year-long learning collaborative in AF-CBT and in similar training programs for 4 other EBTs. The agency's routine data collection system was used to document the clinical and adjustment outcomes of 52 families presenting with a physically abused child who received their services between 2 and 5 years after the AF-CBT training had ended. Measures of the use of all 5 EBTs documented their frequency, internal consistency, and intercorrelations. Controlling for the unique content of the other four EBTs, the amount of AF-CBT Abuse-specific content delivered was related to improvements on standardized parent rating scales (i.e., child externalizing behavior, anger, anxiety, social competence) and both parent and clinician ratings of the child's adjustment at discharge (i.e., child more safe, less scared/sad, more appropriate with peers). The amount of AF-CBT General content was related to a few discharge ratings (better child prognosis, helpfulness to parents). These novel data provide suggestive evidence for the sustainability and clinical benefits of AF-CBT in an existing community clinic serving physically abused children and their families, and are discussed in the context of key developments in the treatment model and dissemination literature.