Maternal depression and treatment gains following a cognitive behavioral intervention for posttraumatic stress in preschool children

Stepping Together in Stepped Care Trauma-Focused Cognitive Behavioral Therapy: Case Report of Core Components

New service delivery systems are needed to expand the reach of evidence-based practices for childhood trauma. Cognitive behavioral therapy is an effective approach for treating -childhood trauma, yet treatment barriers remain. Stepped care models that incorporate parent-led -treatment with therapist assistance may be one approach to improve access. This case study highlights the core components of a parent-led therapist-assisted treatment called Stepping Together that serves as a Step 1 treatment within a stepped care model. The components and structure of Stepping Together are described, along with excerpts from therapy sessions to illustrate the therapist's implementation of the model. Results of the case, in which improvements occurred, are presented. Stepping Together, a parent-led therapist-assisted first-line treatment within stepped care trauma-focused cognitive behavioral therapy, may be an effective treatment for some children after trauma and their caregivers, although more research is needed.

Maternal stress and mental health before pregnancy and offspring diurnal cortisol in early childhood

The current study investigates whether prepregnancy maternal posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, and stress predict children's cortisol diurnal slopes and cortisol awakening responses (CARs) adjusting for relevant variables. Mothers were enrolled after delivering a baby and followed through their subsequent pregnancy with 5 years of longitudinal data on their subsequent child. This prospective design allowed assessment of PTSD symptoms, depressive symptoms, and perceived stress prior to pregnancy. Children provided three saliva samples per day on three consecutive days at two timepoints in early childhood (M age = 3.7 years, SD = 0.38; M age = 5.04 years, SD = 0.43). Mothers' PTSD symptoms prior to pregnancy were significantly associated with flatter child diurnal cortisol slopes at 4 and 5 years, but not with child CAR. Findings at the age of 4 years, but not 5 years, remained statistically significant after adjustment for maternal socioeconomic status, race/ethnicity, child age, and other covariates. In contrast, maternal prepregnancy depressive symptoms and perceived stress did not significantly predict cortisol slopes or CAR. Results suggest that maternal prepregnancy PTSD symptoms may contribute to variation in early childhood physiology. This study extends earlier work demonstrating risk of adverse outcomes among children whose mothers experienced trauma but associations cannot be disentangled from effects of prenatal mental health of mothers on children's early childhood.

Pediatrician-friendly perspectives on cognitive behavioral therapy for anxious youth: Current status and clinical implications for the next normal

Pediatric anxiety disorders are common and often debilitating conditions. Cognitive is a psychosocial intervention that represents a potentially powerful antidote to these disorders. This article reviews data from treatment outcome studies, meta-analyses, and systematic reviews as well as from moderation/mediational investigations. The literature supports the efficacy, effectiveness, and durability of positive treatment outcomes for pediatric anxiety disorders. Recommendations for clinical applications are suggested.

Predictors and moderators of treatment outcome for single incident paediatric PTSD: a multi-centre randomized clinical trial

BACKGROUND

With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments.

OBJECTIVE

To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT).

METHOD

Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8-18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child's baseline sociodemographic and clinical characteristics, and parent's psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups.

RESULTS

At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile.

CONCLUSIONS

The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (<4 hours) of both treatments, the present findings suggest a focus on implementation and dissemination, rather than tailoring, of evidence-based trauma-focused treatments for paediatric PTSD tied to a single event.

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

Trauma-focused cognitive behavioral therapy (TF-CBT) is regarded as one of the most effective treatments for children who have experienced trauma and is rapidly being disseminated. To best ensure efficacy, even among treatment refractory symptoms, a better understanding of the factors that lead TF-CBT to be more or less effective for some children is warranted. One major factor that has not been systematically considered is the role of caregiver psychopathology. Therefore, this systematic review of 18 empirical studies examined how TF-CBT has incorporated caregiver psychopathology into the treatment of childhood trauma and how it is related to treatment outcomes. The results of this review provide preliminary support for TF-CBT decreasing caregiver psychopathology, in terms of symptoms of depression, PTSD, and emotional distress related to the child's experience of trauma, as well as partial support for caregiver depression, rather than caregiver PTSD or distress, influencing child treatment outcomes. It also illuminates the strong need for future TF-CBT studies to routinely measure caregiver psychopathology. Several recommendations are provided to ensure that the emerging research base can inform clinical practice guidelines on how to incorporate caregivers who exhibit psychopathology and potentially develop modifications to the existing treatment to address trauma and symptoms in both members of the caregiver-child dyad, when needed.

Co-Occurring Posttraumatic Stress Disorder and Depression Among Young Children

The purpose of this study was to examine differences in: (1) mental health emotional and behavioral problems between young children experiencing PTSD with and without MDD; (2) the incidence of caregiver PTSD and MDD between children with PTSD ± MDD; and (3) the number of traumatic events and interpersonal versus non-interpersonal nature of trauma events among children whose parents sought child trauma-focused treatment. Sixty-six caregivers of children aged 3-7 with PTSD completed semi-structured interviews regarding caregiver and child diagnoses, and caregivers completed self-report measures regarding child symptomatology. Results indicated that young children with PTSD + MDD had significantly higher internalizing symptoms, dissociative symptoms, and posttraumatic stress severity than those without comorbid MDD. There were no significant group differences in the incidence of caregiver PTSD or MDD, or the number or types of traumatic events. Future research to understand the unique contributors to the etiology of MDD in the context of PTSD among young children is needed.

Parental Factors Associated with Child Post-traumatic Stress Following Injury: A Consideration of Intervention Targets

Post-traumatic stress disorder (PTSD) symptoms are relatively common following pediatric traumatic injury and are related to poor long-term child outcomes. However, due to concerns regarding the efficacy of early child preventive interventions, and difficulty intervening with injured and medicated children soon after the event, it is not feasible to provide early psychological interventions to children exposed to traumatic injury. Parental PTSD symptoms and reactions to the child's traumatic injury impact child outcomes and provide potential targets for early intervention to reduce child symptom development without involving the child. The authors conducted a review of the literature using Psycinfo and Pubmed research databases (publication years = 1990-2017) and identified 65 published studies relevant to the topic of the review. The present review considers parent factors [parenting styles, parental post-traumatic pathology (PTS), adaptive and maladaptive coping strategies, and communication regarding the traumatic injury] and their impact on child PTS. We focus specifically on factors amenable to intervention. We further review moderators of these relationships (e.g., child age and gender, parent gender) and conclude that it is unlikely that a one-size-fits-all approach to treatment will be successful. Rather, it is necessary to consider the age and gender of parent child dyads in designing and providing targeted interventions to families following the traumatic injury of a child.

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind-body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind-body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind-body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind-body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.

Moderators of treatment response to trauma-focused cognitive behavioral therapy among youth in Zambia

BACKGROUND

The effectiveness of mental health interventions such as trauma-focused cognitive behavioral therapy (TF-CBT) may vary by client, caregiver, and intervention-level variables, but few randomized trials in low- and middle-income countries (LMIC) have conducted moderation analyses to investigate these characteristics. This study explores moderating factors to TF-CBT treatment response among a sample of orphans and vulnerable children (OVC) in Zambia.

METHODS

Data were obtained from a completed randomized trial of TF-CBT among 257 OVC in Zambia. Trauma symptoms and functioning were measured at baseline and following the end of treatment. Mixed effects regression models were estimated for each moderator of interest: gender, age, number of trauma types experienced, history of sexual abuse, orphan status, primary caretaker, school status, and parental involvement in treatment.

RESULTS

Treatment effectiveness was moderated by history of sexual abuse with greater reductions in both outcomes (trauma, p < .05; functioning, p < .01) for those that experienced sexual abuse. Primary caretaker was also a moderator with greater trauma reductions in those who identified their mother as the primary caretaker (p < .01), and better functioning in those that identified their father as the primary caretaker (p < .05). Nonorphans and single orphans (mother alive) showed greater reduction in functional impairment (p < .01) compared with double orphans. There was no significant moderator effect found by gender, age, number of trauma types, school status, or caregiver participation in treatment.

CONCLUSIONS

This study suggests that TF-CBT was effective in reducing trauma symptoms and functional impairment among trauma-affected youth overall and that it may be particularly effective for survivors of child sexual abuse and children whose primary caretaker is a biological parent. Scale-up of TF-CBT is warranted given the wide range of effectiveness and prevalence of child sexual abuse. Future randomized trials of interventions in LMIC should power for moderation analyses in the study design phase when feasible.

Early Treatment Response in Children and Adolescents Receiving CBT for Trauma

OBJECTIVES

To investigate the incidence and correlates of early treatment response among youth receiving cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD).

METHODS

56 youth who participated in a randomized controlled trial of CBT for PTSD and D-cycloserine were included. Youth with PTSD symptoms below clinical cutoff after Session 4 of a 12-session protocol were classified as early treatment responders (32% of parent reports, 44.6% of child reports). Pretreatment characteristics were examined in relation to responder status.

RESULTS

Lower levels of pretreatment PTSD, depression, and anxiety symptoms and fewer trauma types were related to child- and parent-reported responder status (d = .57, d = .52, respectively). Early treatment response was maintained at follow-up.

CONCLUSIONS

Pretreatment symptoms levels and number of traumas may play an important role in predicting early treatment response. Correlates of early treatment response may provide avenues for identifying youth who could benefit from abbreviated protocols.

Youth offspring of mothers with posttraumatic stress disorder have altered stress reactivity in response to a laboratory stressor

Parental Posttraumatic Stress Disorder (PTSD), particularly maternal PTSD, confers risk for stress-related psychopathology among offspring. Altered hypothalamic-pituitary-adrenal (HPA) axis functioning is one mechanism proposed to explain transmission of this intergenerational risk. Investigation of this mechanism has been largely limited to general stress response (e.g., diurnal cortisol), rather than reactivity in response to an acute stressor. We examined cortisol reactivity in response to a laboratory stressor among offspring of mothers with a lifetime diagnosis of PTSD (n=36) and age- and gender- matched control offspring of mothers without PTSD (n=36). Youth (67% girls; mean age=11.4, SD=2.6) participated in a developmentally sensitive laboratory stressor and had salivary cortisol assessed five times (one pre-stress, one immediate post-stress, and three recovery measures, spaced 15min apart). Results were consistent with the hypothesis that offspring of mothers with PTSD would exhibit a dysregulated, blunted cortisol reactivity profile, and control offspring would display the expected adaptive peak in cortisol response to challenge profile. Findings were maintained after controlling for youth traumatic event history, physical anxiety symptoms, and depression, as well as maternal depression. This finding contributes to the existing literature indicating that attenuated HPA axis functioning, inclusive of hyposecretion of cortisol in response to acute stress, is robust among youth of mothers with PTSD. Future research is warranted in elucidating cortisol reactivity as a link between maternal PTSD and stress-related psychopathology vulnerability among offspring.

The change and the mediating role of parental emotional reactions and depression in the treatment of traumatized youth: results from a randomized controlled study

BACKGROUND

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been shown to efficiently treat children and youth exposed to traumatizing events. However, few studies have looked into mechanisms that may distinguish this treatment from other treatments. The objective of this study was to investigate whether the parents' emotional reactions and depressive symptoms change over the course of therapy in the treatment conditions of TF-CBT and Therapy as Usual (TAU), and whether changes in the reactions mediate the difference between the treatment conditions on child post-traumatic stress (PTS) symptoms and child depressive symptoms.

METHOD

A sample of 135 caregivers of 135 traumatized children and youth (M age = 14.8, SD = 2.2, 80% girls) was randomly assigned to receive either TF-CBT or TAU. The parents' emotional reactions were measured using the Parental Emotional Reaction Questionnaire (PERQ), and their depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). The children's outcomes were post-traumatic stress (PTS) reactions and depression, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) and Mood and Feelings Questionnaire (MFQ), respectively.

RESULTS

The parents' emotional reactions and depressive symptoms decreased significantly from pre- to post-therapy, but no significant differences between the two treatment conditions were found. The changes in reactions did not significantly mediate the treatment difference between TF-CBT and TAU on child PTS symptoms. However a mediating effect was found on child depressive symptoms.

CONCLUSION

The results showed that although the parents experienced reductions in emotional reactions and depressive symptoms when their child received therapy, this was only significantly related to the difference in outcome between TF-CBT and TAU on child depressive symptoms. Possible explanations for these results are discussed along with the implications for clinicians and suggestions for future research.

CLINICAL TRIALS IDENTIFIER

NCT00635752.

Offspring psychological and biological correlates of parental posttraumatic stress: review of the literature and research agenda

Millions of individuals with posttraumatic stress disorder (PTSD) are parents. A burgeoning literature suggests that offspring of parents with this condition may be at increased risk for psychological problems. The current paper provides an integrative and comprehensive review of the diverse research literature examining the sequelae of parental posttraumatic stress among offspring. Over 100 studies that evaluated psychological and/or biological variables among children of parents with PTSD are reviewed. Findings suggest parental symptoms of posttraumatic stress are uniquely related to an array of offspring outcomes, including internalizing-type problems, general behavioral problems, and altered hypothalamic-pituitary-adrenal axis functioning. Although very little work has directly evaluated mechanisms of transmission, there is increasing support for genetic and epigenetic effects as well as parenting behaviors. These and other mechanisms are discussed; drawing upon findings from other literatures to consider how parental PTSD may impart psychobiological vulnerability upon offspring. We conclude with a detailed discussion of the methodological strengths and challenges of the extant research, along with a recommended agenda for future research in this important area of study.