Adaptation and implementation of a trauma-focused cognitive behavioral intervention for girls in child welfare

Evaluation of "Cognitive Behavioral Intervention for Trauma in Schools" (CBITS) in child welfare programs in Germany: study protocol of a randomized controlled trial

BACKGROUND

Children and adolescents growing up in child welfare institutions have been frequently exposed to traumatic events and psychosocial stress and show elevated rates of mental disorders. Yet, there is a lack of empirically supported treatments to provide adequate mental health care for children in care suffering from trauma-related mental disorders such as posttraumatic stress disorder (PTSD), depression, and anxiety. The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is an evaluated trauma-focused cognitive-behavioral group intervention, which has proven to be effective in reducing symptoms of PTSD, depression, and anxiety for traumatized children in group settings. The trial will evaluate the effectiveness of the CBITS intervention as an outreach treatment compared with an enhanced treatment-as-usual condition (TAU +) within the German mental health and child welfare system.

METHODS

In a randomized controlled trial (RCT) involving N = 90 children and adolescents, we will compare CBITS with TAU + . Participants between 8 and 16 years, reporting at least one traumatic event and moderate posttraumatic stress symptoms (PTSS), will be randomized within their child welfare institution to either one of the conditions using a CATS-2 severity-stratified block randomization. Assessments will take place at baseline, as well as 4 months and 10 months after baseline. The primary outcome is the severity of PTSS after 4 months. Secondary outcomes are depression, anxiety, irritability/anger, quality of life, and global functioning level.

DISCUSSION

The results of our trial will provide evidence regarding effective treatment options for traumatized children in care, which represent an understudied population with limited access to mental health care. Additionally, it could serve as a blueprint for implementing trauma-focused outreach group treatments for children in care and increase the accessibility to appropriate treatment.

TRIAL REGISTRATION

Clinical Trials.gov NCT06038357 D. September 13, 2023.

A qualitative study on the implementation of a transdiagnostic cognitive behavioral therapy for children in a child welfare residential treatment program

BACKGROUND

Youth with severe emotional or behavioral issues who are involved with child welfare authorities are sometimes placed in intensive care services in a residential treatment program. Evidence-based psychotherapies are often used in residential treatments, but there is very little research on how to adapt psychotherapy for residential treatment.

OBJECTIVE

To describe the implementation of a transdiagnostic cognitive behavioral therapy (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children) in a residential treatment program for children.

PARTICIPANTS AND SETTING

Staff (n = 20) at a residential facility in Calgary, Canada.

METHODS

A combination of qualitative interviews and focus groups were conducted before and after therapy to identify barriers and facilitators to implementation. Data were analyzed and reported using the Consolidated Framework for Implementation Research and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies.

RESULTS

Modifications were made to the program including creating inclusive language, integrating relevant content targeting pediatric irritability, delivering sessions online for caregivers, and using additional staff to support youth to learn and practice the application of the content and behavioral interventions. Key barriers to implementation of the Unified Protocol included staff turnover and the difficulty of sustaining a critical mass of knowledge surrounding the Unified Protocol. The major facilitators to implementation were the perceived quality of the program and advantages of the program to children and their caregivers.

CONCLUSIONS

This study supports the feasibility and acceptability of providing transdiagnostic cognitive behavioral therapies for children in residential treatment and provides a template for how to implement evidence-based practice in residential treatment.

Systematic Review and Meta-analysis: Group-Based Interventions for Treating Posttraumatic Stress Symptoms in Children and Adolescents

OBJECTIVE

Trauma exposure in childhood is common and can lead to a range of negative mental health outcomes, including posttraumatic stress disorder (PTSD). In many settings, resources to address this distress are scarce. Group-based interventions require minimal resources and training, can be delivered by non-mental health specialists, and target larger numbers of children and adolescents. This meta-analysis sought to establish whether such an approach is an effective method for targeting PTSD symptoms and to identify potential moderators of effectiveness.

METHOD

PubMed, PsycNET, and PTSDPubs were searched for randomized controlled trials that used a group-based PTSD intervention with children and adolescents aged 6 to 18 years. Data were extracted for PTSD symptoms and depression symptoms. A random-effects meta-analysis was conducted to obtain between-group pooled effect size estimates. This study was registered on PROSPERO (CRD42020187214).

RESULTS

The initial search identified 9,650 studies, of which 42 were eligible for inclusion (N = 5,998). Children randomized to a group-based intervention had significantly lower PTSD symptoms after treatment compared with a control group, with a medium pooled effect (g = -0.55, 95% CI [-0.76, -0.35]). Group interventions were superior when compared with either active or passive controls, at follow-up, and for depression symptoms. There was a large amount of heterogeneity, but no evidence that this was explained by whether the intervention was delivered in a low- and middle-income or high-income country, included caregivers, or was universal or targeted.

CONCLUSION

Group PTSD interventions, particularly cognitive-behavioral therapy-based interventions, are effective at targeting posttrauma distress in children and adolescents. There was evidence of effectiveness when delivered in highly complex and resource-scarce settings and to a range of trauma-exposed groups, including groups exposed to war/conflict, natural disasters, and abuse.

Effectiveness of Psychotherapy for Internalising Symptoms in Children and Adolescents When Delivered in Routine Settings: A Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to examine the effectiveness of psychological interventions for internalising disorders in youth when delivered in routine settings. Secondary aims were to examine the effectiveness of cognitive behavioural therapy and determine moderators of treatment response. The study was pre-registered (PROSPERO 2020 CRD42020202776). Databases were systematically searched (PsycINFO, Medline, Embase, PubMed, ERIC) in December 2022 and screened according to the PRISMA 2020 statement. Inclusion: School aged participants (4-18 years) with a primary internalising disorder; psychotherapy delivered in a routine setting (e.g. outpatient clinic, school) by setting staff; compared psychotherapy to any control in a randomised controlled trial; reported pre-to-post or pre-to-follow-up comparisons on the primary disorder according to child, parent or independent evaluator report; and was published in English. Risk of bias was assessed using the ROB 2.0 Cochrane tool. Results were synthesised using random effects to pool estimates. Risk ratios were used to analyse dichotomous data and standardised mean differences (SMD) for continuous data. Forty-five studies were included (N = 4901 participants; M = 13 years; range 8-16; SD = 2.5). Nine used waitlist control, 17 treatment as usual, 4 placebo; 15 compared psychotherapy to active control. Psychotherapy was associated with small significant effects pre- to post-treatment compared to non-active controls for anxiety (SMD =  - 0.24 to 0.50) and depression (SMD =  - 0.19 to 0.34) with effects differing by informant. Psychotherapy led to small significant pre-to-post-benefits in youth internalising disorders in routine settings. Results are limited by reporter type and follow-up.

Child Maltreatment, Mental Health, and Self-Reported Health Among Adolescent Girls in Child Welfare: Mediating Pathways

Child maltreatment is common in the US and has been shown to be associated with physical and psychological health problems in adolescence and adulthood. Based on the allostatic load theory, this study examined the association between different types of child maltreatment (emotional, physical, and sexual abuse, and physical neglect) and self-rated health, and the mediating roles of post-traumatic stress and depression in these relationships. Participants were 249 girls involved in the child welfare system, ages 12-19 years, the majority of whom were African American. A one item self-reported general health measure, the Child Trauma Questionnaire-Short Form (CTQ-SF), Child PTSD Symptom Scale (CPSS) and the Child Depression Inventory (CDI) measured self-reported health, child maltreatment, and posttraumatic and depression symptoms, respectively. Higher levels of emotional, physical, and sexual abuse, and physical neglect were significantly associated with poorer ratings of health. PTSD and depression were significant mediators between histories of childhood emotional, physical, and sexual abuse and physical health. In conclusion, results indicate that the pathways from child abuse to physical health problems in adolescents are through psychological distress. Trauma focused interventions to reduce symptoms of PTSD and depression among this vulnerable group of adolescents are essential to improve health.

Comparative efficacy for different age groups of psychological or psychosocial treatments on post-traumatic stress disorder: protocol for systematic review, meta-analysis and meta-regression analysis

INTRODUCTION

It remains unknown whether psychological or psychosocial treatments for post-traumatic stress disorder (PTSD) have comparable effects across the life span. This study aims at comparing the effects of psychological/psychosocial treatments for PTSD between different age groups of youth, early-middle adults and late adults.

METHODS AND ANALYSIS

A systematic search will be conducted among thirteen electronic databases, including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, EMBASE, ERIC, PubMed, SCOPUS, Web of Science, Published International Literature on Traumatic Stress, China National Knowledge Infrastructure Database, the Wanfang database, the Chinese Scientific Journal Database (VIP Database) and ProQuest Dissertations and Theses, from inception to 15 May 2022. Electronic searches will be supplemented by a comprehensive grey literature search in Conference proceedings and trial registries. Randomised controlled trials (RCTs) comparing psychological or psychosocial treatments for PTSD with control conditions in all age groups will be included. The primary outcome is the between-treatments efficacy for PTSD that refers to the outcomes of the RCTs included in the meta-analysis. Effect sizes will be calculated for all comparisons and pooled with a fixed effects model or a random effects model. Differences in the efficacy of psychological/psychosocial therapies for PTSD across the age groups will be examined by stratified analyses and meta-regression analyses.

ETHICS AND DISSEMINATION

Data used in this study will be anonymised. These data will not be used for other purposes than research. Authors who supply the data will be acknowledged. The authors declare that no conflicts of interest exist. The findings of this study will be disseminated through briefing reports, publications and presentations.

TRIAL REGISTRATION NUMBER

CRD42022334305.

Relative efficacy of psychological interventions following interpersonal trauma on anxiety, depression, substance use, and PTSD symptoms in young people: A meta-analysis

AIM

Interpersonal trauma exposures are associated with anxiety, depression, and substance use in youth populations (aged 12-25 years). This meta-analysis reports on the efficacy of psychological interventions on these symptom domains in addition to post-traumatic stress.

METHODS

Following PRISMA guidelines, a search of electronic databases was performed for randomized controlled trials (RCTs) assessing interventions for young people following interpersonal trauma exposure. Risk of bias was assessed using the Cochrane Risk of Bias tool. Data were analysed using random-effects meta-analyses.

RESULTS

Of the 4832 records screened, 78 studies were reviewed, and 10 RCTs, involving 679 participants (mean age 15.6 years), were analysed. There was a large pooled effect size for post-traumatic stress (7 studies, g = 1.43, 95% CI [0.37, 2.15], p = .002) and substance use (2 studies, g = 0.70, 95% CI [-0.11, 1.22], p < .001) and small effect sizes for anxiety (4 studies, g = 0.30, 95% CI [0.10, 0.49], p = .003), and trend-level effect for depression (10 studies, g = 0.27, 95% CI [0.00, 0.54], p = .052). Heterogeneity was significant for post-traumatic stress and moderate for depression.

CONCLUSIONS

High-quality RCTs of psychological interventions for anxiety, depression, substance use, and post-traumatic stress symptoms in young people exposed to interpersonal trauma are scarce. While available studies show either statistically significant or trend-level efficacy for psychological interventions in reducing these symptoms, wide confidence intervals, heterogeneity and small sample size mean that results need to be interpreted with caution.

Adaptations of evidence-based trauma-focused interventions for children and adolescents: a systematic review

BACKGROUND

Rates of potentially traumatic events (PTEs) and other forms of adversity among children are high globally, resulting in the development of a number of evidence-based interventions (EBIs) to address the adverse outcomes stemming from these experiences. Though EBIs are intended to be delivered according to set parameters, these EBIs are frequently adapted. However, little is known about existing adaptations of EBIs for children who experienced PTEs or other adversities. As such, this review aimed to determine: (1) why existing EBIs designed to address PTEs and other adversities experienced by children are adapted, (2) what processes are used to determine what elements should be adapted, and (3) what components of the intervention are adapted.

METHODS

Nine academic databases and publicly available search engines were used to identify academic and grey literature. Initial screening, full-text review, data extraction, and quality determinations were completed by two members of the research team. Data were synthesized narratively for each adapted EBI by research question.

RESULTS

Forty-two studies examining the adaptations of nine different EBIs were located, with Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools being the most commonly adapted EBIs. Most frequently, EBIs were adapted to improve fit with a new population and to address cultural factors. Most commonly, researchers in combination with others made decisions about adapting interventions, though frequently who was involved in these decisions was not described. Common content adaptations included the addition of intervention elements and the tailoring/tweaking/refining of intervention materials. Common contextual adaptations included changes to the intended population, changes to the channel of treatment delivery, and changes to who administered the intervention.

CONCLUSIONS

Most published studies of EBI adaptions have been developed to improve fit and address cultural factors, but little research is available about adaptations made by clinicians in day-to-day practice. Efforts should be made to evaluate the various types of adaptations and especially whether adaptations improve access to services or improve child outcomes in order to ensure that all children exposed to trauma can access effective treatment.

TRIAL REGISTRATION

The protocol for this systematic review was published with PROSPERO (CRD42020149536).

Associations between therapist factors and treatment efficacy in randomized controlled trials of trauma-focused cognitive behavioral therapy for children and youth: A systematic review and meta-analysis

Previous research suggests that the effect of therapist factors on patient outcomes is significant. Yet, to date, no reviews have explored the potential effects of therapist characteristics on treatment outcomes for children and youth with posttraumatic stress disorder (PTSD). This systematic review and meta-analysis aimed to summarize the professional characteristics of trial therapists delivering trauma-focused cognitive behavioral interventions (TF-CBT) for child PTSD in clinical trials and understand the association between treatment efficacy and therapist factors. Systematic searches for randomized controlled trials (RCTs) published through November 3, 2020, were conducted; 40 RCTs were included in the full review. PTSD treatment outcome data were extracted from each publication along with any available data regarding trial therapists. Subgroup analyses were conducted to compare the outcomes of interventions conducted by different types of therapists. All therapist groups yielded significant effects for TF-CBT relative to active and passive control conditions, with the largest effect size, Hedges' g = -1.11, for RCTs that used clinical psychologists and psychiatrists. A significant moderating effect was found when comparing the treatment outcomes of clinical psychologists and psychiatrists versus other professionals, p = .044; however, this effect was no longer apparent when only studies with an active control arm were included. Further moderator analyses demonstrated no significant differences regarding therapists' educational and professional backgrounds and PTSD treatment outcomes. The current RCT evidence for TF-CBT for children and youth with PTSD does not suggest that therapist educational or professional background influences treatment efficacy. Limitations and implications for future research are discussed.

Addressing Mental Health and Trauma-Related Needs of Sheltered Children and Families with Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)

Children and adolescents ("youth") experiencing homelessness are at a disproportionately high risk of exposure to potentially traumatic events (PTE). However, limited evidence exists as to what interventions are effective when implemented with this high-risk population. The purpose of this study was to (1) document the mental health and trauma-related needs of sheltered youth and their mothers, and (2) examine the feasibility/effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) administered within the context of a homeless shelter. Three hundred and twenty-one youth (Mage = 10.06 years, SD = 3.24 years, 56.4% male, 70.1% Black/African American, 34.6% Hispanic/Latinx) and their mothers were recruited from a homeless shelter and provided 10 weeks of TF-CBT, with the option for up to eight additional weeks of therapy based on clinical need. Families completed pre- and post-intervention assessments. Results demonstrated clinically elevated pre-intervention PTSD symptoms and rates of exposure to PTE in sheltered youth well above those previously reported in the general population. TF-CBT resulted in substantial reductions in both maternal and self-reported severity of youth PTSD symptomology, which were largely attributable to reductions in re-experiencing and arousal. Effectiveness of TF-CBT varied by age and the number of exposures to PTE. Overall, these findings illustrate the importance of assessing and addressing the mental health and trauma-related needs of sheltered youth and the feasibility and efficacy of embedding an evidence-based trauma-focused treatment protocol within a shelter environment. Additional implications of these findings are discussed.

What Young People Think About Music, Rhythm and Trauma: An Action Research Study

A number of popular theories about trauma have suggested rhythm has potential as a mechanism for regulating arousal levels. However, there is very little literature examining this proposal from the perspective of the young people who might benefit. This action research project addresses this gap by collaborating with four groups of children in the out-of-home-care system to discover what they wanted from music therapists who brought a strong focus on rhythm-based activities. The four music therapy groups took place over a 12 month period and each cycle of action and reflection led to adjustments in what activities were offered, as well as exploring different levels of structure and ways of building relationships in the groups. The initial group incorporated a strong emphasis on highly structured rhythm-based activities, but young people found the format difficult to engage with. The second cycle included more opportunities for creativity and self-direction within semi-structured activities which children reported enjoying, but too much freedom also became overwhelming at times. The two groups in the third cycle seemed to balance structure and responsiveness successfully but were also influenced by the introduction of individual sessions prior to group commencement, which was designed to contribute to safety and trust building. Final reflections on the role of rhythm in supporting young people who have had adverse experiences were centred around the ideas of co-regulation. This was qualitatively different to our expectations that practicing rhythm-based activities would lead to an expanded window of tolerance that resulted in less time being spent in either hypo-arousal or hyper-arousal. Instead of entraining to an external rhythm, young people felt safe when their rhythms were matched, even if they were irregular, out of time and unpredictable. The small moments of co-regulation resulted in pleasure, comfort, satisfaction and peace and these moments were highly valued by the young people, who described just wanting to be relaxed and happy. Although not as rhythm-specific as the literature might suggest, music making with trusted adults helped the young people in this study feel more content.

Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review

Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.

Is There an Ace Up Our Sleeve? A Review of Interventions and Strategies for Addressing Behavioral and Neurobiological Effects of Adverse Childhood Experiences in Youth

Exposure to early life adversity (ELA) is a major public health crisis posing as a significant risk of immediate and sustained mental and physical health consequences. While a remarkable body of knowledge has been amassed showing psychological, cognitive, social, developmental, and neurobiological consequences of ELA exposure, little has been done to improve the long-term mental and physical health outcomes for youth exposed to ELA. Furthermore, neurobiological processes underlying poor outcomes in this population have been largely left out of prevention and intervention target efforts. In this review, we first describe ELA-related alterations across psychological and neurobiological systems in children and adolescents. Next, we describe existing evidence-based interventions targeting ELA-related outcomes. We then turn to experimental studies examining individual differences in mechanistic functioning consequent to ELA exposure, and strategies that target these mechanisms and modulate disrupted functioning. Finally, we highlight areas of future research that may be promising in engaging behavioral and neurobiological targets through novel preventive interventions or augmentation of existing interventions, thereby reducing negative mental and physical health outcomes later in life.

Effectiveness of a trauma-focused group intervention for young refugees: a randomized controlled trial

BACKGROUND

As access to evidence-based treatments for young refugees with posttraumatic stress symptoms (PTSS) is limited, we developed the trauma-focused group intervention Mein Weg to be delivered by trained social workers. A recently published pilot study delivered preliminary evidence of the intervention with regard to symptom reduction and its feasibility. The aim of this study was, therefore, to determine whether the intervention, in addition to usual care (UC), is more effective in reducing PTSS (primary outcome) compared to UC alone.

METHODS

A parallel group randomized controlled trial was conducted in seven German child and adolescent welfare agencies. Participants were randomly assigned to either six sessions Mein Weg (n = 50; M_age  = 17.00, 94% male) or UC (n = 49; M_age  = 16.92, 92% male). Mixed effect models, with fixed effects of group and time as well as their interaction, were performed on the relevant outcome measures. This trial was registered in the German Clinical Trials Registry (#DRKS00010915, https://www.drks.de/drks_web/).

RESULTS

Intention-to-treat analyses showed that Mein Weg was significantly superior to UC regarding symptom improvement of self-reported PTSS (Mein Weg: d = .61, UC: d = .15) and depression (Mein Weg: d = .63, UC: d = -.06), but not regarding caregiver-reported symptoms and self-reported dysfunctional posttraumatic cognitions.

CONCLUSIONS

Mein Weg is effective for young refugees according to self-reports and can be viewed as a valuable component in a stepped care approach for this vulnerable population. The findings need to be replicated with independent clinical assessments.

Mental Health and School Functioning for Girls in the Child Welfare System: the Mediating Role of Future Orientation and School Engagement

This study investigated the association between mental health problems and academic and behavioral school functioning for adolescent girls in the child welfare system and determined whether school engagement and future orientation meditated the relationship. Participants were 231 girls aged between 12 and 19 who had been involved with the child welfare system. Results indicated that 39% of girls reported depressive symptoms in the clinical range and 54% reported posttraumatic symptoms in the clinical range. The most common school functioning problems reported were failing a class (41%) and physical fights with other students (35%). Participants reported a mean number of 1.7 school functioning problems. Higher levels of depression and PTSD were significantly associated with more school functioning problems. School engagement fully mediated the relationship between depression and school functioning and between PTSD and school functioning, both models controlling for age, race, and placement stability. Future orientation was not significantly associated with school functioning problems at the bivariate level. Findings suggest that school engagement is a potentially modifiable target for interventions aiming to ameliorate the negative influence of mental health problems on school functioning for adolescent girls with histories of abuse or neglect.