Trust-Based Relational Intervention (TBRI): A Systemic Approach to Complex Developmental Trauma

Do weighted blankets improve sleep among children with a history of maltreatment? A randomized controlled crossover trial

STUDY OBJECTIVES

Sleep disruption is prevalent and persistent among children who experience maltreatment/interpersonal trauma. Weighted blankets have gained popularity in recent years as a potential nonpharmacological intervention for improving sleep in various populations, but their efficacy has not been examined among maltreated children. The current study used a randomized, within-subjects, crossover design to examine whether the use of a weighted blanket improves objective and/or subjective indices of sleep among 30 children, ages 6-15 years (mean = 9.7, standard deviation = 2.9) adopted from foster care.

METHODS

Participants used a weighted blanket for 2 weeks and their usual (unweighted) blanket for 2 weeks in a counterbalanced order. Sleep outcomes were measured using actigraphy and subjective sleep diaries.

RESULTS

No differences in actigraphy-based or subjective estimates of total sleep time, sleep onset latency, wake after sleep onset, or sleep quality ratings were found based on blanket type. Child age, biological sex, timing of participation (school year vs summer months), and maltreatment/trauma history did not impact outcomes.

CONCLUSIONS

Although we did not find evidence that weighted blankets improve sleep among children with a history of maltreatment/interpersonal trauma, additional well-controlled studies using larger samples of children are needed.

CITATION

Cifre AB, Vieira A, Baker C, et al. Do weighted blankets improve sleep among children with a history of maltreatment? A randomized controlled crossover trial. J Clin Sleep Med. 2024;20(9):1405-1413.

Start-Up and Implementation Costs for the Trust Based Relational Intervention

Capturing costs associated with prevention activities related to substance use disorders (SUD) and mental health (MH) is critical. In this study, Trust Based Relational Intervention (TBRI®), an attachment-based, trauma-informed intervention, is conceptualized as a preventive intervention to reduce substance and opioid use among youth involved with the legal system. When implemented alongside community reentry, TBRI leverages family systems as youth transition from secure residential care into communities through emotional guidance and role modeling. Activity-based cost (ABC) analysis was used to guide cost data collection and analysis for both start-up and implementation of the TBRI intervention. Start-up costs were estimated using data across eight sites during their start-up phase. All components, activities, personnel involved, and time associated with implementation of TBRI sessions according to protocol were defined. National wages were extracted from O*NET and utilized to calculate total costs for each TBRI component. Total and average TBRI intervention costs were calculated with a breakdown by TBRI sessions and number of staff and participants. A sensitivity analysis was conducted to estimate TBRI implementation costs with travel. The total cost for the TBRI intervention, representing 42 sessions, ranges from $6,927, without travel expenses or $12,298, with travel expenses. The average per family cost ranges from $1,385 (without travel) to $2,460 (with travel). Costs are primarily generated by time investments from primary interventionists. The sensitivity analysis shows costs for responsive coaching would double with travel costs included. Results aim to show that using ABC for prevention activities, like TBRI, to understand cost drivers can facilitate future intervention sustainability.Clinical Trail.gov ID: NCT04678960.

Beyond Victim Identification: A Practitioner's Guide to Designing a Youth Anti-Sex Trafficking Advocacy Program

Thousands of youth are sexually trafficked each year in the United States. In order to address this concern, anti-trafficking advocates often emphasize the importance of uniform screening protocols to assist with the identification of survivors. Unfortunately, an oft-overlooked component of sex trafficking identification is what to do once a victim has been identified, and how to best meet survivors' complex needs. In this article, the authors provide social work practitioners and other advocates with best practice guidelines for how to design and evaluate anti-sex trafficking advocacy programs for children and youth. These guidelines include considerations related to direct services with clients, community partnerships, and organizational capacity, as well as recommendations for how to begin and then evaluate programming. Regardless of the form selected for the program, all anti-sex trafficking programs should be designed to provide effective, client-centered follow-up and advocacy once a positive identification is made in the community. The recommendations included in this paper are based upon extant literature, the authors' practice experience with survivors, and insights from anti-sex trafficking program evaluations.

Effects of a behavioral intervention with foster families: A randomized controlled trial

BACKGROUND

The health and well-being of children in foster care are of high concern. A resource with which to disrupt maladaptation and promote healing are positive relationships among children and caregivers within the foster home. The research question was: Can an online intervention improve family hardiness and sibling relationships within foster care families?

OBJECTIVES

To: (1) establish feasibility and acceptability of an online behavioral intervention within the foster family, (2) explore the effects of the intervention on relational quality outcomes, and (3) decompose the mechanisms driving improved family hardiness through mediation analysis.

PARTICIPANTS AND SETTING

95 currently fostering families across the US, participated in a 4-week, online, self-paced, behavioral intervention with an emphasis on the relationship between children residing in the home.

METHODS

We employed a randomized control trial design with multiple regression analysis. Stress and relational quality outcomes were measured through psychometrically validated questionnaires on family hardiness, preparedness, and sibling relationships.

RESULTS

Significant increase in family hardiness (Cohen's d = 0.97, p < 0.001) were found compared to the control group. Measures of a positive sibling relationship score increased significantly in the intervention group (d = 0.76, p < 0.002), mediating 32 % of the total effect in hardiness score. Sibling relationship served as a mediator for increasing indicators of family hardiness.

CONCLUSIONS

Providing families the sibling-inclusive intervention caused an increase in positive indicators of sibling relationship and overall family hardiness. Researchers should consider the implications of supporting foster siblings and the affects their inclusion may have on outcomes for children in foster care.

Adaptation of a trauma-informed intervention to prevent opioid use among youth in the legal system

INTRODUCTION

Youth in the legal system are at high risk for opioid and other substance use problems and exhibit high rates of trauma exposure. Trauma-focused therapeutic approaches to prevent substance use show promise, but few evidence-based interventions are designed with justice-involved youth in mind. Consequently, implementing trauma-informed, evidence-based interventions within juvenile justice systems is challenging. The current paper describes the systematic adaptation of Trust-Based Relational Intervention (TBRI) as a family-centered substance use prevention program for youth transitioning from secure residential facilities.

METHODS

The study utilized the ADAPT-ITT methodological framework to adapt TBRI Caregiver Training, an evidence-based, trauma-informed intervention designed to help caregivers support children and youth with histories of trauma. Phases of adaptation included (1) Assessment, (2) Decision, (3) Prototype Development, and (4) Testing and Integration. The adaptation process explored contextual factors (e.g., systems, facilities, and staff) and the needs of the new target population (i.e., youth in the legal system and their caregivers). Adaptations were made to both content (e.g., terminology and activities) and structure (e.g., session duration and delivery setting) with input from participants from the target population, key stakeholders, and content experts.

RESULTS

The systematic adaptation of the intervention model resulted in a two-phase, four-component intervention package that can be implemented in juvenile justice settings as part of youth reentry services. The primary intervention, delivered while youth are in residential facilities, includes the TBRI Caregiver Curriculum, TBRI Youth & Young Adult Curriculum, and TBRI Nurture Groups. The secondary intervention, delivered after youth transition home, includes the TBRI Family Coaching Curriculum.

CONCLUSIONS

Utilizing a systematic methodological framework to guide adaptation has implications for developing accessible, culturally relevant, and contextually appropriate interventions. Accounting for contextual factors and population needs can improve the fit of evidence-based interventions for youth in the legal system, facilitating uptake and ultimately improving outcomes for youth at risk for substance use problems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04678960.

Helping Institutionalised Children through a Trusting Relationship-Findings from a One-Year Psychosocial Intervention Programme

Children growing up in institutions lack a stable relationship-essential for development. A significant proportion of them have disorganised attachment, which is associated with negative outcomes. Therefore, interventions aimed at improving attachment security are needed. We conducted a case series study (involving five participants aged 8-11 years) in a newly established psychosocial rehabilitation daycare centre to describe the changes in attachment security and mental health of institutionalised children after one year of attendance. The intervention consisted of individualised care focusing on staff building a trusting relationship with participants using the principles of Trust-Based Relational Intervention® (TBRI). Measures such as the Child Attachment Interview, SDQ, CBCL6/18, TRF6/18, and clinical interviews were used to follow change. The descriptive data of five participants are presented. All five children improved in mental health, and for two participants, organisation of attachment changed. Three children experienced relational ruptures. The findings suggest that psychosocial interventions that focus on building trusting relationships may be beneficial in institutionalised children. For these children, given their life history, it can be damaging to experience repeated breakdowns. Thus, the practical implication is that any new relationship for them with an adult should be established after an assessment of whether the relationship can be sustained.

Exploring the Effectiveness and Sustainability of Trust Based Relational Intervention (TBRI®) as a Trauma-informed Approach in Two Tasmanian Child and Family Learning Centres

The impact of adverse childhood experiences (ACEs) is well documented and poses challenges for all those living and working with children who have experienced early adversity. The need to be trauma-informed when working with children in all educational settings is now recognised as essential if healing and learning are to take place. There are an increasing number of trauma-informed approaches available, but empirical evidence that supports their efficacy, particularly in the early years of education, is currently scarce. This paper presents the findings of a small-scale study which explored early childhood professionals' perceptions of the effectiveness and sustainability of one trauma-informed approach, Trust Based Relational Intervention (TBRI®). Used widely across the US and Europe, TBRI® is relatively new to Australia and was trialled for the first time in this Tasmanian study. Substance Abuse and Mental Health Services Administration's (SAMHSA, 2014) concept of trauma and guidance for a trauma-informed approach was used to provide a theoretical framework. Online surveys were used to gather data after each professional learning workshop and three and six-months later. Participants reported several positives of TBRI®, including self-development and improved outcomes for children. Whilst challenges/barriers to using the approach were noted, many related to contextual issues rather than to TBRI® specifically. Findings also showed that equipping families with a similar skill set would be advantageous and integral to effecting sustainable change.

Trust-Based Relational Intervention® (TBRI®) Impact for Traumatized Children-Meaningful Change on Attachment Security and Mental Health after One Year

Children from vulnerable backgrounds often have insecure attachment or disorganized attachment, which are related to psychological troubles, and such children need interventions to help them heal. The attachment system reorganizes in middle childhood, and other important adults play a considerable role in children's lives. Thus, it is essential to weigh the impact of psychosocial interventions, while the main focus of the intervention is the staff member's direct work with the child through a trusting relationship. The primary purpose of this study is to investigate whether children's attachment security and mental health outcomes change after participating in a trauma-informed, attachment-based, Trust-Based Relational Intervention (TBRI) provided in a daycare center. It was a case-series study involving twelve children aged 8-11 years. The child attachment interview (CAI), CBCL/6-18, TRF/6-18, and clinical interviews for parents and children were used, measuring the change between the TBRI implementation in the daycare center and after one year. For ten participants, we noticed an improvement in mental health; for seven participants, security scales improved; for two participants, their disorganized attachment changed into insecure-dismissing. We have preliminary evidence that vulnerable children may benefit in terms of attachment security and mental health from the trusting relationship that staff build using the TBRI.

Leveraging the Full Continuum of Care to Prevent Opioid Use Disorder

Substance use disorder prevention programs are most effective when matched appropriately to the baseline risk of the population. Individuals who misuse opioids often have unique risk profiles different from those who use other substances such as alcohol or cannabis. However, most substance use prevention programs are geared toward universal audiences, neglecting key inflection points along the continuum of care. The HEAL Prevention Cooperative (HPC) is a unique cohort of research projects that represents a continuum of care, from community-level universal prevention to indicated prevention among older adolescents and young adults who are currently misusing opioids or other substances. This paper describes the theoretical basis for addressing opioid misuse and opioid use disorder across the prevention continuum, using examples from research projects in the HPC.

Prevention of Opioid Use and Disorder Among Youth Involved in the Legal System: Innovation and Implementation of Four Studies Funded by the NIDA HEAL Initiative

Youth involved in the legal system (YILS) experience rates of opioid and substance use disorders (OUD/SUDs) and overdose that is well above those in the general population. Despite the dire need, and the existing programs that focus on treatment of these problems in YILS, research on opioid initiation, and OUD prevention, including feasibility and sustainability, are severely limited. We present four studies testing interventions that, while not necessarily novel as SUD treatments, test novel structural and interpersonal strategies to prevent opioid initiation/OUD precursors: (1) ADAPT (Clinical Trial No. NCT04499079) provides real-time feedback using community-based treatment information system data to create a more effective mental health and SUD treatment cascade to prevent opioid use; (2) HOME (Clinical Trial No. NCT04135703) provides youth experiencing homelessness, including YILS, with direct access to shelter in independent living without prerequisites as an opioid initiation prevention strategy; (3) LeSA (Clinical Trial No. NCT04678960) uses the Trust-Based Relational Intervention® to equip YILS and their caregivers with self-regulatory and communication skills during the transition from secure confinement to reduce opioid initiation/re-initiation; and (4) POST (Clinical Trial No. NCT04901312) tests two interventions integrating interpersonal/drinking and drug refusal skills, case management, and goal setting among YILS in transitioning out of secure detention as opioid initiation prevention strategies. We discuss early implementation barriers and facilitators, including complexities of prevention research with YILS and adaptations due to COVID-19. We conclude by describing anticipated end products, including implementation of effective prevention interventions and integration of data from multiple projects to address larger, multi-site research questions.

Multidisciplinary Strategies for Preventing Opioid Misuse and Escalation by Targeting Mental Health Symptoms and Conditions

We aim to review the association between childhood-onset mental health conditions and increased risk for early substance use including opioid misuse and opioid use disorders (OUD). The association between mental health conditions and opioid misuse suggests youth with mental health conditions may benefit from opioid prevention efforts that concurrently address mental health. To aid in the identification of youth with mental health conditions who could benefit from interventions, we will review opportunities and challenges associated with screening for mental health symptoms or substance use in settings where youth at high risk for mental health conditions present. We will also review how research projects within the National Institutes of Health's Helping to End Addiction Long-term (HEAL) Prevention Cooperative are addressing mental health within opioid misuse and OUD prevention interventions for youth.

Effects of COVID-19 on School Nurse Mental Health Intervention Practices

Mental health issues have been exacerbated by COVID-19; therefore we examined how the school nurses' role in addressing mental health changed during the pandemic. We administered a nationwide survey in 2021, guided by the Framework for the 21st Century School Nurse, and analyzed self-reported changes in mental health interventions by school nurses. Most mental health practice changes after the start of the pandemic occurred in the care coordination (52.8%) and community/public health (45.8%) principles. An overall decrease in students visiting the school nurse's office (39.4%) was seen, yet the frequency of students visiting with mental health concerns had increased (49.7%). Open-ended responses indicated that school nurse roles changed due to COVID-19 protocols, including decreased access to students and changes in mental health resources. These insights into the role of school nurses in addressing student mental health during public health disasters have important implications for future disaster preparedness efforts.

Enhancing supports to children of incarcerated parents: Introducing trauma informed training to church mentors

A child who has a parent incarcerated is likely to experience a number of life challenges including school failure, poverty, substance abuse, and justice system involvement. The negative outcomes associated with having a parent incarcerated disproportionately expose children to adverse childhood events (ACE's) which have been associated with higher morbidity and mortality. However, engagement with caring adults who can provide both practical and spiritual mentorship can increase a child's resilience and buffer the impact of these negative outcomes. Church-based mentors have the capacity to provide support to this population when adequately trained in trauma-informed responses. This study describes Camp Agape California (CAC), a church-based mentoring program for children with an incarcerated parent. Specifically, this study describes the development and implementation of a trauma focused mentorship training purposed to equip church members to better meet the needs of this vulnerable population. Seventy-six volunteer mentors from various churches participated in the training and completed the post-training survey. Results suggest that the trauma informed training was effective at increasing knowledge and self-efficacy and was identified as being relevant to the mentor role. Implications for the utility of church-based mentorship for vulnerable populations are explored.

Using Time-out for Child Conduct Problems in the Context of Trauma and Adversity: A Nonrandomized Controlled Trial

Importance

Exposure to adverse childhood experiences substantially increases the risk of chronic health problems. Originally designed to treat child conduct problems, parent management training programs have been shown to be effective in preventing children from being exposed to further adversity and supporting children's recovery from adversity; however, there are increasing concerns that a core component of these programs, the discipline strategy time-out, may be harmful for children with a history of exposure to adversity.

Objective

To investigate the comparative benefits and potential harms to children exposed to adversity that are associated with parenting programs that include time-out.

Design, Setting, and Participants

This nonrandomized waiting list-controlled clinical study was conducted at a specialist clinic for the treatment of conduct problems in Sydney, Australia. The self-referred sample included children with conduct problems and their caregivers. Eligibility was confirmed through clinician-administered interviews. Data were collected between February 14, 2018, and February 1, 2021.

Interventions

Caregivers participated in a 10-session, social learning-based parent management training program. Caregivers were provided with parenting strategies aimed at encouraging desired behaviors through effective reinforcement and managing misbehavior through consistent limit setting, including the use of time-outs.

Main Outcomes and Measures

The primary outcome was the parent-reported Strengths and Difficulties Questionnaire score, and secondary outcomes included subscale scores from the clinician-administered Diagnostic Interview Schedule for Children, Adolescents, and Parents. Multi-informant measures of child adversity were collected using the parent-reported Adverse Life Experiences Scale and the clinician-rated Maltreatment Index.

Results

A total of 205 children were included in analysis (156 in the full intervention and 49 in the control condition; 158 boys [77.1%]; mean [SD] age, 5.6 [1.8] years [range, 2-9 years]). Compared with children with low adversity exposure, children with high adversity exposure showed greater reductions in the Strengths and Difficulties Questionnaire score from baseline (mean difference, 3.46 [95% CI, 1.51-5.41]; P < .001) to after treatment (mean difference, 1.49 [95% CI, -0.46 to 3.44]; P = .13) and in the internalizing symptom subscale score (baseline mean difference, 1.00 [95% CI, -2,00 to 0.00]; P = .50; posttreatment mean difference, 0.06 [95% CI, -0.82 to 0.94]; P = .90). No significant differences in the externalizing symptom subscale score were found.

Conclusions and Relevance

In this nonrandomized clinical study, children with high exposure to adversity experienced equivalent, if not greater, benefits associated with parenting programs that include time-out compared with children with low exposure to adversity. Results suggest that time-out was an effective component of parenting programs for children exposed to adversity.

Trial Registration

anzctr.org.au Identifier: ACTRN12617001472369.

Caring for nontraditional families: Kinship, foster, and adoptive

PURPOSE

Information about nontraditional (kinship, foster, and adoptive) families is typically scattered or overlooked both in nursing education and nursing practice settings. Using a nursing-centric, population-focused lens, the current state of nontraditional families in the United States is briefly described. An overview of the challenges and psychological dynamics involved when a nonbiological parent assumes the role of caregiver is provided.

CONCLUSION

Based on the 2010 Census findings and other indicators, we now understand that nontraditional families and their children make up a considerable portion of the population. Nurses, regardless of level of practice, have the potential to positively impact health outcomes of nontraditional parents and their children. Knowledge of the formation and needs of nontraditional families can inform, and improve, culturally safe, trauma-informed nursing care.

PRACTICE IMPLICATIONS

This discussion is a first step in appreciating the formation of nontraditional families and the importance of trauma-informed, unbiased, nonstereotypic discourse in nursing care. By describing the heterogeneity of how families are built through kinship care, foster placements, and adoptive homes, nurses' assessments and interventions will be informed and through a lens of the high potential for past traumas. With this foundational knowledge, nurses interfacing with nontraditional families are better prepared to provide much needed support and relevant care for this unique population.

Preventing opioid use among justice-involved youth as they transition to adulthood: leveraging safe adults (LeSA)

BACKGROUND

Juvenile justice (JJ) youth are at high risk of opioid and other substance use (SU), dysfunctional family/social relationships, and complex trauma. The purpose of the Leveraging Safe Adults (LeSA) Project is to examine the effectiveness of Trust-Based Relational Intervention® (TBRI®; leveraging family systems by providing emotional and instrumental guidance, support, and role modeling) in preventing opioid and other SU among youth after release from secure residential facilities.

METHODS

An effectiveness-implementation Hybrid Type 1 design is used to test the effectiveness of TBRI for preventing non-medical use of opioids among JJ-youth (delayed-start at the site level; a randomized controlled trial at participant level) and to gain insight into facility-level barriers to TBRI implementation as part of JJ re-entry protocols. Recruitment includes two samples (effectiveness: 360 youth/caregiver dyads; implementation: 203 JJ staff) from nine sites in two states over 3 years. Participant eligibility includes 15 to 18-year-olds disposed to community supervision and receiving care in a secure JJ facility, without active suicide risk, and with one caregiver willing to participate. Effectiveness data come from (1) youth and caregiver self-report on background, SU, psychosocial functioning, and youth-caregiver relationships (Months 0, 3, 6, 12, and 18), youth monthly post-release check-ins, and caregiver report on youth psychological/behavioral symptoms, and (2) JJ facility records (e.g., recidivism, treatment utilization). Fidelity assessment includes post-session checklists and measures of TBRI strategy use. Collected four times over four years, implementation data include (1) JJ staff self-report on facility and staff characteristics, use of trauma-informed care and TBRI strategies, and (2) focus groups (line staff, leadership separately) on use of trauma-informed strategies, uptake of new interventions, and penetration, sustainment, and expansion of TBRI practices.

DISCUSSION

The LeSA study is testing TBRI as a means to empower caregivers to help prevent opioid use and other SU among JJ-youth. TBRI's multiple components offer an opportunity for caregivers to supplement and extend gains during residential care. If effective and implemented successfully, the LeSA protocol will help expand the application of TBRI with a wider audience and provide guidance for implementing multi-component interventions in complex systems spanning multiple contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04678960 ; registered November 11, 2020; https://clinicaltrials.gov/ct2/show/NCT04678960 .

Australian Maltreated Infants and Young Children Can Achieve Positive Relational Health With Neurodevelopmentally- and Trauma-Informed Interventions Provided Within Relationally-Positive and Stable Environments

Background: Childhood maltreatment such as abuse, neglect and family violence has a profound impact on children's psychological and relational functioning and their lifelong trajectory, with associated adverse physical and mental health outcomes, higher mortality rates and reduced socioeconomic opportunities. The aim of the study was to explore the impact of neurodevelopmentally- and trauma-informed interventions on the relational health of children who have experienced maltreatment. Context: The study was conducted at Berry Street Take Two, an Australian therapeutic service. Take Two provides services to Victorian children aged 0-18 years, to address the impact of the trauma they have experienced from maltreatment. Take Two clinicians use relational and ecological frameworks, neurodevelopmental research and evidence-informed approaches to repair family relationships and develop networks of caring adults that focus on meeting the child's needs. Take Two uses the NMT approach as a framework for clinical intervention-planning and is site-certified in the use of the NMT Clinical Practice tools. Method: The mixed methods study had two components. A cross sectional study of baseline and repeat clinical measure data (HoNOSCA and SDQ) with a cohort of children aged 2-11 years (n = 91), who were clients of Berry Street Take Two between 2014 and 2019, was conducted utilizing SPSS. The quantitative data analysis was supplemented by three case studies of Berry Street Take Two clients, which explored the process of intervention, including intervention type, timing and dosage. The case studies drew on the full case record for each child to illustrate the impact of NMT-informed interventions on the relational health, psychological and behavioral functioning of children. Results: The study found that Take Two intervention was associated with improved relational health, measured by the NMT metric and supported by significant positive changes on the SDQ and HoNOSCA with medium effect sizes (cohen's d). The case study analysis highlighted the importance of intervention addressing individual, family and systems elements to bring about positive change. Conclusions: This study illustrates the value of neurodevelopmental trauma-informed interventions in positively impacting on the relational health and current functioning of maltreated children and the potential to reduce the lifelong impact of maltreatment.

Adverse Childhood Experiences: The Protective and Therapeutic Potential of Nature

Adverse childhood experiences (ACEs) are prevalent in many western populations. Large studies have put the likelihood of having at least one ACE above 50% of the general population. ACEs and the associated experience of chronic stress, moreover, have been consistently linked with a variety of negative physical and psychological health outcomes across the lifespan from behavioral problems and cognitive difficulties early on, to greater chance of suffering from a mental health disorder and engaging in self destructing behaviors. The literature puts forward several protective factors, such as mother-child relations, parental health, and community engagement. In this perspective paper we put forward the potential of regular nature engagement as a possible additional protective factor. Nature's therapeutic potential has been well documented, for many psychopathologies and mental health difficulties. Yet studies looking at the protective and therapeutic potential of nature with people with ACEs are remarkably limited in numbers. In this perspective piece we conduct a search of the literature to find previous applications of nature as a protective or therapeutic intervention for people with ACEs. We highlight the gap in the current literature, and put forward various mechanisms of action that justify a closer exploration of this area in further research.

Interventions for children with reactive attachment disorder

Characterized by aggressive or violent behaviors, reactive attachment disorder (RAD) affects children who have been repeatedly exposed to traumatic experiences. This article discusses the underlying causes of RAD and provides insight on therapies and interventions.

A laboratory model for evaluating relapse of undesirable caregiver behavior

The success of behavioral treatments like functional communication training depends on their continued implementation outside of the clinical context, where failures in caregiver treatment adherence can lead to the relapse of destructive behavior. In the present study, we developed a laboratory model for evaluating the relapse of undesirable caregiver behavior that simulates two common sources of disruption (i.e., changes in context and in treatment efficacy) believed to affect caregiver treatment adherence using simulated confederate destructive behavior. In Phase 1, the caregiver's delivery of reinforcers for destructive behavior terminated confederate destructive behavior in a home-like context. In Phase 2, the caregiver implemented functional communication training in a clinical context in which providing reinforcers for destructive or alternative behavior terminated confederate destructive behavior. In Phase 3, the caregiver returned to the home-like context, and caregiver behavior produced no effect on confederate destructive or alternative behavior, simulating an inconsolable child. Undesirable caregiver behavior relapsed in three of four treatment-adherence challenges.

Association Between Trust and Mental, Social, and Physical Health Outcomes in Veterans and Active Duty Service Members With Combat-Related PTSD Symptomatology

Background: Trust represents a complex emotion and interpersonal concept which assumes abandoning control over a given situation or set of circumstances, in turn yielding such control to another party. Advances in our knowledge of post-traumatic stress disorder and moral injury have underscored the need to more closely examine how trust stands to impact health outcomes in these disorders. The aim of the present study is to examine and identify relationships linking general trust with select health outcomes in a mixed sample of Veterans and Service members with a self-reported history of deployment to a combat theater and PTSD symptomatology. Methods: This study applied a cross-sectional methodology, surveying n = 427 participants recruited across six sites. This included 373 Veterans and 54 active duty Service members in the United States. Measures included demographic characteristics, combat exposure, general trust, post-traumatic stress disorder symptomatology, depressive/anxiety symptomatology, alcohol use, social involvement, religiosity, and physical health. Data were analyzed descriptively as well as using Pearson correlations, Student's t-test, and multivariate regression. Results: Several significant relationships were identified, indicating an inverse relationship between trust and PTSD, depressive, and anxiety symptomatology. Greater levels of trust were also significantly associated with increased social interaction and religiosity. Lastly, no significant associations were identified with either physical functioning or pain level. Conclusion: The findings suggest that trust is correlated with a variety of health outcomes in Veterans and Service members affected by combat-related PTSD. Additional, hypothesis-driven research, informed by longitudinal data, is needed to better understand how trust stands to impact health outcomes, including the development of strategies and intervention options for repairing trust.

Qualitative Reflections: CASA's Trauma and Attachment Group (TAG) Program for Youth who have Experienced Early Developmental Trauma

OBJECTIVE

We demonstrated previously that the Trauma and Attachment Group (TAG) program for youth in middle childhood significantly improved caregiver/child attachment relationships, reduced children's symptoms of attachment trauma, and increased the caregiver's ability for self-reflection. Here we examine the perspectives of both those administering and those taking part in this intensive dyad-based group intervention.

METHODS

Utilizing an ethnographic design we collected and analyzed qualitative data obtained through a focus group and interviews with program facilitators, as well as interviews with participating caregivers. Data were collected from six TAG facilitators through a formal focus group interview (n=4), and informal interviews with TAG facilitators unable to attend the focus group (n=2). Four interviews were also carried out with caregivers (three females and one male). Thematic analysis of the focus group and interview transcripts was conducted.

RESULTS

Three key themes were identified in the focus group and interview data: Relationship as locus of change, Group process, and Psychoeducation-based content. That the TAG program provides psychoeducation about the effects of trauma to caregiver/child dyads in a group setting appears important in supporting the effectiveness of the program. Structured parent-child play and sensory activities together ("kit-time") were also highly valued.

CONCLUSIONS

This qualitative study suggests that establishment of a healthy and focused caregiver/child relationship may be the key mechanism to promoting change in relationships that have been challenged by adverse effects of early developmental trauma. Further evaluation may help to identify other components that contribute to the success of the program.

The CASA Trauma and Attachment Group (TAG) Program for Children who have Attachment Issues Following Early Developmental Trauma

OBJECTIVE

There is relatively little research about effective therapeutic approaches for children in middle childhood who have attachment related diagnoses as a result of experiencing significant, early developmental trauma. This study describes findings from an intensive, dyad-based intervention, aimed at stabilizing attachment relationships with primary caregivers, increasing caregiver reflective function skills, and reducing children's trauma-related behavioural sequelae.

METHOD

We analyzed retrospective data from 51 caregiver/child dyads who participated in the Trauma and Attachment Group (TAG) Program from September 2011-December 2014. This data included pre- and post-intervention scores retrieved from the Parenting Relationship Questionnaire (PRQ), the Parent Report of Post-Traumatic Stress Symptoms (PROPS), and the Parental Reflective Functioning Questionnaire (PRFQ-1).

RESULTS

The preliminary findings show statistically significant improvements in attachment, communication, discipline practices, involvement, and relational frustration. Additionally there were statistically significant improvements in parental reflective functioning, and a trend towards a reduction in symptoms typical of post-traumatic stress disorder.

CONCLUSION

Poor quality or inconsistent interactions with early caregivers can lead to life-long impairments in physical and mental health. This intensive program shows potential as a way to improve longer-term outcomes for children exposed to early developmental trauma. Longer-term research is required to further substantiate outcomes, appraise cost analysis, as well as to consider evaluation with appropriate comparison groups.

Decrease in Behavioral Problems and Trauma Symptoms Among At-Risk Adopted Children Following Web-Based Trauma-Informed Parent Training Intervention

Children who have experienced early adversities are at risk for behavioral problems and trauma symptoms. Using a two-group, pre-post intervention design, the authors evaluated the effectiveness of an online parent training for Trust-Based Relational Intervention, a trauma-informed, attachment-based intervention, in reducing behavioral problems and trauma symptoms in at-risk adopted children. Children of parents in the treatment group (n = 48) demonstrated significant decreases in behavioral problems and trauma symptoms after intervention. Scores for children in a matched-sample control group did not change. Findings suggest this intervention can effectively reduce behavioral problems and trauma symptoms in children with histories of adversities.

Decrease in Behavioral Problems and Trauma Symptoms Among At-Risk Adopted Children Following Trauma-Informed Parent Training Intervention

Children who have experienced early adversities are at risk for behavioral problems and trauma symptoms. Using a two-group, pre-post intervention design, the current study evaluated the effectiveness of a parent training utilizing Trust-Based Relational Intervention, a trauma-informed, attachment-based intervention, in reducing behavioral problems and trauma symptoms in at-risk adopted children. Children of parents in the treatment group (n = 48) demonstrated significant decreases in behavioral problems on the Strengths and Difficulties Questionnaire and significant decreases in trauma symptoms on the Trauma Symptoms Checklist for Young Children after intervention. Scores for children in a matched-sample control group did not change. Findings suggest that Trust-Based Relational Intervention is effective at addressing many behavioral problems and trauma symptoms in children with histories of adversities.