Trauma-focused cognitive behavioral therapy for children and families

The Role of Pediatric Psychologists in Critical Care: Lessons Learned and Future Directions in Integrating Mental Health Care Into PICUs

Pediatric psychologists are essential staff in the PICU. Their role in caring for critically ill children aligns with clinical practice guidelines for the mental health care needs of this population of patients. This article highlights the role of pediatric psychology in the PICU through illustrative case examples. We discuss lessons learned and future directions for the development and provision of mental health services in PICUs. We address relevant ways for critical care providers to understand the importance of evidence-based psychological care and advocate for the inclusion of psychologists on multidisciplinary PICU teams. As the critical care field continues to focus on an improved understanding of post-intensive care syndrome in pediatrics and the psychological needs of critical care patients, it will be important to consider the vital roles of psychologists and to advocate for improved integration of mental health care in PICUs.

A community-based study of the impact of trauma exposure on school-aged children's self-concept and improvements following TF-CBT

BACKGROUND

Experiencing trauma in childhood has been associated with more severe psychopathology and a greater risk of engaging in harmful behavior later in life. Traumatic exposure can also erode a child's self-concept. Negative self-concept has been associated with shame, self-doubt, and helplessness in the face of adverse experiences. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based model for children; however, research on its effectiveness in improving children's self-concept is limited.

OBJECTIVE

To investigate the impact of trauma on school-aged children's self-concept and improvements following TF-CBT.

PARTICIPANTS AND SETTING

A demographically diverse sample of trauma-exposed school-aged children referred to community-based agencies in Canada and a normative sample of school-aged children randomly selected from the general population in the United States.

METHOD

A longitudinal design was used to assess trauma-exposed children's self-reported self-concept using the short-form Tennessee Self-Concept Scale - Second Edition (TSCS:2; Fitts & Warren, 1996) prior to and following TF-CBT.

RESULTS

Trauma-exposed children had a significantly more negative mean self-concept compared to that of the normative sample. Improvements following TF-CBT - and not the passage of time alone - were found with gains maintained six months post-therapy.

CONCLUSIONS

School-aged children awaiting treatment at community-based agencies are likely to hold clinically concerning negative views of themselves. TF-CBT was effective in significantly improving their self-concept with continued and lasting improvements observed after the therapy had been completed.

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.

Attachment Theory and Sexual Offending: Making the Connection

PURPOSE OF REVIEW

The purpose of this review is to discuss how attachment theory can be applied to explain sexual violence. Specifically, it discusses how the development of certain risk factors contributes to these behaviors and how attachment-based models can be used to address this issue through prevention and therapeutic interventions.

RECENT FINDINGS

Recent research demonstrates that individuals who commit sexual offenses have higher rates of insecure attachment styles and that these styles are associated with a number of criminogenic risk factors associated with sexual offending. Such risk factors include cognitive processing difficulties, affect dysregulation, and challenges in interpersonal relationships, among others. Fortunately, treatment interventions have been shown to foster more secure attachment styles and reduce these risk factors. Attachment theory is a viable theory to both understand and intervene with those who have committed sexual violence to reduce the risk factors associated with sexual violence.

The feasibility and utility of trauma screening for children involved in the juvenile justice system

Childhood exposure to potentially traumatic events and adversity is highly prevalent and linked to adverse outcomes. Many children suffering from symptoms related to traumatic stress are not identified or do not receive appropriate trauma-focused treatment, including evidence-based treatments. Trauma screening is a promising strategy to improve identification, but many child-serving staff members have concerns about asking youth and caregivers about trauma. This study aimed to describe staff perceptions about the feasibility, utility, and potential for distress associated with trauma screening. Between 2014 and 2019, the Child Trauma Screen was used in 1,272 trauma screenings completed by juvenile probation officers or mental health clinicians as part of routine practice with youth in the juvenile justice system. Further, 1,190 caregiver reports about youth trauma were completed for youth in the juvenile justice system. Staff completed a brief postscreening survey about the feasibility and utility of the screening and the perceived level of child or caregiver distress. Across staff roles, trauma screening was deemed to be feasible and worthwhile to practice, with very few staff members reporting that children or caregivers appeared very uncomfortable as a result of screening, although some differences in feasibility and utility by staff role did occur. Trauma screening measures appear to be useful and practical in juvenile justice settings when appropriate support is provided, including when administered by nonclinical staff. Nonclinical staff may benefit from additional training, consultation, or support with trauma screening.

Comparative effectiveness of psychological interventions for treating the psychological consequences of sexual abuse in children and adolescents: a network meta-analysis

BACKGROUND

Following sexual abuse, children and young people may develop a range of psychological problems, including anxiety, depression, post-traumatic stress disorder (PTSD), and a range of behaviour problems. Those working with children and young people experiencing these problems may use one or more of a range of psychological approaches.

OBJECTIVES

To assess the relative effectiveness of psychological interventions compared to other treatments or no treatment controls, to overcome psychological consequences of sexual abuse in children and young people up to 18 years of age. Secondary objectives To rank psychotherapies according to their effectiveness. To compare different 'doses' of the same intervention.

SEARCH METHODS

In November 2022 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and two trials registers. We reviewed the reference lists of included studies, alongside other work in the field, and communicated with the authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing psychological interventions for sexually abused children and young people up to 18 years old with other treatments or no treatments. Interventions included: cognitive behavioural therapy (CBT), psychodynamic therapy, family therapy, child centred therapy (CCT), and eye movement desensitisation and reprocessing (EMDR). We included both individual and group formats.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias for our primary outcomes (psychological distress/mental health, behaviour, social functioning, relationships with family and others) and secondary outcomes (substance misuse, delinquency, resilience, carer distress and efficacy). We considered the effects of the interventions on all outcomes at post-treatment, six months follow-up and 12 months follow-up. For each outcome and time point with sufficient data, we performed random-effects network and pairwise meta-analyses to determine an overall effect estimate for each possible pair of therapies. Where meta-analysis was not possible, we report the summaries from single studies. Due to the low number of studies in each network, we did not attempt to determine the probabilities of each treatment being the most effective relative to the others for each outcome at each time point. We rated the certainty of evidence with GRADE for each outcome.

MAIN RESULTS

We included 22 studies (1478 participants) in this review. Most of the participants were female (range: 52% to 100%), and were mainly white. Limited information was provided on socioeconomic status of participants. Seventeen studies were conducted in North America, with the remaining studies conducted in the UK (N = 2), Iran (N = 1), Australia (N = 1) and Democratic Republic of Congo (N = 1). CBT was explored in 14 studies and CCT in eight studies; psychodynamic therapy, family therapy and EMDR were each explored in two studies. Management as usual (MAU) was the comparator in three studies and a waiting list was the comparator in five studies. For all outcomes, comparisons were informed by low numbers of studies (one to three per comparison), sample sizes were small (median = 52, range 11 to 229) and networks were poorly connected. Our estimates were all imprecise and uncertain. Primary outcomes At post-treatment, network meta-analysis (NMA) was possible for measures of psychological distress and behaviour, but not for social functioning. Relative to MAU, there was very low certainty evidence that CCT involving parent and child reduced PTSD (standardised mean difference (SMD) -0.87, 95% confidence intervals (CI) -1.64 to -0.10), and CBT with only the child reduced PTSD symptoms (SMD -0.96, 95% CI -1.72 to -0.20). There was no clear evidence of an effect of any therapy relative to MAU for other primary outcomes or at any other time point. Secondary outcomes Compared to MAU, there was very low certainty evidence that, at post-treatment, CBT delivered to the child and the carer might reduce parents' emotional reactions (SMD -6.95, 95% CI -10.11 to -3.80), and that CCT might reduce parents' stress. However, there is high uncertainty in these effect estimates and both comparisons were informed only by one study. There was no evidence that the other therapies improved any other secondary outcome. We attributed very low levels of confidence for all NMA and pairwise estimates for the following reasons. Reporting limitations resulted in judgements of 'unclear' to 'high' risk of bias in relation to selection, detection, performance, attrition and reporting bias; the effect estimates we derived were imprecise, and small or close to no change; our networks were underpowered due to the low number of studies informing them; and whilst studies were broadly comparable with regard to settings, the use of a manual, the training of the therapists, the duration of treatment and number of sessions offered, there was considerable variability in the age of participants and the format in which the interventions were delivered (individual or group).

AUTHORS' CONCLUSIONS

There was weak evidence that both CCT (delivered to child and carer) and CBT (delivered to the child) might reduce PTSD symptoms at post-treatment. However, the effect estimates are uncertain and imprecise. For the remaining outcomes examined, none of the estimates suggested that any of the interventions reduced symptoms compared to management as usual. Weaknesses in the evidence base include the dearth of evidence from low- and middle-income countries. Further, not all interventions have been evaluated to the same extent, and there is little evidence regarding the effectiveness of interventions for male participants or those from different ethnicities. In 18 studies, the age ranges of participants ranged from 4 to 16 years old or 5 to 17 years old. This may have influenced the way in which the interventions were delivered, received, and consequently influenced outcomes. Many of the included studies evaluated interventions that were developed by members of the research team. In others, developers were involved in monitoring the delivery of the treatment. It remains the case that evaluations conducted by independent research teams are needed to reduce the potential for investigator bias. Studies addressing these gaps would help to establish the relative effectiveness of interventions currently used with this vulnerable population.

Developing a trauma focused cognitive behavioral therapy application for adolescents with problematic sexual behaviors: A conceptual framework

Sexual abuse (SA) perpetration is a significant public health problem; SA perpetration is most likely to emerge during adolescence and youth ages 13 to 17 account for a significant portion of all child sexual abuse. While research shows that these youth have high rates of adversity, once they have engaged in problem sexual behavior (PSB), their own trauma histories are often ignored with treatment primarily focused on reducing risk for reoffending. Although sexual re-offense rates among adolescents with PSB are very low, the rates of non-sexual recidivism are considerably higher; with almost half of known youth have reoffended non-sexually, requiring development, implementation, and testing of therapeutic interventions responsive to the indicated risks and unmet needs of adolescents who have engaged in a range of problematic sexual behaviors (PSB-A) and their families. Yet, there are no empirically supported interventions designed specifically to address PSB-A with trauma histories. This article introduces how Trauma-Focused Cognitive Behavioral Therapy can be applied to PSB-A and provides implications for practice and future research.

Structural equation modeling of treatment-related changes in neural connectivity for youth with PTSD

BACKGROUND

Previous studies suggest that improvement in symptoms of posttraumatic stress disorder (PTSD) is accompanied by changes in neural connectivity, however, few studies have investigated directional (effective) connectivity. The current study assesses treatment-related changes in effective connectivity in youth with PTSD undergoing Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

METHODS

Functional MRI scans before and after 16 weeks of TF-CBT for 20 youth with PTSD, or the same time interval for 20 healthy controls (HC) were included in the analysis. Structural equation modeling was used to model group differences in directional connectivity at baseline, and changes in connectivity from pre- to post-treatment.

RESULTS

At baseline, the PTSD group, relative to the HC group, had significantly greater connectivity in the path from dorsal cingulate to anterior cingulate and from dorsal cingulate to posterior cingulate corticies. From pre- to post-treatment, connectivity in these paths decreased significantly in the PTSD group, as did connectivity from right hippocampus to left superior temporal gyrus. Connectivity from the left amygdala to the lateral orbital frontal cortex was significantly lower in PTSD vs HC at baseline, but did not change from pre- to post-treatment.

CONCLUSION

Although based on a small sample, these results converge with previous studies in suggesting a central role for the dorsal cingulate cortex in PTSD symptoms. The direction of this connectivity suggests that the dorsal cingulate is the source of modulation of anterior and posterior cingulate cortex during trauma-focused cognitive behavioral therapy.

Towards assessing subcortical "deep brain" biomarkers of PTSD with functional near-infrared spectroscopy

Assessment of brain function with functional near-infrared spectroscopy (fNIRS) is limited to the outer regions of the cortex. Previously, we demonstrated the feasibility of inferring activity in subcortical "deep brain" regions using cortical functional magnetic resonance imaging (fMRI) and fNIRS activity in healthy adults. Access to subcortical regions subserving emotion and arousal using affordable and portable fNIRS is likely to be transformative for clinical diagnostic and treatment planning. Here, we validate the feasibility of inferring activity in subcortical regions that are central to the pathophysiology of posttraumatic stress disorder (PTSD; i.e. amygdala and hippocampus) using cortical fMRI and simulated fNIRS activity in a sample of adolescents diagnosed with PTSD (N = 20, mean age = 15.3 ± 1.9 years) and age-matched healthy controls (N = 20, mean age = 14.5 ± 2.0 years) as they performed a facial expression task. We tested different prediction models, including linear regression, a multilayer perceptron neural network, and a k-nearest neighbors model. Inference of subcortical fMRI activity with cortical fMRI showed high prediction performance for the amygdala (r > 0.91) and hippocampus (r > 0.95) in both groups. Using fNIRS simulated data, relatively high prediction performance for deep brain regions was maintained in healthy controls (r > 0.79), as well as in youths with PTSD (r > 0.75). The linear regression and neural network models provided the best predictions.

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.

Child sexual abuse survivors: Differential complex multimodal treatment outcomes for pre-COVID and COVID era cohorts

BACKGROUND

Child sexual abuse (CSA) is a form of early-life trauma that affects youth worldwide. In the midst of the current COVID-19 pandemic, it is imperative to investigate the potential impact of added stress on already vulnerable populations.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a multimodal treatment program on mental health outcomes for youth CSA survivors aged 8-17. Secondary to this, we explored the potential impact of the COVID-19 on treatment outcomes.

PARTICIPANTS AND SETTING

Participants of this study were children and youth aged 8-17 who were engaged in a complex multimodal treatment program specifically designed for youth CSA survivors.

METHODS

Participants were asked to complete self-report surveys at baseline and at the end of two subsequent treatment rounds. Surveys consisted of measures pertaining to: (1) PTSD, (2) depression, (3) anxiety, (4) quality of life, and (5) self-esteem.

RESULTS

Median scores improved for all groups at all timepoints for all five domains. For the pre-Covid participants, the largest improvements in the child program were reported in depression (36.6 %, p = 0.05); in the adolescent program anxiety showed the largest improvement (-35.7 %, p = 0.006). Improvements were generally maintained or increased at the end of round two. In almost every domain, the improvements of the pre-COVID group were greater than those of the COVID-I group.

CONCLUSIONS

A complex multimodal treatment program specifically designed for youth CSA survivors has the capacity to improve a number of relevant determinants of mental health and well-being. The COVID-19 pandemic may have retraumatized participants, resulting in treatment resistance.

The impact of social support on students' mental health: A new perspective based on fine art majors

College students face a variety of challenges today, and the degree of their psychological health directly impacts their ability to overcome these challenges. A good psychological state helps college students to invest better in their career development and improve the degree of social integration. This paper uses the SCL-90 Symptom Self-Assessment Scale and the Social Support Rating Scale (SSRS) to investigate the mental health, psychological support, and social support of students from low income backgrounds in two universities in Hainan City. The research results showed that there was no significant difference between the objective support scores of students from low income backgrounds in higher vocational colleges and non-poor students, while the subjective support and utilization of support scores were significantly lower than those of non-poor students. In essence, successful social support should not only be one-dimensional support from the subject to the object, but should be a process of two-sided interaction, or a process of “mutual construction” between supporters and those supported. According to the research conclusions, this paper suggests how to improve the degree of mental health of college students by way of forming a comprehensive educational environment including campus culture construction, ideological and moral education, and economic assistance system.

Safeguarding Children Subjected to Violence in the Family: Child-Centered Risk Assessments

Assessing risk, planning for safety and security, and aiding recovery for children subjected to violence in a family setting is a complex process. The aim of the article is to synthesize the current research literature about risks for children subjected to violence in the family and outline an empirical base for a holistic and practically usable model of risk assessments placing the individual child at the center. Such assessments need to recognize four different areas of risk: (1) child safety, i.e., known risk factors for severe and dangerous violence aimed at both adults and children and how they play out in the individual case; (2) the child's response in situations with violence; (3) the child's perspective, especially fear and feelings of powerlessness in situations with violence; (4) developmental risks, e.g., instability in the child's situation and care arrangements, lack of a carer/parent as a "secure base" and "safe haven", the child developing difficulties due to the violence (e.g., PTSD), problems in parents' caring capacities in relation to a child with experiences of, and reactions to, violence, and lack of opportunities for the child to make sense of, and create meaning in relation to, experiences of violence. In addition to the four areas of risk, the article emphasizes the importance of assessing the need for immediate intervention and safety planning in the current situation as regards safety, the child's responses, the child's perspectives, and long-term developmental risks.

The relationship between youth involvement, alliance and outcome in trauma-focused cognitive behavioral therapy

OBJECTIVE

Research suggests that combining the trauma-specific elements with a strong alliance helps optimize treatment outcomes in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth. Building on this, we investigate whether more positive and less negative involvement behaviors during trauma narration are associated with a stronger alliance and predict fewer posttraumatic stress symptoms (PTSS).

METHOD

Participants were 65 youth (M age = 15.5, SD = 2.2; 77% girls) receiving TF-CBT. Both youth self-report (Child PTSD Symptom Scale and Therapeutic Alliance Scale for Children) and observer ratings (Client Involvement Rating Scale) were used, and relationships were investigated with correlations and regression analyses.

RESULTS

The positive involvement behaviors demonstration of treatment understanding and self-disclosure predicted fewer PTSS but were not associated with the alliance - while initiation of discussions and showing enthusiasm predicted more PTSS but were associated with a stronger alliance. The negative involvement behaviors passivity and avoidance did not predict PTSS but were negatively associated with the alliance.

CONCLUSION

The relationships between traumatized youths' positive and negative involvement behaviors, alliance and PTSS outcomes appear mixed. The combination of a clear understanding of why processing the trauma can be helpful, more trauma-related self-disclosure and a stronger alliance seem favorable for alleviating PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Family-Based Prevention of Child Traumatic Stress

Most children experience potentially traumatic events, and some develop significant emotional and behavioral difficulties in response. Although the field has mainly focused on treatment, a prevention framework provides an alternate approach to reducing the public health burden of trauma. Because parents and families can affect children's trauma exposure and reactions, family-based preventive interventions represent a unique opportunity to address child traumatic stress. This article discusses family-based programs that address child traumatic stress across 3 categories: preventing children's exposure to traumatic events, preventing traumatic stress reactions following exposure, and preventing negative long-term sequelae of trauma.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

Examining the effectiveness of trauma-focused cognitive behavioral therapy on children and adolescents' executive function

BACKGROUND

Children and adolescents impacted by childhood trauma often demonstrate executive function difficulties, which negatively affect self-regulation and potentiate the risk for trauma-related psychopathology and functional impairment. Evidence-based treatments for traumatized youth such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) aim to equip youth directly with skills for effective self-regulation and may thus also improve executive function. Moreover, adolescence is a sensitive period for executive function development, and interventions aimed at improving executive function may confer greater benefits for adolescents relative to school-aged children. No study has examined executive function improvements during TF-CBT or the potential differences in these outcomes between children and adolescents.

OBJECTIVE

In the current study, we examined changes in caregiver-reported executive function difficulties during TF-CBT among children ages 6 to 11 and adolescents ages 12 to 17.

PARTICIPANTS AND SETTING

Participants were 278 racially and ethnically diverse youth with interpersonal trauma histories and their caregivers enrolled in a community-based effectiveness trial of TF-CBT in an urban setting. Caregivers reported on youth executive function at pre, mid, and posttreatment assessments.

RESULTS

Both children and adolescents demonstrated reductions in global executive function difficulties during TF-CBT. Improvements were seen across domains of emotional, behavioral, and attentional control and problem solving, with larger effect sizes for adolescents. Follow-up analyses indicated that executive function improvements were positively associated with PTSD symptom reduction in adolescents, but not in children.

CONCLUSIONS

Findings add to the growing evidence of the effectiveness of TF-CBT among youth and highlight caregiver-reported executive function as a potential treatment target during TF-CBT.

Conceptual Application of Trauma-Focused Cognitive Behavioral Therapy to Treat Victims of Bullying

Bullying is a critical pediatric public health problem; estimates across diverse methodologies generally indicate that roughly 36% of youth are bullied. Although policy initiatives aim to address the universal prevention of bullying, and school-level secondary prevention programs aim to reduce the occurrence of bullying, tertiary prevention and intervention programs that mitigate the negative consequences experienced by victims of bullying remain an understudied need. The nature of bullying (that it occurs as events, leaves children feeling unsafe, and engenders emotional distress) and the association of bullying with posttraumatic stress symptoms among youth suggests that trauma treatment for bullying is promising. This manuscript presents the rationale for treating victims of bullying with trauma-focused cognitive behavioral therapy (TF-CBT), describes the components of TF-CBT, and discusses how to use TF-CBT specifically for bullying. Conducting research on treatment outcomes when using TF-CBT for bullying is critical to evaluate its efficacy and effectiveness in this group. Behavioral clinical trials would provide evidence for whether TF-CBT reduces the mental health harm experienced by youth victims of bullying. This evidence is an essential step to address the public health problem of bullying because the scientific literature currently does not have a well-established individual-level treatment for victims of bullying that mental health providers in diverse settings can deliver, despite individuals' beliefs that health care providers are important sources of help for youth who have been bullied.

Assessing and Responding to the Trauma of Child Maltreatment

Child maltreatment is a significant risk factor for severe psychiatric outcomes in childhood and contributes to problematic symptoms that direct parents, teachers, or other invested parties to seek psychiatric intervention. With ongoing workforce shortages, much of the pediatric psychiatric care to this population is delivered by generalists. Child maltreatment and trauma can critically alter a child's development trajectory, affecting potential success in school and other important life pursuits. In addition, child maltreatment and resultant traumatic stress can dramatically disrupt child and adolescent development of healthy emotional regulation, distress tolerance, and the ability to form effective interpersonal relationships. Such disruption can lead to presentations within children and adolescents that mimic other symptoms of psychopathology but that typically respond poorly to traditional psychopharmacology. Ineffective treatment trials can lead to increased risk of polypharmacy and inaccurate expectations for treatment benefits. Such treatment efforts may impede addressing important environmental contributors and delay indicated therapeutic strategies. This article seeks to review child maltreatment-including core features and prevalence, overlap of child maltreatment with adverse childhood experiences, developmental impacts of exposure and resultant traumatic stress, guidance for appropriate assessment, and evidence-based interventions-and provide basic deprescribing guidelines to reduce polypharmacy burden.

A Trauma-Informed Approach to Assessment, Case Conceptualization, and Treatment Planning for Youth Exposed to Intimate Partner Violence

Children’s exposure to intimate partner violence (IPV) is a prevalent public health problem that can result in serious mental health impairments, including traumatic stress. These can emerge early and persist across development. IPV early in life has also been described as a “gateway exposure” to other forms of adversity and trauma. Children and families impacted by IPV have complex needs that complicate assessment and intervention. This paper highlights these issues and reviews best practices in assessment, case conceptualization, and treatment planning as they pertain to the treatment of IPV-exposed children. A case vignette illustrates the complex nature of IPV and application of best practices by telling the story of Isaiah, a 13-year-old boy with an extensive history of IPV exposure and co-occurring adversity and trauma.

Childhood Trauma May Increase Risk of Psychosis and Mood Disorder in Genetically High-risk Children and Adolescents by Enhancing the Accumulation of Risk Indicators

Background

Genetically high-risk children carry indicators of brain dysfunctions that adult patients with schizophrenia or bipolar disorder display. The accumulation of risk indicators would have a higher predictive value of a later transition to psychosis or mood disorder than each individual risk indicator. Since more than 50% of adult patients report having been exposed to childhood trauma, we investigated whether exposure to trauma during childhood was associated with the early accumulation of risk indicators in youths at genetic risk.

Methods

We first inspected the characteristics of childhood trauma in 200 young offspring (51% male) born to a parent affected by DSM-IV schizophrenia, bipolar disorder, or major depressive disorder. A subsample of 109 offspring (51% male) had measurements on four risk indicators: cognitive impairments, psychotic-like experiences, nonpsychotic nonmood childhood DSM diagnoses, poor global functioning. Trauma was assessed from direct interviews and reviews of lifetime medical and school records of offspring.

Results

Trauma was present in 86 of the 200 offspring (43%). The relative risk of accumulating risk indicators in offspring exposed to trauma was 3.33 (95% CI 1.50, 7.36), but more pronounced in males (RR = 4.64, 95% CI 1.71, 12.6) than females (RR = 2.01, 95% CI 0.54, 7.58).

Conclusion

Childhood trauma would be related to the accumulation of developmental precursors of major psychiatric disorders and more so in young boys at high genetic risk. Our findings may provide leads for interventions targeting the early mechanisms underlying the established relation between childhood trauma and adult psychiatric disorders.

Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study

Background: Complex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD. Objectives: This study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth. Methods: Youth (n = 73, 89.0% girls, M age = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT. Results: Among the 73 youth, 61.6% (n = 45) fulfilled criteria for CPTSD and 38.4% (n = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions. Conclusions: This is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.

Functional near-infrared spectroscopy brain imaging predicts symptom severity in youth exposed to traumatic stress

Functional near-infrared spectroscopy (fNIRS) is a non-invasive neuroimaging technique with the potential to enable the assessment of posttraumatic stress disorder (PTSD) brain biomarkers in an affordable and portable manner. Consistent with biological models of PTSD, functional magnetic resonance imaging (fMRI) and fNIRS studies of adults with trauma exposure and PTSD symptoms suggest increased activation in the dorsolateral prefrontal cortex (dlPFC) and ventrolateral PFC (vlPFC) in response to negative emotion stimuli. We tested this theory with fNIRS assessment among youth exposed to traumatic stress and experiencing PTSD symptoms (PTSS). A portable fNIRS system collected hemodynamic responses from (N = 57) youth with PTSS when engaging in a classic emotion expression task that included fearful and neutral faces stimuli. The General Linear Model was applied to identify cortical activations associated with the facial stimuli. Subsequently, a prediction model was established via a Support Vector Regression to determine whether PTSS severity could be predicted based on fNIRS-derived cortical response measures and individual demographic information. Results were consistent with findings from adult fMRI and fNIRS studies of PTSS showing increased activation in the dlPFC and vlPFC in response to negative emotion stimuli. Subsequent prediction analysis revealed ten features (i.e., cortical responses from eight frontocortical fNIRS channels, age and sex) strongly correlated with PTSS severity (r = 0.65, p < .001). Our findings suggest the potential utility of fNIRS as a portable tool for the detection of putative PTSS brain biomarkers.

Parental Internalizing Psychopathology and PTSD in Offspring after the 2012 Earthquake in Italy

Post-traumatic stress disorder (PTSD) is common in youths after earthquakes, with parental psychopathology among the most significant predictors. This study investigated the contribution and the interactional effects of parental internalizing psychopathology, the severity of exposure to the earthquake, and past traumatic events to predict PTSD in offspring, also testing the reverse pattern. Two years after the 2012 earthquake in Italy, 843 children and adolescents (9-15 years) living in two differently affected areas were administered a questionnaire on traumatic exposure and the UCLA PTSD Reaction Index. Anxiety, depression, and somatization were assessed in 1162 parents through the SCL-90-R. General linear model showed that, for offspring in the high-impact area, predictors of PTSD were earthquake exposure, past trauma, and parental internalizing symptoms, taken individually. An interaction between earthquake exposure and parental depression or anxiety (not somatization) was also found. In the low-impact area, youth PTSD was only predicted by earthquake exposure. The reverse pattern was significant, with parental psychopathology explained by offspring PTSD. Overall, findings support the association between parental and offspring psychopathology after natural disasters, emphasizing the importance of environmental factors in this relationship. Although further research is needed, these results should be carefully considered when developing mental health interventions.

Changes in Brain Volume Associated with Trauma-Focused Cognitive Behavioral Therapy Among Youth with Posttraumatic Stress Disorder

This study investigated group differences and longitudinal changes in brain volume before and after trauma-focused cognitive behavioral therapy (TF-CBT) in 20 unmedicated youth with maltreatment-related posttraumatic stress disorder (PTSD) and 20 non-trauma-exposed healthy control (HC) participants. We collected MRI scans of brain anatomy before and after 5 months of TF-CBT or the same time interval for the HC group. FreeSurfer software was used to segment brain images into 95 cortical and subcortical volumes, which were submitted to optimal scaling regression with lasso variable selection. The resulting model of group differences at baseline included larger right medial orbital frontal and left posterior cingulate corticies and smaller right midcingulate and right precuneus corticies in the PTSD relative to the HC group, R² = .67. The model of group differences in pre- to posttreatment change included greater longitudinal changes in right rostral middle frontal, left pars triangularis, right entorhinal, and left cuneus corticies in the PTSD relative to the HC group, R² = .69. Within the PTSD group, pre- to posttreatment symptom improvement was modeled by longitudinal decreases in the left posterior cingulate cortex, R² = .45, and predicted by baseline measures of a smaller right isthmus (retrosplenial) cingulate and larger left caudate, R² = .77. In sum, treatment was associated with longitudinal changes in brain regions that support executive functioning but not those that discriminated PTSD from HC participants at baseline. Additionally, results confirm a role for the posterior/retrosplenial cingulate as a correlate of PTSD symptom improvement and predictor of treatment outcome.

Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making

BACKGROUND

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians' use of TNs. The behavioral insights literature-an interdisciplinary field studying judgment and decision-making-offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants.

METHODS

Through semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N = 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the "Easy Attractive Social Timely" framework, a behavioral insights design approach.

RESULTS

We generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation.

CONCLUSIONS

Our study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.

Relationships Between CSA Characteristics, Waiting Time, and Psychotherapy Treatment Response

Child sexual abuse (CSA) can cause negative outcomes on cognitive, emotional, physical, and social development of the victims. A significant amount of symptoms related to CSA can be minimized or even treated with professional interventions. Thereby, it is important to examine factors related to treatment response. This article aimed to identify the relationships between CSA characteristics (abuse form, age, relationship with the offender, context, and frequency), waiting time for psychotherapy, and treatment response. Zero-order correlation analysis and network analysis were performed. The analyses called the attention to two important aspects: victims' perception of guilt and waiting time for treatment. In conclusion, these results show that it is crucial to prioritize the development of guilt-related interventions on the treatment of CSA victims. Additionally, it also demonstrates that the immediate psychological care after the disclosure of the abuse can contribute for impact minimization of this experience on children and adolescents.

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.

Sociodemographic characteristics of youth in a trauma focused-cognitive behavioral therapy effectiveness trial in the city of Philadelphia

While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder, TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study-drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia-we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants' addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p > .05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.

Do caregivers' perspectives matter? Working alliances and treatment outcomes in trauma-focused cognitive behavioural therapy with children and adolescents

Background: Caregivers play a key role in the success of trauma-focused cognitive behavioural therapy (TF-CBT). Yet, the effect of their alliance on treatment outcomes besides the other parties in treatment has hardly been studied. Objective: This study examined the working alliance (WA) of therapists, patients and caregivers in TF-CBT and its contribution on treatment outcome over time. Methods: N = 76 children and adolescents (mean age = 12.66 years, range 7-17, M/F ratio: .43) participated in the TF-CBT arm of a randomized controlled trial. The WA was assessed with the Working Alliance Inventory Short Version (WAI-S) at two measurement points, while symptom level of posttraumatic stress symptoms (PTSS) was assessed with the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). Paired sample t-tests, intraclass correlations (ICC), and mixed-effects regression models for longitudinal data were performed. Results: The alliance rating was high across all informants, with caregivers achieving the highest rating. The average level of cross-informant agreement on the alliance was low between therapists and caregivers (ICC = .26) and moderate between therapists and patients (ICC =.65). A significant contribution of an alliance improvement to the reduction of PTSS over time was found in each of the two tested models: therapists with patients model (b = .682) and therapists with caregivers model (b = .807). However, these effects were not detected with all four perspectives in one comprehensive model. Conclusion: In summary, the potential of caregivers' views should receive more attention in the therapeutic process of trauma-focused therapy.

The Role of Executive Function in Predicting Children's Outcomes in a Cognitive Behavioral Treatment for Trauma-Related Nightmares and Secondary Sleep Disturbances

Predictors of children's outcomes in trauma-focused interventions are well documented. However, little is known about the role of higher-order cognitive processes, specifically executive function (EF) abilities, in determining children's responses to treatments specifically for trauma-related sleep disturbances. EF is independently related to PTSD reactions, sleep deficits, and nightmares. Furthermore, well-developed EF can be protective; thus, we sought to examine whether higher EF predicted better treatment outcomes for trauma-related sleep disturbances. Twenty-three children aged 5 to 17 presenting with post-traumatic nightmares (PTNs) participated in a cognitive behavioral therapy to address their trauma-related nightmares (CBT-NC). Pre- and post-treatment data were used in analyses. Findings from discriminant function analyses revealed that EF was not a statistically significant predictor of treatment outcomes across indices of nightmare frequency and distress, sleep quality, and PTSD symptomology. However, effect sizes suggested that EF was a moderate predictor of sleep quality outcomes, which has clinical implications. Treatment duration for sleep problems could be related to EF with briefer interventions being more suitable for children with high EF, whereas children with low EF may benefit from longer treatment protocols.

Child Sexual Abuse among a Representative Sample of Quebec High School Students: Prevalence and Association with Mental Health Problems and Health-Risk Behaviors

OBJECTIVE

The objective of this study was to estimate the prevalence of child sexual abuse in a representative sample of Quebec high school youths and document its associations with mental health problems and health-risk behaviors.

METHOD

Data were drawn from the Quebec Youths' Romantic Relationships Survey, which involved a one-stage stratified cluster sampling of 34 Quebec high schools from Grades 10 to 12. A total of 8,194 youths (mean age = 15.35) were recruited. The survey assessed child sexual abuse, mental health problems (psychological distress, post-traumatic stress symptoms, suicidality), health services utilization, and health-risk behaviors (alcohol, drug, and cannabis use). Gender-stratified multivariate analyses were used to assess associations between child sexual abuse and mental health problems and health-risk behaviors while controlling for confounding demographic variables and other forms of child maltreatment experienced in childhood.

RESULTS

A total of 14.9% of girls and 3.9% of boys reported having experienced child sexual abuse. Child sexual abuse was independently associated with an increased risk of psychological distress, greater health services utilization, and increased health-risk behaviors, after controlling for other forms of childhood maltreatment experienced.

CONCLUSIONS

Child sexual abuse is prevalent among youths in Quebec and is associated with an increased risk of a host of negative consequences. Continued efforts in the development of early detection strategies as well as prevention and intervention programs are warranted.

High-risk psychotropic medications for US children with trauma sequelae

Children exposed to trauma are predisposed to develop a number of mental health syndromes. They are prone to under-treatment with effective psychosocial interventions and over-treatment with high-risk psychotropic medications, especially polypharmacy and the use of antipsychotics for unapproved conditions. We review the evidence for psychosocial and pharmacological treatments for mental health problems associated with high exposure to childhood trauma - identifying those in foster care as an index group - and the frequency of high-risk pharmacological practices. We describe current efforts to reduce over-treatment of children with high-risk psychotropic medications and propose further recommendations to protect and provide effective care for these vulnerable children.

Longitudinal changes in brain function associated with symptom improvement in youth with PTSD

BACKGROUND

Previous studies indicate that youth with posttraumatic stress disorder (PTSD) have abnormal activation in brain regions important for emotion processing. It is unknown whether symptom improvement is accompanied by normative changes in these regions. This study identified neural changes associated with symptom improvement with the long-term goal of identifying malleable targets for interventions.

METHODS

A total of 80 functional magnetic resonance imaging (fMRI) scans were collected, including 20 adolescents with PTSD (ages 9-17) and 20 age- and sex-matched healthy control subjects, each scanned before and after a 5-month period. Trauma-focused cognitive behavioral therapy was provided to the PTSD group to ensure improvement in symptoms. Whole brain voxel-wise activation and region of interest analyses of facial expression task data were conducted to identify abnormalities in the PTSD group versus HC at baseline (BL), and neural changes correlated with symptom improvement from BL to EOS of study (EOS).

RESULTS

At BL, the PTSD group had abnormally elevated activation in the cingulate cortex, hippocampus, amygdala, and medial frontal cortex compared to HC. From BL to EOS, PTSD symptoms improved an average of 39%. Longitudinal improvement in symptoms of PTSD was associated with decreasing activation in posterior cingulate, mid-cingulate, and hippocampus, while improvement in dissociative symptoms was correlated with decreasing activation in the amygdala.

CONCLUSIONS

Abnormalities in emotion-processing brain networks in youth with PTSD normalize when symptoms improve, demonstrating neural plasticity of these regions in young patients and the importance of early intervention.

Changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress symptoms

OBJECTIVE

To understand the meaning of trauma narration, we examined changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy (TF-CBT) and explored the relationship between changes in narratives and in posttraumatic stress.

METHOD

The sample consisted of 12 non-responders and 12 maximum-responders to treatment (M = 14.3, SD = 2.35, range = 10-17; 75% girls). The youth were assessed with the Clinical-Administered PTSD-Scale for Children and Adolescents both pre- and post-treatment. Their first and last narratives were coded according to a standardized coding manual.

RESULTS

For the group as a whole there was an increase in organized thoughts and reports of internal events (e.g., descriptions of thoughts and feelings), while narrative fragmentation decreased. There were no significant narrative changes in external events (e.g., descriptions of actions and dialogues). Max-responders differed significantly from non-responders in developing more organized thoughts. We did not find a significant relationship between changes in narratives and changes in posttraumatic stress symptoms (PTSS).

CONCLUSIONS

Youth receiving TF-CBT develop narratives that contain more organized thoughts and a greater internal focus, which are both thought to be helpful for traumatized youth. However, more coherent and organized trauma narratives were not related to reductions in PTSS. Clinical or methodological significance of this article: This study suggests that trauma-focused cognitive behavioral therapy contributes to more organized and coherent trauma narratives for traumatized youth. Although, this may be important and contribute to meaning making, therapist should be aware that this may not be sufficient in reducing posttraumatic stress symptoms in youth.

The impact of polyvictimisation on children in LMICs: the case of Jamaica

Children who experience polyvictimization in high-income countries (HICs) are at higher risk for mental health-related trauma symptoms. There is limited information on the impact of polyvictimisation on children with high levels of exposure, as occurs in some low- and middle-income countries (LMICs). This study investigates the impact of poyvictimization on Jamaican children's intellectual functioning, achievement, and disruptive behaviors. Data from a geographical subgroup (n = 1171) of a 1986 population based birth cohort study were utilised.  At age 11-12 years, the sub-group completed questionnaires on exposure to violence at school, at home and in their communities, and tests of academic and intellectual functioning. Their parents completed questionnaires on family resources (socioeconomic status) and children's behaviour. Findings from Structural Equational Modelling indicated that for both genders, exposure to polyvictimisation had a direct negative effect on intellectual functioning, and an indirect negative effect on achievement mediated through intellectual functioning. For boys, polyvictimisation had a direct negative effect on behavioural risk. Family resources was negatively associated with exposure to polyvictimisation.  In Jamaica, a LMIC country with high levels of polyvictimisation, there is a significant negative effect of polyvictimisation on children. The secondary- and tertiary-level interventions to address these effects are costly to LMICs with limited financial resources. Prevention of exposure to violence in all its forms is therefore the recommended approach to reduce violence-related morbidity.