Promotion of evidence-based practices for child traumatic stress in rural populations: identification of barriers and promising solutions

"I'm tired of being pulled from pillar to post": A qualitative analysis of barriers to mental health care for trauma-exposed young people

AIM

Traumatic experiences in childhood are pervasive and associated with a range of deleterious mental health outcomes. Despite this, trauma-exposed young people often do not seek help from mental health services. While barriers to care for general mental health concerns are well established, less is known about those specifically facing young people who have experienced trauma. The present paper sought to examine the barriers in seeking mental health care faced by trauma-exposed young people through a qualitative analysis of online forums where individuals discuss and seek informal support for trauma.

METHODS

This study used a qualitative, netnographic design, following the six-step LiLEDDa framework, developed for the analysis of online forums. Posts about trauma written in 2016 from five Internet forums targeting young people were included and analysed via thematic analysis.

RESULTS

Barriers to mental health care for trauma-exposed young people were categorized into two interrelated themes: (a) structural and (b) relational barriers. Structural barriers related to practical challenges faced when accessing and engaging with mental health services. Relational barriers focused on interpersonal relationships with mental health service providers and how these influenced experiences of, and consequent engagement with, services.

CONCLUSIONS

Trauma-exposed young people appear to experience multiple barriers to mental health care, whereby interactions between structural and relational barriers determine ongoing engagement. Service-wide reform including trauma-informed mental health training for practitioners is urgently needed to improve access to care and engagement for this vulnerable group.

Implementing Trauma-Informed Practice in Juvenile Justice Systems: What can Courts Learn from Child Welfare Interventions?

Many youth entering juvenile court systems show manifestations of psychological trauma. Focusing on rural juvenile courts, systems with greatly underserved and under-researched populations, we assessed practices, barriers, and recommendations around trauma-informed practice, an evidence-based approach for addressing trauma and reducing delinquent behavior and recidivism. As part of a pilot trauma-informed practice initiative at four rural Michigan juvenile courts, semi-structured qualitative interviews were conducted with 15 court staff, including probation officers, referees, judges, and on-site clinical therapists. Respondents expressed an ideological affinity for trauma-informed practice, describing growing inclinations to rely on referral-making around mental health treatment in lieu of traditional (punitive) sentencing. Key implementation barriers included limited access to local mental health resources, insufficient buy-in from K-12 schools, government, and police, and concerns over professional abilities/boundaries. Respondents recommended additional technical trainings on trauma-informed practice and cross-disciplinary education for clients' families and external stakeholders.

Treating PTSD in Pregnant and Postpartum Rural Women with Substance Use Disorders

The co-occurrence of posttraumatic stress disorder and substance use disorder (PTSD-SUD) can pose significant problems for rural pregnant and postpartum women (PPW) and the well-being of their children. Although effective treatments exist, PPW experience limitations in their ability to access and engage in treatment that may be compounded by various aspects of rural settings, so providers must be attentive to these barriers in order to address this pressing public health need. In addition, as part of increasing rural access to care, it is important to consider the costs and benefits to PPW of selecting exposure-based techniques (e.g., prolonged exposure) to disseminate. The current article discusses the treatment of PTSD-SUD in rural PPW in the context of the authors' experiences providing an exposure-based cognitive behavioral treatment for PTSD in this population. Barriers to treatment access and engagement are discussed and recommendations are provided.

Adults with Pedophilic Interests in the United States: Current Practices and Suggestions for Future Policy and Research

Adults with pedophilic interests are often viewed by the public as a homogenous subgroup based on what we know from those who sexually offend against children. The stigma associated with child sexual abuse may serve to deter such behaviors but may also interfere with the person's stability and willingness to seek assistance in managing pedophilic interests. This article contrasts the sex offender response and prevention efforts typically employed in the U.S. (i.e., containment, registration, and notification policies and public education programs) with treatment programs aimed at preventing child sexual abuse in Germany, Belgium, and Canada. Five major areas are identified that should be further examined with regard to implementing preventative outreach and treatment programs in the U.S.: barriers to outreach and treatment programs, how to expand or reframe current preventative educational programs, implementation of such programs in light of current mandating reporting policies, promising treatment approaches for pedophilic interests among non-offenders, and ethical concerns relevant to preventative psychological interventions.

Delivering CBT to Rural Latino Children with Anxiety Disorders: A Qualitative Study

Qualitative methods were used to understand community perspectives about ways to deliver cognitive behavior therapy (CBT) to rural Latino youth with anxiety. First, four focus groups were conducted with 28 bilingual Latino mental health providers to examine perceptions of CBT using telephone based, therapist supported bibliotherapy, and bibliotherapy without therapist support. Second, qualitative interviews were conducted with 15 Latino parents from a rural community to better understand attitudes toward CBT, and modes of service delivery. Qualitative findings revealed that parents were mostly positive about psychotherapy, and the core elements of CBT for anxiety. However, both parents and providers emphasized the need for adaptations to address practical and perceived barriers to treatment, such as time, convenience, homework, and literacy. Many parents spoke favorably of a telephone-based approach that could address many of their perceived barriers, while providers were expressed more negative views. Such findings are important for data-driven treatment development efforts.

Adverse Childhood Experiences and Health in Adulthood in a Rural Population-Based Sample

BACKGROUND

Adverse childhood experiences (ACEs), including emotional abuse, substance abuse in the household, separation or divorce, physical abuse, violence between adults, mental illness in the household, sexual abuse, or incarceration of a household member, have the potential to profoundly impact health and well-being in adulthood. To assess whether previously reported relationships between ACEs and health outcomes withstand validation, we conducted a community-based ACE study with the unique capacity to link self-reported ACEs and other survey results to validated health data in an electronic medical record (EMR).

METHODS

Information regarding ACEs and health outcomes was captured from 2013-2014 via a telephone survey of residents of the predominantly rural northern and central regions of Wisconsin and electronic abstraction of EMR data. ACE score was calculated by counting each exposure as one point. We examined the relationship between ACE score, type, and self-reported and validated health outcomes.

RESULTS

A total of 800 participants completed the telephone survey. Overall, 62% reported at least one ACE and 15% reported experiencing four or more. All self-reported measures of poor health were associated with increased ACE score. EMR data were positively correlated with ACE score for increased body mass index and diagnoses of depression, anxiety, and asthma. In contrast, diagnoses of hypertension, hypercholesterolemia, myocardial infarction, and skin and other cancers were inversely related to ACE score. Emotional abuse was the most common ACE reported followed by substance abuse in the household. ACEs tended to cluster so that people who reported at least one ACE were likely to have experienced multiple ACEs. There was no clear correlation between abuse type (e.g., direct abuse vs. household dysfunction) and health outcomes.

CONCLUSIONS

In the first community-based study to link self-reported ACEs to comprehensive health measures documented in the medical record, we observed previously reported associations between childhood adversity and poor outcomes in adulthood, but also noted an inverse relationship between ACE score and certain medical diagnoses. Potential explanations for this finding warrant further investigation.

Childhood sexual abuse: community-based treatment practices and predictors of use of evidence-based practices

BACKGROUND

Cognitive behavior therapy with abuse-focused components is empirically supported for children/adolescents who have experienced childhood sexual abuse (CSA). We examined the extent to which community-based psychologists use evidence-based practices (EBP) for CSA and identified predictors of EBP use.

METHOD

Psychologists (N = 231) providing CSA treatment services to children/adolescents in Ontario (Canada) were identified through the first census of child and adolescent psychology clinicians registered with the College of Psychologists of Ontario. Participants completed a questionnaire on treatment strategies, sociodemographics, work setting, treatment provision, and attitudes toward EBP. Data were collected between December 2009 and June 2010.

RESULTS

The majority (78%) of psychologists providing CSA services reported never having received training in specific treatment approaches for this population. Only 5% of psychologists received training in the EBP of trauma-focused cognitive behavior therapy. Multiple regressions indicated that age, theoretical orientation, continuing education, and attitudes predicted the use of an empirically based intervention for CSA.

CONCLUSION

Study findings show that few community-based psychologists have received training in specific treatment approaches for CSA victims and very few are trained to deliver EBP for this population. There are ethical concerns about the practice of psychologists who are untrained and unsupervised doing this work. Research findings, which underline the need for training, supervision, and continuing education, need to be translated into clinical practice.

Elder mistreatment and emotional symptoms among older adults in a largely rural population: the South Carolina elder mistreatment study

Although two recent major studies provide some insight into the prevalence and correlates of elder mistreatment, the relationship between elder mistreatment and mental health remains unclear. This study begins to address this issue by examining the relationship between elder mistreatment (i.e., a recent history of emotional and physical abuse) and negative emotional symptoms (e.g., anxiety and depression) among 902 older adults aged 60 and above residing in South Carolina. Results demonstrate that emotional, but not physical, abuse is significantly correlated with higher levels of emotional symptoms. This relationship is sustained when controlling for established demographic and social/dependency risk factors. These data suggest that mistreated older adults also suffer from greater emotional symptoms and highlight the need for more research in this area.

Child physical abuse and the related PTSD in Taiwan: The role of Chinese cultural background and victims' subjective reactions

OBJECTIVE

This study aimed to investigate child physical abuse (CPA) while taking into account the more rigorous definitions of CPA in the Chinese societies. The prevalence of CPA and CPA-related PTSD were estimated, together with the examination of peri-traumatic subjective reactions and their impacts on PTSD.

METHODS

In a Taiwanese sample of 1966 4th to 8th graders, the Chinese version of UCLA PTSD Reaction Index for DSM-IV (Steinberg, Brymer, Decker, & Pynoos, 2004) was used to investigate the lifetime exposure to CPA. A sub-sample of 236 traumatized CPA victims was examined with respect to related PTSD symptoms.

RESULTS

Thirty-four percent of the children had been exposed to CPA. The estimated current prevalence of full and partial PTSD was 13.6% and 16.9%, respectively.

CONCLUSIONS

The current CPA prevalence was found to be higher than the Western countries, but lower than the previous findings in other East Asian societies. The full PTSD prevalence was close to the findings in the Western countries, whereas sub-clinical PTSD was less observed in Taiwan. Peri-traumatic subjective reactions, that is, Criterion A2 and perceived threat, were shown to be major predictors of PTSD symptom severity. The role of attitudes of child discipline in the Chinese societies in the prevalence of CPA and CPA-related PTSD is discussed.

PRACTICE IMPLICATIONS

By providing explicit epidemiological information of CPA and CPA-related PTSD in Taiwan, the current study extends our understanding of CPA and CPA-related PTSD more broadly from Western countries to the Eastern societies. By separately investigating CPA relating to different perpetrators, cross-study comparison is enhanced. In the current study, the significance of considering cultural background in defining CPA and examining CPA-related PTSD was pointed out. Meanwhile, the role of victims' subjective reactions in the psychopathology of PTSD is highlighted. The findings and discussions could contribute for generating a more sophisticated clinical practice, especially with Asian or Chinese cases.

Implementing trauma-focused CBT with fidelity and flexibility: a family case study

Effective approaches for the treatment of childhood posttraumatic stress disorder and traumatic grief are needed given the prevalence of trauma and its impact on children's lives. To effectively treat posttraumatic stress disorder in children, evidence-based practices should be implemented with flexibility and responsiveness to culture, developmental level, and the specific needs of the family. This case study illustrates flexibility with fidelity in the use of a manualized treatment, describing the implementation of Trauma Focused-Cognitive Behavior Therapy with three traumatized family members-a caregiver and two children. Particular attention is paid to the use of creative strategies to tailor interventions to the individual clients while maintaining fidelity to the principles and components of this evidence-based treatment.