The Relevance of Cognitive Behavioral Models of Post-Traumatic Stress Following Child Maltreatment: A Systematic Review

A Longitudinal Investigation of the Relationship Between Trauma-Related Cognitive Processes and Internalising and Externalising Psychopathology in Young People in Out-of-Home Care

Young people in out-of-home care are at increased risk of developing a range of posttrauma mental health difficulties, including PTSD, but more commonly anxiety, depression and externalising symptoms. Cognitive models of PTSD indicate that trauma-related maladaptive appraisals, coping strategies and trauma memory qualities are key processes in the development and maintenance of PTSD, yet there has been limited investigation of the potential role of these processes in broader posttrauma psychopathology, particularly in young people who have been exposed to complex, rather than acute, trauma. We recruited 120 10-18 years olds in out-of-home care, and their caregivers, who completed assessments at two time points: baseline and 12-month follow-up. Young people completed self-report measures of trauma-related maladaptive appraisals, coping strategies and trauma-memory qualities, as well as reporting on PTSD, anxiety, depression and externalising symptoms. Carers also reported on internalising and externalising symptoms. We found that all three cognitive processes were associated with baseline self-reported internalising symptoms, with maladaptive appraisals most robustly associated with both anxiety and depression. Changes in all three processes over 12-months predicted a change in self-reported internalising and externalising symptoms, with maladaptive appraisals and coping predicting anxiety symptoms, and coping uniquely predicting depression and externalising symptoms. Effects remained after controlling for co-occurring PTSD symptoms. Findings were not replicated when using carer-reported symptoms. These findings suggest that existing cognitive models of PTSD may also usefully explain broader posttrauma depression, anxiety and externalising symptoms in young people who have experienced maltreatment and live in out-of-home care. Clinical implications are discussed.

Processes of Multiprofessional Child Protection Decision Making in Hospital Settings: Systematic Narrative Review

The aim of this systematic narrative literature review is to explore empirical evidence as to how a multiprofessional approach to child protection decision making is implemented in hospitals settings. Child protection cases where there is a suspicious serious injury suspected sexual abuse or serious neglect are often investigated in hospital, involving a number of relevant professions. Five electronic bibliographic databases were used for the search. To be included in the review studies had to be published in a peer-reviewed journal, report on empirical research, be available full text in English, and have used an identifiable research design. The search was restricted to 10 years, from January 1, 2010, to December 31, 2019, and retrieved 6,934 studies. The review includes 26 studies undertaken in 10 countries. In all the hospital-based settings studied, child protection decision-making tasks were assigned to a designated multiprofessional team. However, there was remarkable diversity in models of team structure, regulation of workflow, structured procedures, and standardized tools through which practice was carried out. Research focused on evaluating the teams' effectiveness in fulfilling their duties which were, first and foremost, the identification of possible child maltreatment. The analysis identifies various systemic approaches and quality improvement methods to promote effective team-based decision-making processes in hospitals. The interactional aspect of collaborative team-based practice was generally missing from the published research. This article discusses next steps for the development of practice, policy, and research to enhance useful multiprofessional child protection team working in hospitals.

Childhood maltreatment and decision-making autonomy in adulthood: The mediating roles of self-esteem and social support

BACKGROUND

Childhood maltreatment (CM) is connected with a large number of maladaptive long-term outcomes. Effective prevention and intervention hinges partly on our understanding of the key mediating mechanisms that help account for the relationship between child maltreatment and its long-term consequences. We know the consequences of CM can extend into adulthood, including the intergenerational transmission of violence, re-victimization, high-risk behavior, and persisting mental health problems. We argue that CM also likely affects decision-making autonomy in adulthood, limiting their independence and exaggerating their risk for other poor outcomes. We suggest that the effects of CM on self-esteem and access to social support mediate this relationship, helping to explain how and why CM impacts autonomy in the long term.

OBJECTIVE

This study aimed to examine these relationships using a cross-sectional sample of currently married women of Bangladesh aged 15-49 years (N = 426).

METHOD

A multi-stage random sampling technique was employed for data collection and a multivariate logistic regression technique was applied for data analysis.

RESULTS

Results from the multivariate logistic regression model revealed a direct effect of a history of CM on limited decision-making autonomy in adulthood and a full mediating effect of self-esteem and social support on the associations between CM and decision-making autonomy in women, even after adjusting for theoretically and empirically relevant covariates.

CONCLUSIONS

The study findings provide insight into the mechanisms by which early childhood experiences impact autonomous decision-making. However, causality cannot be determined because of the cross-sectional design. Finally, our findings suggest that the influence of CM on autonomy could be augmented by self-esteem recovery through social support from family, friends, and peers.

The Interplay of Depression and Hostile Attributions in the Link Between PTSD Symptoms and Peer Victimization in Child Victims of Sexual Abuse

This study sought to test a serial mediation model in which depressive symptoms and hostile attributions mediate the relationship between post-traumatic stress symptoms and peer victimization in a sample of child victims of sexual abuse. Participants included 771 children aged 6 to 12 years old, consulting specialized intervention settings following disclosure of sexual abuse. Children completed questionnaires assessing their levels of post-traumatic stress symptoms, depressive symptoms and experiences of peer victimization in the school context. Vignettes were used to assess hostile attributions for instrumental and relational provocations. Results of the path analysis revealed that post-traumatic stress symptoms were associated with depressive symptoms, which were linked to greater hostile attributions for relational provocations, which were in turn associated to a greater likelihood of reporting peer victimization. Hostile attributions for instrumental provocations were not related to peer victimization.

A longitudinal study of cognitive predictors of (complex) post-traumatic stress in young people in out-of-home care

BACKGROUND

Young people in out-of-home care are substantially more likely to meet criteria for PTSD than their peers, while their early maltreatment exposure may also place them at greater risk of developing the newly proposed complex PTSD. Yet, there remains limited empirical evidence for the mechanisms that might drive either PTSD or complex features in this group, and ongoing debate about the suitability of existing cognitive behavioural models and their related NICE-recommended treatments. In a prospective study of young people in out-of-home care, we sought to identify demographic and cognitive processes that may contribute to the maintenance of both PTSD symptom and complex features.

METHODS

We assessed 120 10- to 18-year-olds in out-of-home care and their primary carer at two assessments: an initial assessment and 12-month follow-up. Participants completed questionnaires on trauma history, PTSD symptoms and complex features, while young people only also self-reported on trauma-related (a) maladaptive appraisals, (b) memory quality and (c) coping. Social workers reported on maltreatment severity.

RESULTS

Young people's maltreatment severity was not a robust predictor of either PTSD symptoms or complex features. All three cognitive processes were moderately-to-strongly correlated with baseline and 12-month PTSD symptoms and complex features, with maladaptive appraisals the most robust unique driver of both, even when controlling for initial PTSD symptom severity.

CONCLUSIONS

Existing cognitive models of PTSD are applicable in this more complex sample of young people. The model was also found to be applicable to the additional features of complex PTSD, with the same processes driving both outcomes at both time points. Clinical implications are discussed.

Supporting the emotional needs of young people in care: a qualitative study of foster carer perspectives

OBJECTIVES

Young people who have been removed from their family home and placed in care have often experienced maltreatment and there is well-developed evidence of poor psychological outcomes. Once in care, foster carers often become the adult who provides day-to-day support, yet we know little about how they provide this support or the challenges to and facilitators of promoting better quality carer-child relationships. The aim of this study was to understand how carers support the emotional needs of the young people in their care and their views on barriers and opportunities for support.

DESIGN AND PARTICIPANTS

Participants were 21 UK foster carers, recruited from a local authority in England. They were predominantly female (86%), aged 42-65 years old and ranged from those who were relatively new to the profession (<12 months' experience) to those with over 30 years of experience as a carer. We ran three qualitative focus groups to gather in-depth information about their views on supporting their foster children's emotional well-being. Participants also completed short questionnaires about their training experiences and sense of competence.

RESULTS

Only half of the sample strongly endorsed feeling competent in managing the emotional needs of their foster children. While all had completed extensive training, especially on attachment, diagnosis-specific training for mental health problems (eg, trauma-related distress, depression) was less common. Thematic analysis showed consistent themes around the significant barriers carers faced navigating social care and mental health systems, and mixed views around the best way to support young people, particularly those with complex mental health needs and in relation to reminders of their early experiences.

CONCLUSIONS

Findings have important implications for practice and policy around carer training and support, as well as for how services support the mental health needs of young people in care.