Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

Examining the Feasibility of Telehealth Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) with Young People in Foster Care

Purpose: Despite the high rate of trauma exposure among young people with child welfare involvement, various systematic and patient barriers exist that inhibit utilization of evidence-based trauma treatments. One strategy for alleviating barriers to such treatments is using telehealth. A few studies have found that the clinical outcomes of telehealth TF-CBT are comparable to those found from clinic-based, in-person treatment administration. Studies have yet to examine the feasibility of telehealth TF-CBT with young people in care. The current study sought to address this gap by examining outcomes for patients who received telehealth TF-CBT, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care. Methods: Patient data were collected retrospectively from the electronic health records of 46 patients who received telehealth TF-CBT between March 2020 and April 2021, and feedback was sought via focus group from 7 of the clinic's mental health providers. A paired-sample t-test was conducted to evaluate the impact of the intervention for the 14 patients who completed treatment. Results: Responses from the Child and Adolescent Trauma Screen showed a significant decrease in posttraumatic stress symptoms when comparing pre-treatment scores (M = 25.64, SD = 7.85) to post-treatment scores (13.57, SD = 5.30), t(13) = 7.50, p < .001. The mean decrease in scores was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Themes emerging from the focus group centered on home environment, caregiver participation, and systemic topics. Conclusions: Findings suggest that telehealth TF-CBT with young people in care is feasible but relatively low completion rates suggest that barriers to treatment completion remain.

Successes, challenges, and opportunities in providing evidence-based teletherapy to children who have experienced trauma as a response to Covid-19: A national survey of clinicians

While teletherapy is not a new phenomenon, most clinicians have not been trained and do not routinely practice it. The current study was designed to ascertain challenges and opportunities presented by the widescale usage of teletherapy especially for traumatized children, which was necessitated by the COVID-19 pandemic. Two hundred and fifty clinicians across the United States providing teletherapy to traumatized children completed an online survey. Results revealed that many logistical aspects of treatment were perceived to be easier when implemented remotely. Some clinical aspects of care were also perceived to be easier, notably engagement with caregivers. Developing rapport, assessing emotions, and keeping children's attention, however, were perceived as more challenging. Child characteristics such as age, attention span, and screen fatigue were viewed as creating challenges. Most clinicians had not received training in relevant topics for teletherapy and were eager to receive such training. These results suggest many avenues for refining and fine-tuning remote mental health services especially for children.

Comparing Trauma Treatment Outcomes Between Homeless and Housed Veterans in a VA PTSD Clinical Program

Homeless veterans are likely to experience Post Traumatic Stress Disorder (PTSD). Homelessness itself is traumatic, and PTSD may exacerbate homelessness risk for veterans. Often, PTSD goes untreated in this subpopulation of veterans. Our study examined trauma-focused treatment (TFT) and non-TFT initiation and completion in a sample of housed and homeless veterans being served by a PTSD clinical team in Washington, DC. Findings included a high percentage of veterans who experienced homelessness in the sample and lower treatment completion rates among homeless veterans compared to housed veterans. This difference was no longer significant when comparing only those veterans who engaged in treatment, reinforcing the critical role of treatment engagement in successful treatment completion across populations.

Perspectives of underweight people with eating disorders on receiving Imagery Rescripting trauma treatment: a qualitative study of their experiences

BACKGROUND

The prognosis for underweight individuals with an eating disorder (ED) and posttraumatic stress disorder (PTSD) is worse than for their peers without these comorbid symptoms. This qualitative study explores the experiences of trauma-focused Imagery Rescripting (ImRs) therapy of underweight inpatients being treated for an ED.

OBJECTIVE

To test the feasibility and to improve ImRs by understanding the experiences and perspectives of people with an ED and PTSD who, when underweight, received ImRs as an adjunct to their inpatient ED treatment.

METHOD

To explore how underweight people with an ED experience and perceive ImRs, we used a qualitative study design involving semi-structured interviews with 12 participants. After analysis, the data were summarized and classified within a thematic framework that focused on experiences and improving the ImRs method.

RESULTS

The thematic analysis resulted in the following 6 main themes; (1) Expectations of ImRs; (2) Ability to participate in ImRs; (3) Effect of ImRs; (4) Experience of ImRs technique; (5) Conditions under which ImRs is given; (6) In depth-analysis. The results show that despite the fear of disappointment the participants appreciate addressing the PTSD and ED symptoms simultaneously. Further, results showed that it had been possible for them to attend ImRs but that the effects of ImRs were not uniformly perceived. Also, participants indicated that a caring context is important and that ImRs should not be scheduled immediately before a meal. Finally, the treatment generated hope.

CONCLUSIONS

The findings of this study demonstrated the feasibility of the integration of ImRs trauma treatment for individuals who are being treated in an ED inpatient treatment setting, and are in contrast to standard practice where the focus of inpatient treatment has been ED-symptom improvement without comprehensively addressing past traumatic experiences during an underweight phase. Trial registration International Clinical Trials Registry Platform (ICTRP) (NTR6094). Date of registration 09/23/2016. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6094.

Interpersonal Psychotherapy of Posttraumatic Stress Disorder for Veterans and Family Members: An Open Trial

OBJECTIVE

Military service members and veterans have high rates of posttraumatic stress disorder (PTSD), as do military family members. Exposure-based, cognitive-behavioral approaches have received ample research, but other PTSD therapies require further empirical attention. Interpersonal psychotherapy (IPT) targets affective awareness, life circumstances, and social support. IPT has shown efficacy for civilians with PTSD but awaits rigorous testing among military personnel; only two small military pilot studies and two case reports have been published. Military family members have received minimal attention from clinical outcomes research. Addressing these gaps, this open trial examined IPT for PTSD among veterans, service members, and family members, including a patient subset with comorbid PTSD and depression.

METHODS

Fifty U.S. military service members, veterans, and family members (age ≥18 years) were offered 14 sessions of IPT for PTSD. Individuals with psychosis, bipolar disorder, moderate or severe substance use disorders, or high suicide risk were excluded. PTSD and depressive symptoms were assessed at baseline, midtreatment, posttreatment, and 3-month follow-up.

RESULTS

Clinician-assessed PTSD (Clinician-Administered PTSD Scale) and depression (Hamilton Depression Rating Scale) symptoms decreased over time in the full sample and the comorbid PTSD/depression subset (p<0.05). Service members, veterans, and family members had similar treatment responses.

CONCLUSIONS

Patients receiving IPT showed reductions in PTSD and depressive symptoms. These open trial findings provide preliminary support for the utility of IPT in reducing PTSD symptoms among veterans and family members. This largest IPT trial to date for PTSD in military patients also bolsters the literature on treating military family members.

[The position of the head during treatment in the emergency room-an explorative analysis of immobilization of the cervical spine]

BACKGROUND

Immobilization of the cervical spine is a standard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests.

METHODS

In the present study biomechanical motion data of the cervical spine of a test subject were analyzed. The test subject was placed in a supine position on a mobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing a cervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out a predetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, a motion score was calculated that can represent the motion of the cervical spine.

RESULTS

When the test subject's head was positioned on a standard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination.

CONCLUSION

The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with a cervical collar and a head rest. The application of a cervical collar and the positioning on the concave pillow may achieve a good immobilization of the cervical spine in trauma patients in the early trauma phase.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and Adolescents

Traumatic experiences and sleep disturbances are both common in children and adolescents. Because of the reciprocal relationship between sleep complaints and trauma, a mental health evaluation should include not only an assessment of posttraumatic stress disorder and other trauma symptoms but also a specific evaluation of sleep-related complaints. Similarly, if a history of both trauma and sleep complaints is identified, an effective trauma-informed intervention, whether psychological, psychopharmacologic, or a combination of the two, should directly address sleep issues.

Telemental health for child trauma treatment during and post-COVID-19: Limitations and considerations

The ongoing COVID-19 pandemic has led to unprecedented disruptions and stress in the lives of children and families internationally. Heightened family stress and turmoil can increase risk for, and exacerbate, child maltreatment. As a result, child maltreatment experts are concerned that there will be an influx of children requiring trauma assessment and treatment during and after COVID-19. As physical distancing measures have been implemented and will likely persist into 2021, organizations providing trauma treatment to children and their families have had to rapidly pivot to telemental health to maintain service delivery with clients. While the benefits of telemental health have been identified, including reduced barriers to access, increased cost effectiveness, and broad availability of services, there are unique limitations to its implementation within a child maltreatment population, such as challenges with attention and emotion regulation skills, difficulties identifying dissociative symptoms, and increased time with perpetrators of abuse due to shelter in place orders. These limitations are exacerbated for children and families who are most marginalized and facing the highest levels of social and economic barriers. Lack of access to reliable technology, lack of a private or confidential space for sessions, and reluctance to process trauma in the absence of a safe environment, are all barriers to conducting effective trauma treatment over telemental health. This article discusses both the benefits and barriers to telemental health in a child maltreatment population and offers considerations for child trauma service provision, program development, and policy during and post the COVID-19 pandemic.

Functional reorganization of neural networks involved in emotion regulation following trauma therapy for complex trauma disorders

Objectives

We investigated whether patients with complex interpersonal trauma engage neural networks that are commonly activated during cognitive reappraisal and responding naturally to affect-laden images. In this naturalistic study, we examined whether trauma treatment not only reduces symptoms but also changes neural networks involved in emotional control.

Methods

Before and after eight weeks of phase-oriented inpatient trauma treatment, patients (n = 28) with complex posttraumatic stress disorder (cPTSD) and complex dissociative disorders (CDD) performed a cognitive reappraisal task while electroencephalography (EEG) was registered. Patients were measured as a prototypical dissociative part that aims to fulfill daily life goals while avoiding traumatic memories and associated dissociative parts. Matched healthy controls (n = 38) were measured twice as well. We examined task-related functional connectivity and assessed self-reports of clinical symptoms and emotion regulation skills.

Results

Prior to treatment and compared to controls, patients showed hypoconnectivity within neural networks involved in emotional downregulation while reappraising affect-eliciting pictures as well as viewing neutral and affect-eliciting pictures. Following treatment, connectivity became normalized in these networks comprising regions associated with cognitive control and memory. Additionally, patients showed a treatment-related reduction of negative but not of positive dissociative symptoms.

Conclusions

This is the first study demonstrating that trauma-focused treatment was associated with favorable changes in neural networks involved in emotional control. Emotional overregulation manifesting as negative dissociative symptoms was reduced but not emotional underregulation, manifesting as positive dissociative symptoms.

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Trauma-focused treatment normalized networks involved in emotion regulation.

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Post-treatment patients showed a reduction in clinical symptoms.

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Negative but not positive dissociative symptoms declined across treatment.

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Extensive therapy is warranted to overcome complex interpersonal traumatization.

Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol

BACKGROUND

Alignment across levels of leadership within an organization is needed for successful implementation of evidence-based practice. The leadership and organizational change for implementation (LOCI) intervention is a multi-faceted multilevel implementation strategy focusing on enhancing first-level general and implementation leadership while also engaging with organization upper management to develop an organizational climate for implementation. The aim of the project is to evaluate the effectiveness of LOCI in supporting the implementation of evidence-based treatment for PTSD in child- and adult-specialized mental health clinics in health trusts in Norway.

METHODS

The study design is a stepped-wedge cluster randomized trial with enrollment of clinics in three cohorts. Executives, clinic leaders, and therapists will be asked to complete surveys assessing leadership and implementation climate. Surveys will be completed at baseline, 4, 8, 12, 16, and 20 months. Results from surveys will be shared with executives and clinic leaders to inform the subsequent creation of tailored leadership and climate development plans for enhanced implementation. Patients will complete surveys measuring traumatic events and post-traumatic stress symptoms during the therapy process. Therapy sessions will be audio or video recorded and scored for fidelity as part of training.

DISCUSSION

This study aims to provide knowledge on how to improve leadership and organizational climate to enhance effective implementation of evidence-based treatments in mental health services.

TRIAL REGISTRATION

The study has been registrated in ClinicalTrials with ID NCT03719651 .

Addressing the Needs of Children and Youth in the Context of War and Terrorism: the Technological Frontier

This paper reviews recent literature on the mental health needs of youth in the context of war and terrorism. A human rights lens is used to explore issues of accessibility and sustainability in service utilization during times of crisis. The authors present the evolution of services over the last several decades, progressing through individual, school-based, and community-wide interventions by exploring models that focus on symptom reduction and building resilience. This paper highlights the benefits and limitations of traditional intervention methods and proposes a new frontier of intervention development and research. The authors focus on the emerging field of e-mental health services and specifically highlight the utility of virtual reality games in treating trauma-exposed youth. The rapid and easily accessible nature of e-mental health models is presented as one potential solution to barriers in accessibility that can help promote the human rights of youth exposed to war and terrorism.

Relationships among emotion regulation and symptoms during trauma-focused CBT for school-aged children

This study examined improvement in emotion regulation throughout Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) and the degree to which improvement in emotion regulation predicted improvement in symptoms. Traumatized children, 7-12 years (69.9% female), received TF-CBT. Data from 4 time periods were used: pre-assessment (n=107), pre-treatment (n=78), post-treatment (n=58), and 6-month follow-up (n=44). Questionnaires measured emotion regulation in the form of inhibition and dysregulation (Children's Emotion Management Scales) and lability/negativity and emotion regulation skill (Emotion Regulation Checklist), as well as child-reported (Trauma Symptom Checklist for Children) and parent-reported (Trauma Symptom Checklist for Young Children) posttraumatic stress, and internalizing and externalizing problems (Child Behaviuor Checklist). To the extent that children's dysregulation and lability/negativity improved, their parents reported fewer symptoms following therapy. Improvements in inhibition best predicted improvements in child-reported posttraumatic stress (PTS) during clinical services, but change in dysregulation and lability/negativity best predicted improvement in child-reported PTS symptoms at 6-month follow-up. Moreover, statistically significant improvements of small effect size were found following therapy, for inhibition, dysregulation, and lability/negativity, but not emotion regulation skill. These findings suggest that emotion regulation is a worthy target of intervention and that improvements in emotion regulation can be made. Suggestions for future research are discussed.

The change and the mediating role of parental emotional reactions and depression in the treatment of traumatized youth: results from a randomized controlled study

BACKGROUND

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been shown to efficiently treat children and youth exposed to traumatizing events. However, few studies have looked into mechanisms that may distinguish this treatment from other treatments. The objective of this study was to investigate whether the parents' emotional reactions and depressive symptoms change over the course of therapy in the treatment conditions of TF-CBT and Therapy as Usual (TAU), and whether changes in the reactions mediate the difference between the treatment conditions on child post-traumatic stress (PTS) symptoms and child depressive symptoms.

METHOD

A sample of 135 caregivers of 135 traumatized children and youth (M age = 14.8, SD = 2.2, 80% girls) was randomly assigned to receive either TF-CBT or TAU. The parents' emotional reactions were measured using the Parental Emotional Reaction Questionnaire (PERQ), and their depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). The children's outcomes were post-traumatic stress (PTS) reactions and depression, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) and Mood and Feelings Questionnaire (MFQ), respectively.

RESULTS

The parents' emotional reactions and depressive symptoms decreased significantly from pre- to post-therapy, but no significant differences between the two treatment conditions were found. The changes in reactions did not significantly mediate the treatment difference between TF-CBT and TAU on child PTS symptoms. However a mediating effect was found on child depressive symptoms.

CONCLUSION

The results showed that although the parents experienced reductions in emotional reactions and depressive symptoms when their child received therapy, this was only significantly related to the difference in outcome between TF-CBT and TAU on child depressive symptoms. Possible explanations for these results are discussed along with the implications for clinicians and suggestions for future research.

CLINICAL TRIALS IDENTIFIER

NCT00635752.