Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them.

OBJECTIVE: Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking. METHOD: The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis. RESULTS: Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses. CONCLUSION: Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Improving the content validity of the Trauma and Adverse Childhood Experiences Survey (TRACES) and the Child and Adolescent PTSD Checklist for DSM-5 (CAPC-5): A collaborative research methodological approach.

OBJECTIVE: The current study aimed to improve the content validity of the Trauma and Adverse Childhood Experiences Survey (TRACES) and the Child and Adolescent PTSD Checklist for the DSM-5 (CAPC-5). METHOD: Two community-based collaborative research methods were used-cognitive interviewing and focus groups. Three rounds of cognitive interviews included a racially and economically diverse sample of 12 trauma-exposed youth and 12 caregivers. Three focus groups involved 19 clinicians with diverse disciplines and years of practice. Modifications to the measures were made after each round of interviews and after completion of all focus groups. RESULTS: Both methods provided beneficial information about issues with the measures. Feedback from youth, caregivers, and clinicians was distinct, though data across groups generally converged. Improvements were made to the measures in multiple areas, such as instructions and clarity. CONCLUSIONS: Incorporating feedback from multiple stakeholders increased the content validity of the TRACES and CAPC-5. Collaborative research methods provide a trauma-informed initial step in the development of assessment measures. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

All adverse childhood experiences are not equal: The contribution of synergy to adverse childhood experience scores.

The operationalization of childhood trauma and adversity into checklists commonly known as adverse childhood experiences, or ACEs, has become the most widely adopted methodology linking traumatic childhoods to adult outcomes. As the number of self-reported ACEs increase from 0 to 4 or more (4+), most studies find a roughly stepwise progression in risk for a wide range of negative medical and mental health outcomes. A score of 4+ ACEs, has become a de facto cutpoint, increasingly used clinically to define "high risk" status for a myriad of outcomes. Comparisons across studies using a 4+ cutpoint, however, find considerable heterogeneity in the degree of risk for the same outcomes. In addition to sample and methodological differences, certain pairs of ACEs comprising the cumulative ACE score interact synergistically to significantly increase the overall risk beyond the sum (or product) of the contributions of each ACE to the outcome. This article reviews the empirical literature on synergistic ACEs including results from a general population adult and a mixed trauma, youth sample both sufficiently powered to examine over 20 different ACE pairings for possible synergy. Synergistic pairs of ACEs vary by gender and age group. About 30-40% of the variance in outcomes is accounted for by additive synergistic interactions between certain pairs of ACEs. Across studies, sexual abuse is the most synergistically reactive ACE. The article concludes with a discussion of the implications of synergistic ACE pairings for psychologists and other allied professionals across clinical practice, prevention, research, and policy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Synergistic adversities and behavioral problems in traumatized children and adolescents.

OBJECTIVE: This study investigated synergy of commonly co-occurring pairs of childhood traumas/adversities to determine: 1) if synergistic pairings differ by gender and/or age grouping; and 2) if some traumas/adversities were more synergistically reactive. METHODS: A sample of 10,355 clinic-referred youth (1.5-18 years) from the National Child Traumatic Stress Network Core Data Set was divided by gender and categorized into salient age groups (1.5-5 years, 6-12 years, and 13-18 years). Attributable Proportion (AP), a biomedically relevant metric, was calculated to assess additive synergy for behavior problems on the CBCL. RESULTS: Overall, only four pairs of adversities were synergistic. Three involved sexual abuse with physical abuse, parental loss, and domestic violence. When the sample was analyzed by Gender X Age group, however, a more complicated picture emerges. Twelve of the twenty-one possible pairings (57 %) show additive synergy in one or more categories. The mean AP accounted for approximately 40 % of outcome variance. Males had more synergistic pairings (16) than females (7). The average synergistic effect was higher for males (42 % of variance) than females (36 % of variance). The vast majority of synergy occurs in the 6-12 and 13-18 age groups. Sexual abuse was the most synergistically reactive trauma, pairing most frequently (16) followed by physical abuse (10) or neglect (9). CONCLUSION: Sexual abuse was malignantly synergistic, frequently pairing with other adversities, followed by physical abuse, neglect, and domestic violence. The findings underscore that all ACEs are not equal in their contributions to commonly assessed outcomes. The findings also have considerable implications for prevention, intervention, and future research.

Improving the implementation and sustainment of evidence-based practices in community mental health organizations: a study protocol for a matched-pair cluster randomized pilot study of the Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS).

BACKGROUND: Implementing and sustaining evidence-based programs with fidelity may require multiple implementation strategies tailored to address multi-level, context-specific barriers and facilitators. Ideally, selecting and tailoring implementation strategies should be guided by theory, evidence, and input from relevant stakeholders; however, methods to guide the selection and tailoring of strategies are not well-developed. There is a need for more rigorous methods for assessing and prioritizing implementation determinants (barriers and facilitators) and linking implementation strategies to determinants. The Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS) is an intervention designed to increase the effectiveness of evidence-based practice implementation and sustainment. COAST-IS will enable organizational leaders and clinicians to use Intervention Mapping to select and tailor implementation strategies to address their site-specific needs. Intervention Mapping is a multi-step process that incorporates theory, evidence, and stakeholder perspectives to ensure that implementation strategies effectively address key determinants of change. METHODS: COAST-IS will be piloted with community mental health organizations that are working to address the needs of children and youth who experience trauma-related emotional or behavioral difficulties by engaging in a learning collaborative to implement an evidence-based psychosocial intervention (trauma-focused cognitive behavioral therapy). Organizations will be matched and then randomized to participate in the learning collaborative only (control) or to receive additional support through COAST-IS. The primary aims of this study are to (1) assess the acceptability, appropriateness, feasibility, and perceived utility of COAST-IS; (2) evaluate the organizational stakeholders' fidelity to the core elements of COAST-IS; and (3) demonstrate the feasibility of testing COAST-IS in a larger effectiveness trial. DISCUSSION: COAST-IS is a systematic method that integrates theory, evidence, and stakeholder perspectives to improve the effectiveness and precision of implementation strategies. If effective, COAST-IS has the potential to improve the implementation and sustainment of a wide range of evidence-based practices in mental health and other sectors. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT03799432) on January 10, 2019 (last updated August 5, 2019).

Determinants of Implementing Evidence-Based Trauma-Focused Interventions for Children and Youth: A Systematic Review.

A systematic review was conducted to identify determinants (barriers and facilitators) of implementing evidence-based psychosocial interventions for children and youth who experience emotional or behavioral difficulties due to trauma exposure. Determinants were coded, abstracted, and synthesized using the Exploration, Preparation, Implementation, and Sustainment framework. Twenty-three articles were included, all of which examined implementation of Trauma-Focused Cognitive Behavioral Therapy or Cognitive-Behavioral Intervention for Trauma in Schools. This review identified multilevel and multiphase determinants that can be addressed by implementation strategies to improve implementation and clinical outcomes, and suggests how future studies might address gaps in the evidence base.

Mental Health of Children of Deployed and Nondeployed US Military Service Members: The Millennium Cohort Family Study.

OBJECTIVE: Families experience multiple stressors as a result of military service. The purpose of this study was to investigate the associations among service member deployment experiences, family and military factors, and children's mental health using baseline data from the Millennium Cohort Family Study, a study designed to evaluate the health and mental health effects of military service on families, including children. METHOD: This study examined administrative data on deployment status (combat, noncombat, and no deployments), as well as service member- and spouse-reported data on deployment experiences and family functioning in relation to the mental health of children in the family who were aged 9 to 17 years. RESULTS: Most children were not reported to have mental health, emotional, or behavioral difficulties regardless of parental deployment status. For an important minority of children, however, parental deployments with combat, compared with those with no deployment, were associated with a parental report of attention-deficit disorder/attention-deficit hyperactivity disorder and depression as diagnosed by a clinical provider, after accounting for demographics, psychosocial context, and military factors. Children's odds of a parental report of depression were significantly higher in both the combat and the noncombat deployment groups than in the no deployment group. CONCLUSION: These findings extend our understanding of the association between parental deployments and children's mental health, with implications for services and training mental health providers serving military families.

Pilot to policy: statewide dissemination and implementation of evidence-based treatment for traumatized youth.

BACKGROUND: A model for statewide dissemination of evidence-based treatment (EBT) for traumatized youth was piloted and taken to scale across North Carolina (NC). This article describes the implementation platform developed, piloted, and evaluated by the NC Child Treatment Program to train agency providers in Trauma-Focused Cognitive Behavioral Therapy using the National Center for Child Traumatic Stress Learning Collaborative (LC) Model on Adoption & Implementation of EBTs. This type of LC incorporates adult learning principles to enhance clinical skills development as part of training and many key implementation science strategies while working with agencies and clinicians to implement and sustain the new practice. METHODS: Clinicians (n = 124) from northeastern NC were enrolled in one of two TF-CBT LCs that lasted 12 months each. During the LC clinicians were expected to take at least two clients through TF-CBT treatment with fidelity and outcomes monitoring by trainers who offered consultation by phone and during trainings. Participating clinicians initiated treatment with 281 clients. The relationship of clinician and client characteristics to treatment fidelity and outcomes was examined using hierarchical linear regression. RESULTS: One hundred eleven clinicians completed general training on trauma assessment batteries and TF-CBT. Sixty-five clinicians met all mastery and fidelity requirements to meet roster criteria. One hundred fifty-six (55%) clients had fidelity-monitored assessment and TF-CBT. Child externalizing, internalizing, and post-traumatic stress symptoms, as well as parent distress levels, decreased significantly with treatment fidelity moderating child PTSD outcomes. Since this pilot, 11 additional cohorts of TF-CBT providers have been trained to these roster criteria. CONCLUSION: Scaling up or outcomes-oriented implementation appears best accomplished when training incorporates: 1) practice-based learning, 2) fidelity coaching, 3) clinical assessment and outcomes-oriented treatment, 4) organizational skill-building to address barriers for agencies, and 5) linking clients to trained clinicians via an online provider roster. Demonstrating clinician performance and client outcomes in this pilot and subsequent cohorts led to legislative support for dissemination of a service array of EBTs by the NC Child Treatment Program.

Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment.

Children who have suffered early abuse or neglect may later present with significant health and behavior problems that may persist long after the abusive or neglectful environment has been remediated. Neurobiological research suggests that early maltreatment may result in an altered psychological and physiologic response to stressful stimuli, a response that deleteriously affects the child's subsequent development. Pediatricians can assist caregivers by helping them recognize the abused or neglected child's emotional and behavioral responses associated with child maltreatment and guide them in the use of positive parenting strategies, referring the children and families to evidence-based therapeutic treatment and mobilizing available community resources.

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events.

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind-body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind-body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.

Using the core curriculum on childhood trauma to strengthen clinical knowledge in evidence-based practitioners.

The high prevalence of trauma exposure in mental health service-seeking populations, combined with advances in evidence-based practice, competency-based training, common-elements research, and adult learning make this an opportune time to train the mental health workforce in trauma competencies. The Core Curriculum on Childhood Trauma (CCCT) utilizes a five-tiered conceptual framework (comprising Empirical Evidence, Core Trauma Concepts, Intervention Objectives, Practice Elements, and Skills), coupled with problem-based learning, to build foundational trauma knowledge and clinical reasoning skills. We present findings from three studies: Study 1 found that social work graduate students' participation in a CCCT course (N = 1,031) was linked to significant pre-post increases in self-reported confidence in applying core trauma concepts to their clinical work. Study 2 found significant pre-post increases in self-reported conceptual readiness (N = 576) and field readiness (N = 303) among social work graduate students participating in a "Gold Standard Plus" educational model that integrated classroom instruction in core trauma concepts, training in evidence-based trauma treatment (EBTT), and implementation of that EBTT in a supervised field placement. Students ranked the core concepts course as an equivalent or greater contributor to field readiness compared to standard EBTT training. Study 3 used qualitative methods to "distill" common elements (35 intervention objectives, 59 practice elements) from 26 manualized trauma interventions. The CCCT is a promising tool for educating "next-generation" evidence-based practitioners who possess competencies needed to implement modularized, individually tailored trauma interventions by strengthening clinical knowledge, clinical reasoning, and familiarity with common elements.

Predictors of treatment completion in a sample of youth who have experienced physical or sexual trauma.

Despite significant advances in knowledge and availability of evidence-based models for child traumatic stress, many children simply do not complete treatment. There remain notable gaps in the services research literature about treatment completion among youth, particularly those who have experienced trauma and related sequelae. This study investigated the linkages among child physical and sexual trauma, posttraumatic stress disorder (PTSD) symptomatology, and treatment completion utilizing a clinical sample drawn from a large database from community treatment centers across the United States specializing in childhood trauma. Results from regression analyses indicated that neither the experience of sexual nor physical trauma directly predicted successful treatment completion. The links between sexual trauma and treatment completion, however, were mediated by PTSD avoidance symptoms. Children and youth experiencing sexual trauma reported higher levels of avoidance symptoms that were, in turn, significantly associated with a lower likelihood of completing trauma-focused mental health treatment. Practice implications are discussed and include strategies for clinicians to intervene during pivotal points of treatment to improve rates of service utilization and treatment completion.

Behavioral markers of coping and psychiatric symptoms among sexually abused children.

The current study examined coping and psychiatric symptoms in a longitudinal sample of sexually abused children. Coping was behaviorally coded from children's forensic interviews in the aftermath of sexual abuse. Using principal components analysis, coping behaviors were found to cluster into 3 categories: avoidant, expressive, and positive affective coping. Avoidant coping had predictive utility for a range of psychiatric symptoms, including depressive, posttraumatic stress, anxiety, and dissociative symptoms as well as aggression and attention problems measured 8-36 months following the forensic interview. Specific behaviors, namely fidgetiness and distractibility, were also found to be associated with future symptoms. These findings suggest the predictive utility of avoidant behaviors in general, and fidgetiness and distractibility in particular, among sexually abused children.

Use of the breakthrough series collaborative to support broad and sustained use of evidence-based trauma treatment for children in community practice settings.

Empirically supported treatments for posttraumatic stress reactions in children are not widely available. This observational study evaluates the feasibility and utility of adapting the Institute for Healthcare's Breakthrough Series Collaborative (BSC) to support the broad implementation and sustained use of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in community practice settings. Study findings indicated that agency staff in diverse roles viewed the BSC methodology as a valuable and practicable approach for facilitating skillful delivery of TF-CBT with fidelity. Use of TF-CBT increased over the course of the collaborative and findings from a survey conducted one year later indicated that participating agencies were able to sustain and spread the practice.

Back to school: review of school based interventions: comment on Rolfsness and Idsoe (2011).

We comment on a recently published article in the Journal of Traumatic Stress that reviewed school-based interventions related to trauma. We point out the recent book published by Guilford Press on the International Society for Traumatic Stress Studies Practice Guildelines (2009), which also provides a thorough review of this literature, and discuss reasons why this review may have been missed.

Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: a randomized clinical trial.

BACKGROUND: The evidence base for trauma-focused cognitive behavioral therapy (TF-CBT) to treat posttraumatic stress disorder (PTSD) in youth is compelling, but the number of controlled trials in very young children is few and limited to sexual abuse victims. These considerations plus theoretical limitations have led to doubts about the feasibility of TF-CBT techniques in very young children. This study examined the efficacy and feasibility of TF-CBT for treating PTSD in three- through six-year-old children exposed to heterogeneous types of traumas. METHODS: Procedures and feasibilities of the protocol were refined in Phase 1 with 11 children. Then 64 children were randomly assigned in Phase 2 to either 12-session manualized TF-CBT or 12-weeks wait list. RESULTS: In the randomized design the intervention group improved significantly more on symptoms of PTSD, but not on depression, separation anxiety, oppositional defiant, or attention deficit/hyperactivity disorders. After the waiting period, all participants were offered treatment. Effect sizes were large for PTSD, depression, separation anxiety, and oppositional defiant disorders, but not attention-deficit/hyperactivity disorder. At six-month follow-up, the effect size increased for PTSD, while remaining fairly constant for the comorbid disorders. The frequencies with which children were able to understand and complete specific techniques documented the feasibility of TF-CBT across this age span. The majority were minority race (Black/African-American) and without a biological father in the home, in contrast to most prior efficacy studies. CONCLUSIONS: These preliminary findings suggest that TF-CBT is feasible and more effective than a wait list condition for PTSD symptoms, and the effect appears lasting. There may also be benefits for reducing symptoms of several comorbid disorders. Multiple factors may explain the unusually high attrition, and future studies ought to oversample on these demographics to better understand this understudied population.

Childhood traumatic grief: a multi-site empirical examination of the construct and its correlates.

This study evaluated the construct of childhood traumatic grief (CTG) and its correlates through a multi-site assessment of 132 bereaved children and adolescents. Youth completed a new measure of the characteristics, attributions, and reactions to exposure to death (CARED), as well as measures of CTG, posttraumatic stress disorder (PTSD), depression, and anger. CTG was distinct from but highly correlated with PTSD, depression, and, to a lesser degree, anger. In contrast to a recent study of complicated grief, CTG severity was significantly associated with the degree to which the death was viewed as traumatic. CTG was also associated with caregivers' emotional reaction at the time of the death and caregivers' current sadness. Clinical implications and recommendations for future research are discussed.

Understanding the behavioral and emotional consequences of child abuse.

Children who have suffered early abuse or neglect may later present with significant behavior problems including emotional instability, depression, and a tendency to be aggressive or violent with others. Troublesome behaviors may persist long after the abusive or neglectful environment has changed or the child has been in foster care placement. Neurobiological research has shown that early abuse results in an altered physiological response to stressful stimuli, a response that deleteriously affects the child's subsequent socialization. Pediatricians can assist caregivers by helping them recognize the abused or neglected child's altered responses, formulate more effective coping strategies, and mobilize available community resources.

Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events.

The article reviews the current status (1993-2007) of psychosocial treatments for children and adolescents who have been exposed to traumatic events. Twenty-one treatment studies are evaluated using criteria from Nathan and Gorman (2002) along a continuum of methodological rigor ranging from Type 1 to Type 6. All studies were, at a minimum, robust or fairly rigorous. The treatments in each of these 21 studies also are classified using criteria from Chambless et al. (1996), and Chambless and Hollon (1998). Trauma-Focused Cognitive-Behavioral Therapy met the well-established criteria; School-Based Group Cognitive-Behavioral Treatment met the criteria for probably efficacious. All the other treatments were classified as either possibly efficacious or experimental. Meta-analytic results for four outcomes (i.e., posttraumatic stress, depressive symptoms, anxiety symptoms, and externalizing behavior problems) across all treatments compared to waitlist control and active control conditions combined reveal that, on average, treatments had positive, though modest, effects for all four outcomes. We also cover investigative work on predictors, moderators, and mediators of treatment outcome, as well as the clinical representativeness and generalizability of the studies. The article concludes with a discussion of practice guidelines and future research directions.

Dissociation predicts later attention problems in sexually abused children.

OBJECTIVE: The goals of this research are to develop and test a prospective model of attention problems in sexually abused children that includes fixed variables (e.g., gender), trauma, and disclosure-related pathways. METHODS: At Time 1, fixed variables, trauma variables, and stress reactions upon disclosure were assessed in 156 children aged 8-13 years. At the Time 2 follow-up (8-36 months following the initial interview), 56 of the children were assessed for attention problems. RESULTS: A path analysis involving a series of hierarchically nested, ordinary least squares multiple regression analyses indicated two direct paths to attention problems including the child's relationship to the perpetrator (beta=.23) and dissociation measured immediately after disclosure (beta=.53), while controlling for concurrent externalizing behavior (beta=.43). Post-traumatic stress symptoms were only indirectly associated with attention problems via dissociation. Taken together, these pathways accounted for approximately 52% of the variance in attention problems and provided an excellent fit to the data. CONCLUSIONS: Children who report dissociative symptoms upon disclosure of CSA and/or were sexually abused by someone within their family are at an increased risk of developing attention problems. PRACTICE IMPLICATIONS: Findings from this study indicate that children who experienced sexual abuse at an earlier age, by someone within their family, and/or report symptoms of dissociation during disclosure are especially likely to benefit from intervention. Effective interventions should involve (1) providing emotion regulation and coping skills; and (2) helping children to process traumatic aspects of the abuse to reduce the cyclic nature of traumatic reminders leading to unmanageable stress and dissociation.