The differential impact of the DSM-5 post-traumatic stress symptoms on functional impairment in traumatized children and adolescents.

BACKGROUND: This study aims to provide a better understanding of the individual impact of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) post-traumatic stress symptoms (PTSS) on functional impairment in trauma-exposed children and adolescents. Identifying PTSS that have the most impact on functional impairment can broaden our understanding of post-trauma reactions and guide the selection of treatment components and techniques required to help patients to restore functioning following trauma exposure. METHOD: Utilizing relative importance analyses, unique shared variance of each DSM-5 PTSS with functional impairment were estimated in clinical samples of 3400 Norwegian (Mage = 14.18, SDage = 2.49, rangeage = 7-17) and 747 US (Mage = 10.76, SDage = 3.10, rangeage = 7-17) children and adolescents from naturalistic settings. RESULTS: Negative beliefs, detachment from others, inability to experience positive emotions, and diminished interest in activities within the symptom cluster negative alterations in cognitions and mood, and the hyperarousal symptom concentration problems accounted for the largest proportions of unique variance explained in functional impairment in both samples. Further, the hyperarousal symptom irritability showed a unique high association with functional impairment in the US sample. CONCLUSION: As negative beliefs, emotional numbing symptoms, concentration problems and irritability may be especially related to functional impairment in traumatized children and adolescents, monitoring and targeting these symptoms throughout therapy might be of particular importance to restore functioning as early as possible and to facilitate overall recovery.

Predictors of nonresponse and drop-out among children and adolescents receiving TF-CBT: investigation of client-, therapist-, and implementation factors.

BACKGROUND: There is a paucity of evidence about effective implementation strategies to increase treatment response and prevent drop-out among children receiving evidence-based treatment. This study examines patient, therapist, and implementation factors and their association to nonresponse and drop-out among youth receiving Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). METHODS: Youth (n = 1240) aged 6-18 (M = 14.6) received TF-CBT delivered by 382 TF-CBT therapists at 66 clinics. Odds ratio analyses were used to investigate whether pretreatment child (age, gender, number of trauma experiences, post-traumatic stress symptoms (PTSS), therapist (education), and implementation strategy factors (high-low, low-low, low-high intensity therapist and leadership training respectively) or tele-mental health training during the Covid-19 pandemic are associated with nonresponse (above clinical PTSS level post-treatment) and drop-out (therapist-defined early termination). Fidelity checks were conducted to ensure that TF-CBT was used consistently. RESULTS: One fourth of the children (24.4%) were nonresponders and 13.3 percent dropped out. Exposure to three or more traumatic experiences were related to nonresponse and drop-out. Higher baseline PTSS was related to a higher probability of nonresponse. There was no effect of therapist education or child gender on nonresponse and drop-out, whereas children over 15 years had a higher likelihood of both. After controlling for baseline PTSS, the effect of age on nonresponse was no longer significant. Drop-out was related to fewer sessions, and most dropped out during the first two phases of TF-CBT. Fidelity was high throughout the different implementation phases. High-intensity therapist training was related to a lower probability of both nonresponse and drop-out, whereas low therapist and leadership training were related to a higher likelihood of both. Multivariate analysis revealed higher child age and higher PTSS baseline scores as significant predictors of nonresponse, and number of trauma experiences (> = 3) at baseline as the only predictor of drop-out. CONCLUSIONS: High-intensity therapist training seem key to prevent patient nonresponse and drop-out. Leadership training might positively affect both, although not enough to compensate for less intensive therapist training. More complex cases (higher PTSS and exposure to more traumas) predict nonresponse and drop-out respectively, which underscores the importance of symptom assessment to tailor the treatment. The lack of predictive effect of therapist education increases the utilization of TF-CBT. TRIAL REGISTRATION: Retrospectively registered in ClinicalTrials, ref. nr. NCT05248971.

The bidirectional associations between caregiver and child symptoms in the parent-led treatment stepping together for children after trauma.

BACKGROUND: An innovative approach to child trauma treatment in which caregivers are allocated treatment tasks has shown promising results, but less is known about the bidirectional associations between caregiver and child symptoms during treatment. METHODS: Eighty-two child-caregiver dyads who participated in the parent-led therapist-assisted Stepping Together for Children after Trauma (ST-CT) were included (child age: 7-12 years, mean = 9.9 years). Caregivers' emotional reactions and anxiety/depression and children's posttraumatic stress (PTS) and depression were assessed pretreatment, mid-treatment, and posttreatment. We investigated the possible directional associations between caregivers' emotional reactions and anxiety/depression and children's PTS and depression using random intercept cross-lagged panel models. RESULTS: Symptoms improved in both caregivers and children. Lower levels of caregiver emotional reactions at pretreatment predicted improved child PTS at mid-treatment; lower levels of caregiver emotional reactions at mid-treatment predicted improved child depression at posttreatment; and lower levels of child PTS at mid-treatment predicted improved caregiver emotional reactions at posttreatment. CONCLUSIONS: These findings suggest that caregivers and children can impact each other's responses to a parent-led child trauma-focused treatment. Notably, children with caregivers who were less affected by their own emotional reactions exhibited greater improvement in both PTS and depression. Supporting the caregivers may benefit both children and caregivers. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862.

Parent-led stepped care for traumatised children: parental factors that predict treatment completion and response.

Background: Stepped care cognitive behavioural therapy for children after trauma (SC-CBT-CT; aged 7-12 years) can help to increase access to evidence-based trauma treatments for children. SC-CBT-CT consists of a parent-led therapist-assisted component (Step One) with an option to step up to standard therapist-led treatment (Step Two). Studies have shown that SC-CBT-CT is effective; however, less is known about what parent variables are associated with outcome of Step One.Objective: To examine parent factors and their relationship with completion and response among children receiving Step One.Method: Children (n = 82) aged 7-12 (M = 9.91) received Step One delivered by their parents (n = 82) under the guidance of SC-CBT-CT therapists. Logistic regression analyses were used to investigate whether the following factors were associated with non-completion or non-response: the parents' sociodemographic variables, anxiety and depression, stressful life experiences and post-traumatic symptoms, negative emotional reactions to their children's trauma, parenting stress, lower perceived social support, and practical barriers to treatment at baseline.Results: Lower level of educational achievement among parents was related to non-completion. Higher levels of emotional reactions to their child's trauma and greater perceived social support were related to non-response.Conclusions: The children seemed to profit from the parent-led Step One despite their parents` mental health challenges, stress, and practical barriers. The association between greater perceived social support and non-response was unexpected and warrants further investigation. To further increase treatment completion and response rates among children, parents with lower education may need more assistance on how to perform the interventions, while parents who are very upset about their child's trauma may need more emotional support and assurance from the therapist.Trial registration: ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019).

The children seemed to profit from Step One despite parents' mental health challenges and practical barriers.Response may improve if parents' emotional reactions to a child's trauma is addressed.Parents with lower education may need more assistance in performing Step One.

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.

Antecedentes: El trastorno de estrés postraumático complejo (TEPT-C) ha sido agregado recientemente al sistema de diagnóstico para la clasificación de enfermedades CIE-11. El nuevo trastorno agrega tres grupos de síntomas al trastorno de estrés postraumático (TEPT), relacionados con alteraciones en la autoorganización (desregulación afectiva, autoconcepto negativo y alteraciones en las relaciones). Poco se sabe acerca de si los tratamientos basados en evidencia recomendados para el TEPT en jóvenes son útiles para los jóvenes con TEPT-C.Objetivos: Este estudio examinó si la Terapia Cognitiva Conductual Centrada en el Trauma (TF-CBT en sus siglas en inglés) es útil para reducir el TEPT y el TEPT-C en jóvenes traumatizados.Método: Se incluyó en el estudio a jóvenes derivados a una de las 23 clínicas noruegas de salud mental para niños y adolescentes, que cumplían con los criterios para TEPT o TEPT-C según el CIE-11 y recibieron TF-CBT (n = 73, 89% niñas, M edad = 15,4, DE = 1,8). Se realizaron evaluaciones antes del tratamiento y cada cinco sesiones. Se ejecutaron modelos de efectos mixtos lineales para investigar si los jóvenes con TEPT-C y TEPT respondían de manera diferente a la TF-CBT.Resultados: Entre los 73 jóvenes, el 61,6% (n = 45) cumplió con los criterios de TEPT-C y el 38,4% (n = 28) cumplió con los criterios de TEPT. No hubo diferencias en sexo, edad, país de nacimiento, tipo de trauma, número de tipos de trauma o duración del tratamiento entre los grupos. Los jóvenes con TEPT-C tuvieron una disminución más pronunciada en TEPT y TEPT-C en comparación con los jóvenes con TEPT. Los grupos reportaron niveles similares de TEPT y TEPT-C después del tratamiento. El porcentaje de jóvenes que abandonaron el tratamiento no difirió entre los grupos. Además, los grupos no difirieron significativamente en el número de sesiones de tratamiento recibidas.Conclusiones: Éste es el primer estudio que examina si la TF-CBT es útil para los jóvenes que tienen TEPT-C mediante un instrumento validado para medir el TEPT. Los resultados sugieren que la TF-CBT puede ser útil para tratar el TEPT-C en jóvenes. Estos son hallazgos prometedores que deberían replicarse en estudios con tamaños muestrales más grandes.

Does the therapist matter? Therapist characteristics and their relation to outcome in trauma-focused cognitive behavioral therapy for children and adolescents.

BACKGROUND: There is a broad evidence-base for the effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) in treating children and adolescents with posttraumatic stress disorder (PTSD). The effect of therapist characteristics on patient symptoms has been neglected in psychotraumatology research and necessitates further investigation. OBJECTIVE: This study aims to investigate the impact of therapist characteristics (gender, clinical experience and theoretical background) on posttraumatic stress symptoms (PTSS) in a heterogeneous and international sample of traumatized children and adolescents. METHOD: Data from two RCTs on the effectiveness of TF-CBT in Norway and Germany were included, comprising N = 52 therapists (78.8% female) and N = 153 patients (72.3% female). All therapists underwent thorough training and continuous supervision in TF-CBT. The Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) assessed pre- and post-treatment served as the outcome variable in a linear mixed-effects model with therapists' theoretical background, prior clinical experience and gender as independent variables, adjusted for patient gender, measurement time and country. The possibility of an interaction between therapist and patient gender was investigated subsequently. RESULTS: None of the therapist characteristics were significantly related to PTSS. There was no indication of an interaction between patient and therapist gender (p =.878). CONCLUSION: The lack of evidence for a relationship of therapists' theoretical orientation and clinical experience with outcome suggests that a wider dissemination of TF-CBT may be warranted. More studies with larger therapist and patient sample sizes and including only community practice are needed.

Antecedentes: Hay una amplia base de evidencia de la efectividad de la Terapia Cognitivo Conductual con foco en el trauma (TF-CBT) en el tratamiento de niños y adolescentes con Trastorno de Estrés Postraumático (TEPT). El efecto de las características del terapeuta sobre los síntomas del paciente ha sido dejado de lado en la investigación en psicotraumatología y requiere mayor investigación.Objetivo: Este estudio apunta a investigar el impacto de las características del terapeuta (género, experiencia clínica y conocimiento teórico) sobre los síntomas de estrés postraumático (PTSS) en una muestra heterogénea e internacional de niños y adolescentes traumatizados.Método: Se incluyeron datos de dos ERC (RCTs) acerca de la efectividad de la TF-CBT en Noruega y Alemania, que constan de N=52 terapeutas (78.8% mujeres) y N=153 pacientes (72.3% mujeres). Todos los terapeutas se sometieron a entrenamiento y supervisión contínua en TF-CBT. La Escala de TEPT administrada por clínicos para niños y adolescentes (CAPS-CA) aplicada pre y post tratamiento sirvió como variable de resultado en un modelo lineal de efectos mixtos con el conocimiento teórico del terapeuta, su experiencia clínica previa y género como variables independientes, ajustada por género del paciente, tiempo de medición y país. La posibilidad de una interacción entre el género del terapeuta y del paciente se investigó posteriormente.Resultados: Ninguna de las características del terapeuta se relacionaron significativamente a PTSS. No hubo indicios de una interacción entre el género del paciente y del terapeuta (p=.878).Conclusión: La falta de evidencia para una relación entre la orientación teórica y experiencia clínica del terapeuta y el resultado sugiere que se puede requerir una más amplia diseminación de TF-CBT. Se requiere mós estudios, con muestras de mayor tamaño de pacientes y terapeutas y que incluya sólo práctica comunitaria.

Reported Levels of Upset in Youth After Routine Trauma Screening at Mental Health Clinics.

Importance: Clinical guidelines recommend routine screening for trauma at youth mental health clinics. However, many clinicians are concerned that screening may be upsetting both for youths who have been exposed to trauma and for those who have not. Objectives: To investigate levels of upset following routine trauma screening and whether type of trauma and symptoms of posttraumatic stress were associated with level of upset. Design, Setting, and Participants: Survey study in which data from routine screening for trauma exposure and trauma-related symptoms were collected from January 1, 2015, to December 31, 2017. Nearly half (n = 40) of all youth mental health clinics in Norway submitted survey data. Participants included youths aged 6 to 18 years referred to treatment. Main Outcomes and Measures: The trauma screening inventory, Child & Adolescent Trauma Screening Questionnaire, was administered. Self-reported levels of upset after initial screening were scored on a scale ranging from 1 (not upsetting) to 7 (very upsetting). Results: Among 10 157 youths aged 6 to 18 years (mean [SD] age, 13.0 [3.1] years; 5320 [55.0%] female), surveyed, 8021 (79.1%) reported exposure to at least 1 potentially traumatizing event and a mean (SD) of 2.44 (2.27) different types of events (range, 0-15). Only 453 participants (4.5%) reported high levels of upset, while 2757 participants (27.2%) reported moderate levels of upset and 6942 participants (68.4%) reported no or low levels of upset. Youths who had been exposed to any type of traumatic event reported significantly higher levels of upset compared with those reporting no trauma exposure, and a higher number of reported traumatic events was associated with a higher level of upset (point estimate, 0.23; 95% CI, 0.22-0.24; P < .001). Among participants who reported trauma, exposure to sexual abuse (point estimate, 0.87; 95% CI, 0.77-0.95; P < .001) and higher levels of posttraumatic stress symptoms (point estimate, 0.05; 95% CI, 0.04-0.05; P < .001) were associated with higher levels of upset. Conclusions and Relevance: A high level of trauma exposure was found among youths referred to youth mental health clinics, but trauma screening was well tolerated, with most participants reporting no or low levels of upset. These findings can be used to support therapists and health care leaders in implementing routine trauma screening to better identify youths who are in need of trauma-focused treatment.

Changes in posttraumatic stress symptoms, cognitions, and depression during treatment of traumatized youth.

OBJECTIVE: Although there is compelling evidence that trauma-focused cognitive behavioral therapy (TF-CBT) is an effective treatment for traumatized youth, we know less about the mechanisms contributing to symptom reduction. To improve the understanding of change mechanisms in TF-CBT, this paper investigates the possible bi-directional longitudinal relationship between changes in posttraumatic stress symptoms (PTSS), cognitions and depression in a clinical sample of traumatized youth. METHODS: The study includes 79 youth (M age = 15.0 years, SD = 2.2, 74.7% girls) who received TF-CBT. The youth were assessed for PTSS, posttraumatic cognitions, and depressive symptoms at baseline, mid-treatment, post-treatment, 12 months after baseline, and 18 months after post-treatment. RESULTS: Growth curve analyses showed that PTSS, posttraumatic cognitions and depressive symptoms decreased over time. Cross-lagged mediation analyses demonstrated that reduction in posttraumatic cognitions predicted reduction in both PTSS and depression at the subsequent measurement wave, but we did not find a clear pattern in the longitudinal relationship between PTSS and depression. CONCLUSIONS: Changes in posttraumatic cognitions mediate the therapeutic effects of TF-CBT on symptoms of posttraumatic stress and depression. Future studies should seek to tease out how clinicians can best proceed to help youth reduce their posttraumatic cognitions and thereby improve treatment outcome.

Exploring self-perceived growth in a clinical sample of severely traumatized youth.

OBJECTIVE: The aims of this study were threefold: (1) examine the prevalence of Posttraumatic Growth (PTG) among severely traumatized youth, (2) systematically describe the PTG reported, and (3) study the course of PTG from pre- to post-treatment. METHOD: The sample consisted of 148 severely traumatized Norwegian youth (M age=15, SD=2.2, 79.1% girls) receiving treatment in child mental health clinics. The Clinician Administered PTSD Scale for Children (CAPS) was used to assess level of posttraumatic stress symptoms (PTSS) pre- and post-treatment. One of the questions in CAPS: "How do you think (traumatic event) has affected your life?" formed the basis for our analysis of PTG. Words and phrases indicative of PTG were identified using the Consensual Qualitative Research method. RESULTS: Pre-treatment, the prevalence rate of PTG was low compared to previous findings, and reports of PTG were not related to levels of PTSS. The main PTG themes identified were: personal growth, relational growth, and changed philosophy of life. A sub-theme of personal growth; greater maturity/wisdom, was the most salient theme identified both pre- and post-treatment. Age was significantly related to reports of PTG; older participants reported more growth. Reports of PTG increased significantly from pre- to post-treatment, but were not related to decrease in PTSS. CONCLUSIONS: The findings suggest that PTG is not only possible for youth, but quite similar to that observed among adults. However, we need to carefully consider whether reports of self-perceived positive change among traumatized youth actually are indicative of growth, or simply indicative of increased vulnerability.