Efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents exposed to single versus multiple traumas: meta-analysis of randomised controlled trials.

BACKGROUND: Previous meta-analyses of psychotherapies for children and adolescents with post-traumatic stress disorder (PTSD) did not investigate whether treatment efficacy is diminished when patients report multiple (versus single) traumas. AIMS: To examine whether efficacy of psychological interventions for paediatric PTSD is diminished when patients report multiple (versus single) traumas. METHOD: We systematically searched PsycInfo, MEDLINE, Web of Science and PTSDpubs on 21 April 2022 and included randomised controlled trials (RCTs) meeting the following criteria: (a) random allocation; (b) all participants presented with partial or full PTSD; (c) PTSD is the primary treatment focus; (d) sample mean age <19 years; (e) sample size n ≥ 20. Trauma frequency was analysed as a dichotomous (single versus ≥2 traumas) and continuous (mean number of exposures) potential moderator of efficacy. RESULTS: Of the 57 eligible RCTs (n = 4295), 51 RCTs were included in quantitative analyses. Relative to passive control conditions, interventions were found effective for single-trauma-related PTSD (Hedges' g = 1.09; 95% CI 0.70-1.48; k = 8 trials) and multiple-trauma-related PTSD (g = 1.11; 95% CI 0.74-1.47; k = 12). Psychotherapies were also more effective than active control conditions in reducing multiple-trauma-related PTSD. Comparison with active control conditions regarding single-event PTSD was not possible owing to scarcity (k = 1) of available trials. Efficacy did not differ with trauma exposure frequency irrespective of its operationalisation and subgroup analyses (e.g. trauma-focused cognitive-behavioural therapy only). CONCLUSIONS: The current evidence base suggests that psychological interventions for paediatric PTSD can effectively treat PTSD in populations reporting single and multiple traumas. Future trials for PTSD following single-event trauma need to involve active control conditions.

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.

The relationship between youth involvement, alliance and outcome in trauma-focused cognitive behavioral therapy.

OBJECTIVE: Research suggests that combining the trauma-specific elements with a strong alliance helps optimize treatment outcomes in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth. Building on this, we investigate whether more positive and less negative involvement behaviors during trauma narration are associated with a stronger alliance and predict fewer posttraumatic stress symptoms (PTSS). METHOD: Participants were 65 youth (M age = 15.5, SD = 2.2; 77% girls) receiving TF-CBT. Both youth self-report (Child PTSD Symptom Scale and Therapeutic Alliance Scale for Children) and observer ratings (Client Involvement Rating Scale) were used, and relationships were investigated with correlations and regression analyses. RESULTS: The positive involvement behaviors demonstration of treatment understanding and self-disclosure predicted fewer PTSS but were not associated with the alliance - while initiation of discussions and showing enthusiasm predicted more PTSS but were associated with a stronger alliance. The negative involvement behaviors passivity and avoidance did not predict PTSS but were negatively associated with the alliance. CONCLUSION: The relationships between traumatized youths' positive and negative involvement behaviors, alliance and PTSS outcomes appear mixed. The combination of a clear understanding of why processing the trauma can be helpful, more trauma-related self-disclosure and a stronger alliance seem favorable for alleviating PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Understanding the relationships between trauma type and individual posttraumatic stress symptoms: a cross-sectional study of a clinical sample of children and adolescents.

BACKGROUND: Characteristics of traumatic events may be associated with the level and specific manifestation of posttraumatic stress symptoms (PTSS). This study examined the differences and similarities between overall levels, profiles and networks of PTSS after sexual trauma, domestic violence, community violence, non-interpersonal trauma, sudden loss or serious illness of a loved one, and severe bullying or threats. METHODS: PTSS were measured in a clinical sample of 4,921 children and adolescents (6-18 years old, M = 14.0, SD = 2.7, 63.7% female) referred to Child and Adolescent Mental Health Services. We compared 95% confidence intervals (CI) for each symptom with 95% CI for overall PTSS within each trauma type (self-reported worst trauma). We also computed cross-sectional networks and searched for differences in networks according to trauma type and overall symptom level. RESULTS: The overall frequencies of PTSS were highest following sexual trauma; somewhat lower for domestic violence and severe bullying or threats and lowest after community violence, non-interpersonal trauma and sudden loss or serious illness. Psychological cue reactivity, avoidance and difficulties with sleeping and concentrating were generally among the most frequent symptoms. Sexual trauma, domestic violence and severe bullying or threats were associated with higher frequencies of negative beliefs and persistent negative emotional states. Few differences in symptom networks across trauma type emerged. CONCLUSION: Different types of trauma exposure may be associated with different profiles of symptom frequencies. Knowledge about this may be useful for clinicians and for the movement towards evidence-based personalized psychological treatment.

Professional wellbeing and turnover intention among child therapists: a comparison between therapists trained and untrained in Trauma-Focused Cognitive Behavioral Therapy.

BACKGROUND: Poor professional wellbeing and job turnover is challenging for child mental health clinics and despite an increasing interest in implementing evidence-based practices (EBPs) in mental health services, little is known about if and how using EBPs may influence therapists' professional wellbeing and turnover intention. To investigate this, we compare the average level of compassion satisfaction, burnout, secondary traumatic stress, and turnover intention between therapists trained in an EBP (Trauma-Focused Cognitive Behavioral Therapy - TF-CBT) and untrained therapists. We also explore the prevalence of and the associations between these personal and organizational outcomes. METHOD: In this cross-sectional study, the data is collected from a national sample of 373 therapists 5 years after an implementation program began (i.e., in the sustainment phase). The variables were measured by the Professional Quality of Life and the Turnover Intention Scales. The Evidence-Based Practice Attitude Scale was also used to measure therapists' attitudes toward EBPs. RESULTS: Over 70% of the respondents reported medium to high levels of burnout, secondary traumatic stress symptoms, and compassion satisfaction, whereas one-third of the respondents reported a high level of intention to leave their job in the current or near future. Higher ratings on burnout and secondary traumatic stress were significantly associated with lower compassion satisfaction and higher turnover intention. Finally, we found significantly lower degree of burnout and turnover intention along with higher compassion satisfaction among TF-CBT therapists (n = 96), compared to other therapists who were not trained in TF-CBT (n = 231). These differences could not be explained by between-group differences in age, job tenure, educational background, or therapists' attitudes towards EBPs. However, mean differences in ratings on secondary traumatic stress symptoms were not statistically significant. CONCLUSION: Although the prevalence findings are in general alarming, the present study provides the first empirical evidence for a potential positive effect of being trained in TF-CBT on therapists' wellbeing and turnover intention. We discuss these findings in the light of self-efficacy theory and the job demands-resources model.

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.

Dilemmas when talking about Huntington's disease: A qualitative study of offspring and caregiver experiences in Norway.

Research provides a compelling list of reasons why offspring should be included in honest conversations about disease when the disease affects their caregivers. Despite this, we lack in-depth knowledge about how families affected by the severe and complex genetic condition Huntington's disease (HD) experience talking about the many aspects of how this disease affects their lives. This study aimed to provide an in-depth exploration of how offspring with a caregiver with HD and caregivers with a partner with HD experienced talking about disease throughout childhood. Thematic analysis was conducted with semistructured interviews of both caregivers (n = 14) and offspring (n = 36) from families affected by HD, reflecting both current and past experiences. In addition to highlighting the many needs offspring have for knowledge and conversation about the disease with their caregivers, our findings also show that a variety of dilemmas can follow these conversations, including when to talk, what to say, how often HD should be talked about on a day-to-day basis, and whether to share disease-related information with others outside the family. The findings show the complexity of talking with offspring about HD. A difficult task for both offspring and caregivers seemed to be finding out how to balance the many dilemmas that arise in conversations and how to use dialogue to best help offspring adapt and cope with the many challenges that can come with HD. The findings can assist health care professionals, such as genetic counselors, prepare, and guide families affected by HD in the many and complex conversations that arise about the disease, in turn helping offspring adjust and cope with their current lives or future lives affected by HD.

Four perspectives on traumatized youths' therapeutic alliance: Correspondence and outcome predictions.

OBJECTIVE: Does the rater-perspective of youths' therapeutic alliance matter? To answer this, we evaluated the relationships between four perspectives of youths' alliance, then, we examined whether each perspective and potential discordance between the perspectives predicted outcomes. METHOD: Participants were 65 youth (M age = 15.11, SD = 2.14; 76.9% girls) undergoing trauma-focused cognitive behavioral therapy (TF-CBT) and their therapists (n = 24). Youths' alliance was rated by youth, therapists and parents using the Therapeutic Alliance Scale for Children-revised and by observers using the Therapy Process Observational Coding System-Alliance scale. Posttraumatic stress symptoms (PTSS) were assessed with the Child PTSD Symptom Scale (CPSS) and the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA). RESULTS: The alliance ratings by youth-parent, parent-therapist, and therapist-observer significantly correlated. Only a higher youth-rated alliance significantly predicted fewer PTSS. Furthermore, a higher therapist-rated than youth-rated alliance significantly predicted higher scores on CPSS and CAPS-CA, and a higher parent-rated than youth-rated alliance predicted significantly higher CPSS score. CONCLUSION: Therapists should explicitly check in with youth clients about the alliance; because only youths' evaluation of their alliance predicted the outcome and an overestimation of their alliance by therapists and parents predicted more PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Correction to: Long-term mental health in unaccompanied refugee minors: pre- and post-flight predictors.

In the original publication, the Table 1 was published.

Commentary: I thought I was going to die and the world is not safe-how to help children recover after trauma? Reflections on Meiser-Stedman et al. (2019).

Children all over the world experience exposure to trauma. Why do only some young people have significant traumatic stress symptoms in the days and weeks immediately post-trauma while others do not, and why do some youth then recover without treatment while others go on to suffer from persistent PTSD? This important question is examined in a comprehensive study by Meiser-Stedman et al., (2019). In a sample of single-event trauma exposed youth, they investigate the role cognitive processes may have in shaping early reactions and in maintaining post-traumatic stress symptoms (PTSS) over time. For the onset of PTSS, perceived threat and feeling overwhelmed and confused during the traumatic event was associated with significant PTSS. For the maintenance of PTSS, poorly elaborated, sensory-based memories, dissociation, rumination, and negative appraisals were associated with higher PTSS. The newly revised International Society for Traumatic Stress Studies' guidelines for the prevention and treatment of PTSS found no strong evidence to recommend any of the evaluated preventive or early intervention programs. This commentary highlights how understanding different trajectories for the onset and maintenance of post-traumatic stress may inform our development of prevention and early intervention strategies. Cognitive processes seem to play an important role in the development of PTSS but these may play out differently in youth exposed to single events and youth with interpersonal trauma experiences. Knowledge on memory processing, meaning making, the role of social support and maladaptive cognitions need to be implemented in systems of trauma-informed care.

The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder: Methodology and Development Process.

Over the last two decades, treatment guidelines have become major aids in the delivery of evidence-based care and improvement of clinical outcomes. The International Society for Traumatic Stress Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 and published its latest recommendations, along with position papers on complex PTSD (CPTSD), in November 2018. A rigorous methodology was developed and followed; scoping questions were posed, systematic reviews were undertaken, and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria. In total, 208 meta-analyses were conducted and used to generate 125 recommendations (101 for adults and 24 for children and adolescents) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were eight strong, eight standard, five low effect, 26 emerging evidence, and 78 insufficient evidence to recommend recommendations. The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area. Narrative reviews were undertaken and position papers prepared (one for adults and one for children and adolescents) to consider the current issues around CPTSD and make recommendations to facilitate further research. This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Nuevas guías para la prevención y el tratamiento del trastorno de estrés postraumático de la Sociedad Internacional de Estudios de Estrés Traumático: metodología y proceso de desarrollo GUIAS DE LA ISTSS PARA EL TEPT En las últimas dos décadas, las guías de tratamiento se han convertido en una ayuda importante para la prestación de atención basada en la evidencia y la mejora de los resultados clínicos. La Sociedad Internacional de Estudios de Estrés Traumático (ISTSS en sus siglas en inglés) produjo las primeras guías para la prevención y tratamiento del trastorno de estrés postraumático (TEPT) en 2000 y publicó sus últimas recomendaciones, junto con los documentos de posición sobre el TEPT complejo (TEPT-C), en noviembre de 2018. Se desarrolló y siguió una metodología rigurosa; se plantearon preguntas de alcance, se realizaron revisiones sistemáticas y se incluyeron 361 ensayos controlados aleatorizados de acuerdo con los criterios de inclusión acordados a priori. En total, se realizaron 208 metanálisis y fueron utilizados para generar 125 recomendaciones (101 para adultos y 24 para niños y adolescentes) para intervenciones específicas de prevención y tratamiento, utilizando una definición acordada de la importancia clínica y un algoritmo de configuración de recomendaciones. Hubo ocho estudios con pruebas sólidas, ocho como estándar, cinco con bajo efecto, 26 con evidencia emergente y 78 fueron evaluados como con evidencia insuficiente para ser recomendados en las recomendaciones. Se consideró la inclusión de preguntas de alcance separadas sobre tratamientos para presentaciones complejas de TEPT, pero se decidió en contra debido a cuestiones de definición y ausencia virtual de estudios diseñados específicamente para responder con claridad las posibles preguntas de alcance en esta área. Se realizaron revisiones narrativas y se prepararon documentos de posición (uno para adultos y otro para niños y adolescentes) para considerar los problemas actuales en torno al TEPT-C y hacer recomendaciones para facilitar la investigación adicional. Este documento describe la metodología y los resultados del proceso de la Guía de la ISTSS y considera la interpretación y la implementación de las recomendaciones.

Cost-Effectiveness Analysis of Trauma-Focused Cognitive Behavioral Therapy: A Randomized Control Trial among Norwegian Youth.

Traumatic events by young people can adversely affect their psychological and social well-being when left untreated. This can result in high costs for society. In this study, we aimed to evaluate whether trauma-focused cognitive behavioral therapy (TF-CBT) is a cost-effective alternative to therapy as usual (TAU). Individual-level data were collected from 2008 to 2013, as part of a randomized control trial in Norwegian youth, 10-18 years of age, presenting with symptoms of posttraumatic stress (N = 156). Health outcomes, costs, and patient and family characteristics were recorded. Health-related quality of life (HRQoL) was measured with the 16D instrument, and quality-adjusted life-years (QALYs) were derived; total costs included the costs of therapy, and last we calculated the incremental cost-effectiveness ratio (ratio of differences in costs and QALYs gained). We performed nonparametric bootstrapping and used the results to draw a cost-effectiveness acceptability curve depicting the probability that TF-CBT is cost-effective. HRQoL increased in both treatment groups, whereas no significant differences in QALYs were observed. Resource use measured in minutes per session was significantly higher in the TF-CBT group; however, total minutes of therapy and costs were not significantly different between the two groups. In addition, use of resources, such as psychological counseling services, welfare services, and medication, was lower in the TF-CBT group posttreatment. The likelihood of TF-CBT being cost-effective varied from 91% to 96%. TF-CBT is likely to be a cost-effective alternative to standard treatment and should be recommended as the guideline treatment for youth with posttraumatic stress disorder.

Long-term mental health in unaccompanied refugee minors: pre- and post-flight predictors.

Unaccompanied refugee minors are a particularly vulnerable group. The aim of this study is to increase our knowledge about possible pathways to well-being and integration for unaccompanied refugee minors as they strive to establish new lives in a host county. The present study followed a group of youth who fled to Norway without their caregivers at three time points; 6 months (n = 95; M age = 13.8, 80% boys), 2 years (n = 78; M age = 16.5, 83% boys), and 5 years (n = 47; M age 20.0, 83% boys) after arrival. Linear mixed effects models were used to assess whether age, gender, and trauma exposure prior to arrival were associated with levels and changes in symptoms of posttraumatic stress (PTS), depression, anxiety, and externalizing symptoms over time. Regression analyses were conducted to examine whether daily hassles, perceived social support, and new trauma experiences predict PTS, internalization, externalization, and somatization. The mean levels of depression had decreased significantly at 5 years, but mean levels of anxiety, PTS, and externalizing symptoms did not. Females and severely trauma exposed had higher levels of symptoms. Higher age was associated with less change in symptoms of depression and posttraumatic stress over time. Five years after arrival, many still experienced clinical levels of mental health problems, and level of daily hassles was an important predictor. Support may be needed not only at arrival to handle mental health problems in general and posttraumatic stress in particular, but also after resettlement. Help to manage daily hassles may be especially important to ensure well-being and integration.

Changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress symptoms.

OBJECTIVE: To understand the meaning of trauma narration, we examined changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy (TF-CBT) and explored the relationship between changes in narratives and in posttraumatic stress. METHOD: The sample consisted of 12 non-responders and 12 maximum-responders to treatment (M = 14.3, SD = 2.35, range = 10-17; 75% girls). The youth were assessed with the Clinical-Administered PTSD-Scale for Children and Adolescents both pre- and post-treatment. Their first and last narratives were coded according to a standardized coding manual. RESULTS: For the group as a whole there was an increase in organized thoughts and reports of internal events (e.g., descriptions of thoughts and feelings), while narrative fragmentation decreased. There were no significant narrative changes in external events (e.g., descriptions of actions and dialogues). Max-responders differed significantly from non-responders in developing more organized thoughts. We did not find a significant relationship between changes in narratives and changes in posttraumatic stress symptoms (PTSS). CONCLUSIONS: Youth receiving TF-CBT develop narratives that contain more organized thoughts and a greater internal focus, which are both thought to be helpful for traumatized youth. However, more coherent and organized trauma narratives were not related to reductions in PTSS. Clinical or methodological significance of this article: This study suggests that trauma-focused cognitive behavioral therapy contributes to more organized and coherent trauma narratives for traumatized youth. Although, this may be important and contribute to meaning making, therapist should be aware that this may not be sufficient in reducing posttraumatic stress symptoms in youth.

Change in post-traumatic cognitions mediates treatment effects for traumatized youth-A randomized controlled trial.

Posttraumatic stress symptoms (PTSS) are associated with serious impairments in psychological, social, and academic functioning in youth. The aim of this study was to investigate whether changes in posttraumatic cognitions mediate treatment effects. Participants were multitraumatized youth (N = 156, mean age = 15.1 years, range = 10-18; 79.5% girls) randomly assigned to receive trauma-focused cognitive-behavioral therapy (TF-CBT) or treatment-as-usual (TAU). Mixed-effects models were applied to investigate the impact of treatment conditions on posttraumatic cognitions. Mediation analyses were applied to examine whether changes in posttraumatic cognitions mediated the relationship between treatment conditions and outcome in posttraumatic stress symptoms, depressive symptoms, and general mental health. Participants receiving TF-CBT reported significantly lower levels of negative posttraumatic cognitions at the end of treatment compared to participants in TAU. Change in posttraumatic cognitions mediated the treatment effect difference found for PTSS. When the overall change in cognition was divided into early and late changes, it was only the late change that significantly mediated the PTSS treatment effect. A mediation effect of posttraumatic cognitions was also found for the treatment effect difference in depressive symptoms and in general mental health symptoms. Traumatized youth report having many negative posttraumatic cognitions and changes in negative cognitions plays a key role for treatment outcome. (PsycINFO Database Record

Investigating treatment characteristics and first-session relationship variables as predictors of dropout in the treatment of traumatized youth.

OBJECTIVE: Attrition is a common problem in youth trauma treatment, but there is currently little knowledge of why so many youths drop out. In this study, treatment variables (caregiver attendance in the first session and exposure vs. non-exposure-based treatment) and first-session process variables (the therapeutic alliance and youths' perceptions of parental treatment approval) were investigated as predictors of dropout. METHOD: Participants (N = 156, mean age = 15.1) were randomly assigned to trauma-focused cognitive behavioral therapy or therapy as usual in a community trial. RESULTS: Dropout (n = 39, 25.0%) was predicted by a lack of caregiver attendance, lower rates of youth-perceived parental treatment approval, and weaker therapist-rated youth alliance. Neither type of treatment, youth-rated alliance or caregiver alliance, predicted dropout. CONCLUSIONS: The findings indicate that in addition to caregivers' actual participation in the first session, youths' perception of their parents' approval of treatment seems to influence treatment attendance. This finding implies that therapists should engage caregivers in therapy and address possible discordance in treatment goals and tasks. Furthermore, consistent with adult studies, exposure-based treatments do not appear to increase dropout rates.

Posttraumatic stress disorder and exposure to trauma reminders after a terrorist attack.

The aims of this study were twofold: (a) to systematically describe the type and frequency of trauma reminders reported after a terrorist attack and (b) to examine whether posttraumatic stress disorder (PTSD) is associated with frequency of exposure to trauma reminders. A total of 285 survivors (M age = 22.2, SD = 4.3, 53% males) of the 2011 massacre on Utøya Island, Norway, were interviewed face to face 14-15 months after the terror. Participants were asked how often they had experienced a range of different trauma reminders in the past month and which was most distressing. Current posttraumatic stress reactions were measured using the University of California at Los Angeles PTSD Reaction Index. In all, 33.3% of the survivors reported having experienced 1 or more trauma reminders often/very often in the past month. Auditory reminders were most frequently encountered and were reported to be the most distressing, especially sudden and sharp noises. Meeting the diagnostic criteria for PTSD was significantly associated with frequency of exposure to trauma reminders. The findings suggest that trauma reminders are common among survivors of a terrorist attack almost 1.5 years after the trauma and that PTSD is strongly related to the frequency of exposure to reminders. It is important that clinicians are aware of the significant role trauma reminders may play in maintaining PTSD and help trauma survivors recognize and manage reminders.

Coping responses in the midst of terror: the July 22 terror attack at Utøya Island in Norway.

This study examined the peri-trauma coping responses of 325 survivors, mostly youth, after the July 22, 2011 terror attack on Utøya Island in Norway. The aim was to understand peri-trauma coping responses and their relation to subsequent post-traumatic stress (PTS) reactions. Respondents were interviewed face-to-face 4-5 months after the shooting, and most were interviewed at their homes. Peri-trauma coping was assessed using ten selected items from the "How I Cope Under Pressure Scale" (HICUPS), covering the dimensions of problem solving, positive cognitive restructuring, avoidance, support seeking, seeking understanding, and religious coping. PTS reactions were assessed with the UCLA PTSD Reaction Index. The participants reported using a wide variety of coping strategies. Problem solving, positive cognitive restructuring, and seeking understanding strategies were reported most often. Men reported using more problem-solving strategies, whereas women reported more emotion-focused strategies. There were no significant associations between age and the use of coping strategies. Problem solving and positive cognitive restructuring were significantly associated with fewer PTS reactions. The results are discussed in light of previous research and may help to inform early intervention efforts for survivors of traumatic events.

Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway.

BACKGROUND: Although youths in many countries have been exposed to terrorism, few studies have examined early risk and protective factors for the subsequent development of mental health problems. AIMS: To investigate the levels of post-traumatic stress in survivors of the 2011 massacre on Utøya Island compared with the general population in Norway, and to identify predictive factors. METHOD: Four hundred and ninety survivors were invited to participate. Structured face-to-face interviews were performed 4-5 months after the attack. RESULTS: There were 325 study participants (response rate 66%). Survivors had been highly exposed to danger and loss. Post-traumatic stress levels were more than six times higher in survivors than in the general population. Predictors were female gender, minority ethnic status, high level of trauma exposure, pain, the loss of someone close and social support. CONCLUSIONS: Survivor characteristics that can be assessed in the early aftermath of a terrorist attack strongly predict the subsequent mental health problems of exposed youths. The highly elevated symptoms observed were largely attributable to the traumatic experience and reflect the mental health costs of the terrorist attack.