A pilot randomised control study to investigate the effect of the South African Adolescence Group Sleep Intervention (SAASI) on adolescent sleep and PTSD.

Background: Trauma exposure prevalence and consequent post-traumatic stress disorder among South African adolescents are significant. Sleep disturbances are among the most frequently reported difficulties faced by those dealing with PTSD. The current study examined the feasibility and preliminary efficacy of the South African Adolescence Group Sleep Intervention on PTSD symptom severity and sleep disturbance.Method: Sixty-one adolescents with PTSD diagnoses and sleep disturbance were randomly assigned (1:1) to one individual and four group sessions of a sleep intervention (SAASI) or a control group. Participants completed the Child PTSD symptom scale for DSM5 (CPSS-5) and the Pittsburgh Sleep Quality Index (PSQI) among other sleep and psychiatric measures. The trial was registered on the Pan African Trial Registry (PACTR202208559723690).Results: There was a significant but similar decrease in PSQI scores in both groups over time indicating no overall intervention effect (Wald test = -2.18, p = .029), mean slope = -0.2 (95% CI: -0.37 to -0.02) (p = .583). On the CPSS-5, interaction between groups was also not significant (p = .291). Despite this overall finding, the mean difference in CPSS-SR-5 scores increased over time, with the difference between groups post-treatment -9.10 (95%CI: -18.00 to -0.21), p = .045 and the 1-month follow-up contrast - 11.22 (95%CI: -22.43 to -0.03), p = .049 suggesting that PTSD symptom severity decreased more in the intervention group than the control group. The dropout rate was higher than expected for both the intervention (n = 10; 32%) and control (n = 8; 26.7%) groups. Dropout were mostly school commitments or travel related.Conclusions: Early findings suggest a trend towards dual improvement in sleep quality and PTSD symptom severity in adolescents with a sleep disturbance and PTSD receiving a group sleep intervention (SAASI). Further investigation in a properly powered RCT with detailed retention planning is indicated.

A four-week group sleep intervention seems feasible in adolescents with PTSD and sleep disturbances in a low-resource South African setting.Utilising less specialised mental health resources such as nurses and counsellors in intervention delivery was feasible and effective.Preliminary results are promising and support further research to establish the efficacy of the intervention.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials.

BACKGROUND: Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators. METHODS: This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954. FINDINGS: We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms. INTERPRETATION: This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress. FUNDING: Swiss National Science Foundation.

Psychotherapeutic interventions for childhood posttraumatic stress disorder: an update.

PURPOSE OF THE REVIEW: We review treatment outcome studies and systematic reviews for childhood and adolescent posttraumatic stress disorder (PTSD) between January 2020 and August 2022, including studies involving younger children and different treatment delivery methods and models. We address predictors, moderators, treatment engagement, and attrition. RECENT FINDINGS: Recent randomised controlled trials corroborate earlier trials documenting trauma-focused cognitive behaviour therapy (TF-CBT) as a highly efficacious treatment for PTSD. Evidence for treatment effects in complex PTSD in youth is still sparse. Research on moderators and predictors of treatment continues to be hampered by multiple factors, including a lack of sufficiently large homogeneous trauma samples. SUMMARY: TF-CBT is a very effective treatment for children and adolescents with PTSD. Further work is needed to (i) demonstrate that task-shifting models utilising lay community health counsellors and peer counsellors can effectively and cost-effectively close the mental health treatment gap that exists world-wide in children and adolescents diagnosed with PTSD, but particularly within low- and middle income countries, and (ii) better understand moderators and predictors of treatment which remains a priority.

Long-term follow-up of a randomised controlled trial of prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: a task-shifted intervention.

BACKGROUND: Empirical evidence on the longer-term effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed. The aim of the study was to evaluate the maintenance of treatment gains achieved in a comparative study of effectiveness of prolonged exposure therapy for adolescents (PE-A) and supportive counselling (SC) in adolescents with PTSD up to 24-months post-treatment. METHOD: Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment provided by trained and supervised non-specialist health workers (NSHWs). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale, at pretreatment, post-treatment, and at 3-, 6-, 12- and 24-months post-treatment follow-up (FU) evaluations. RESULTS: Participants in both the prolonged exposure and SC treatment groups attained a significant reduction in PTSD symptoms and maintained this reduction in PTSD symptoms at 12- and 24-month assessment. Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving SC at 12-months FU [difference in PE-A v. SC mean scores = 9.24, 95% CI (3.66-14.83), p < 0.001; g = 0.88] and at 24-months FU [difference in PE-A v. SC mean scores = 9.35, 95% CI (3.53-15.17), p = 0.002; g = 0.68]. CONCLUSIONS: Adolescents with PTSD continued to experience greater benefit from prolonged exposure treatment than SC provided by NSHWs in a community setting 12 and 24 months after completion of treatment.

Prolonged exposure therapy and supportive counselling for posttraumatic stress disorder in adolescents in a community-based sample, including experiences of stakeholders: study protocol for a comparative randomized controlled trial using task-shifting.

BACKGROUND: There is a dearth of empirical evidence on the effectiveness of pharmacological and non-pharmacological treatments for adolescents with posttraumatic stress disorder (PTSD) in developing countries. The primary aim of the study is to examine the effects of prolonged exposure therapy compared with supportive counseling for adolescents with PTSD delivered by nurses trained as counselors. METHODS/DESIGN: A single-blind randomized clinical trial comprising 90 adolescents with PTSD using a permuted block design will be utilized. Nurses previously naïve to prolonged exposure and supportive counselling will be trained to provide these treatments at the adolescents' high schools. Data collection will last from March 2014 to December 2017 and annually thereafter, dependent on the availability of funding. Participants will receive seven to fourteen 60 min sessions of prolonged exposure treatment (n = 45) or supportive counselling (n = 45). All assessments will be conducted before treatment, at mid-treatment, immediately after treatment completion, at 3-, 6-, and 12-month follow-up, and annually thereafter. It is hypothesized that PE-A will be superior to SC in reducing PTSD symptoms at post-treatment as measured by the CPSS-I administered by an independent evaluator. It is further hypothesized that PE-A treatment gains will be maintained at 3-, 6- and 12-month follow-ups and annually thereafter. DISCUSSION: While early indications are that PE-A is an effective treatment for PTSD in adolescents, this study will help determine the effectiveness of PE-A in a South African, community setting (school-based) when task-shifted to nurses, as compared to SC. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201511001345372 , retrospectively registered 11 November 2015.

Adolescent and nurse perspectives of psychotherapeutic interventions for PTSD delivered through task-shifting in a low resource setting.

BACKGROUND: This investigation compared the perceived effectiveness of supportive counselling (SC) and prolonged exposure for adolescents (PE-A) by treatment users (adolescents with PTSD) and non-specialist treatment providers (supervised nurses). METHOD: Adolescent participants and nurse providers were purposively recruited to share their experiences of trial participation through face to face semi-structured in-depth interviews and treatment-specific focus groups (all recorded). Twelve adolescent participant transcripts (ten interviews and two focus groups) and three nurse provider transcripts were doubly transcribed. Thematic content analysis was applied using Atlas.ti software. Two emerging themes are presented in this paper: 1) Perceptions of the intervention and 2) Usefulness of the intervention. RESULTS: Regardless of treatment arm, adolescents experienced warm counselling relationships and described the process of extending trust to the counselor. Adolescents in the PE-A arm provided clear descriptions of session structure and treatment rationale compared with adolescents receiving SC. The most helpful tools were breathing retraining and imaginal exposure for PE-A and creation of distraction strategies during non-directive SC. Adolescents in both arms continued to use the techniques acquired during treatment and reported symptom improvement. Participants who received SC acknowledged ongoing reexperiencing. Nurses perceived SC to be an immediately transferable skill, but feedback on their preference for one intervention over the other was inconclusive. CONCLUSION: Both PTSD treatment strategies, implemented by non-specialists, were perceived as helpful. Overall, adolescents reported warm therapeutic relationships and a reduction in PTSD symptoms. Nurses stated that they would require institutional support to ensure delivery of these interventions in a scalable and sustainable manner.

Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: task-shifting randomised controlled trial.

BACKGROUND: Empirical evidence on the effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed.AimsTo evaluate the comparative effectiveness of prolonged exposure and supportive counselling in adolescents with PTSD. METHOD: Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment (trial registration in the Pan African Clinical Trials Registry: PACTR201511001345372). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale at pre-treatment, post-treatment, and at 3- and 6-month follow-up. RESULTS: Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving supportive counselling (between group differences at post-intervention, mean 12.49, 95% CI 6.82-18.17, P<0.001; d = 1.22). A similar effect size was maintained at 3-month (d = 0.85) and 6-month (d = 1.02) follow-up assessments. CONCLUSIONS: Adolescents with PTSD experienced greater benefit from prolonged exposure treatment when provided by non-specialist health workers (nurses) in a community setting.Declaration of interestNone.

Adolescents' Experience of Stigma When Accessing School-Based PTSD Interventions.

This qualitative investigation, nested within a randomized controlled trial (RCT), describes the experiences of adolescent participants accessing psychotherapy for posttraumatic stress disorder (PTSD) in a school-based setting. Supervised nurses provided the psychotherapeutic interventions. Twelve participants who took part in the RCT were invited, and 10 agreed to share their experiences through recorded face-to-face, semistructured, in-depth interviews and treatment-specific focus groups. Basic thematic analysis was applied using Atlas.ti software. Adolescents described a mixed range of perceived poor, ambivalent, and good support experiences when accessing treatment, and were particularly motivated when they had access to a caring adult. During the trial, adolescents used calculated disclosure strategies to reduce their vulnerability to marginalization and stigma. School-based therapy was well received but could be improved if sessions were offered after school hours. This study provides suggestions for improvement and scale-up of school-based PTSD interventions for adolescents.

Impediments and catalysts to task-shifting psychotherapeutic interventions for adolescents with PTSD: perspectives of multi-stakeholders.

BACKGROUND: This qualitative study was nested within a randomized controlled trial (RCT) where two psychotherapeutic interventions (supportive counselling and prolonged exposure for adolescents) were provided by supervised nurses (who served as 'nurse counsellors') to adolescents with PTSD in school settings. This paper describes the perspectives of nurse counsellors (NCs) and school liaisons (SLs). SLs were teachers or administrative personnel at the schools who coordinated the study visits of participants with the NCs. We focus on the impediments and catalysts to and recommendations for treatment implementation. METHODS: NCs (n = 3) and SLs (n = 3) who participated in the RCT during 2014 were purposively recruited by telephone and participated in face-to-face semi-structured in-depth interviews that were recorded and doubly transcribed. Thematic content analysis was applied using Atlas.ti software to identify emerging themes. This paper describes the impediments and catalysts to provide psychotherapy by task-shifting in a community setting across three sub-themes: personal, community, and collaborative care. RESULTS: Although nurses were initially resistant to supervision it was central to personally coping with complex interventions, managing traumatic content, and working apart from a multi-disciplinary team. Delivering the interventions in the community presented multiple logistical impediments (e.g. transport, communication, venue suitability) which required creative solutions. In light of resource shortages, networking is central to effective delivery and uptake of the interventions. Collaboration between government departments of health and education may have a major impact on providing school-based psychotherapy through task-shifting. CONCLUSIONS: Impediments to implementation are not insurmountable. This article provides recommendations to maximize the success of task-shifting interventions should they be rolled out.

A pilot and feasibility randomised controlled study of Prolonged Exposure Treatment and supportive counselling for post-traumatic stress disorder in adolescents: a third world, task-shifting, community-based sample.

BACKGROUND: There is a dearth of empirical evidence on the effectiveness of pharmacological and nonpharmacological treatments for adolescents with post-traumatic stress disorder (PTSD) in developing country settings. The primary aim of this study was to demonstrate that Prolonged Exposure Treatment for Adolescents (PE-A) and supportive counselling (SC) are implementable by nurses in a South African context. A secondary aim was to perform a preliminary analysis of the effectiveness of registered nurses delivering either PE-A or SC treatment to adolescents with PTSD. It is hypothesised that PE-A will be superior to SC in terms of improvements in PTSD symptoms and depression. METHOD: A pilot, single-blind, randomised clinical trial of 11 adolescents with PTSD. Nurses previously naïve to Prolonged Exposure (PE) Treatment and SC provided these treatments at the adolescents' high schools. Data collection lasted from March 2013 to October 2014. Participants received twelve 60-90-min sessions of PE (n = 6) or SC (n = 5). All outcomes were assessed before treatment, at mid-treatment, immediately after treatment completion and at 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed with the Child PTSD Symptom Scale-Interview (CPSS-I) (range, 0-51; higher scores indicate greater severity). The secondary outcome, depression severity, was assessed with the Beck Depression Inventory (BDI) (range, 0-41; higher scores indicate greater severity). RESULTS: Data were analysed as intention to treat. During treatment, participants in both the PE-A and SC treatment arms experienced significant improvement on the CPSS-I as well as on the BDI. There was a significant difference between the PE-A and SC groups in maintaining PTSD and depression at the 12-month post-treatment assessment, with the participants in the PE-A group maintaining their gains both on PTSD and depression measures. CONCLUSION: The treatment was adequately implemented by the nurses and well-tolerated by the participants. Preliminary results suggest that the delivery of either intervention led to a significant improvement in PTSD and depression symptoms immediately post treatment. The important difference was that improvement gains in PTSD and depression in the PE-A group were maintained at 12-month follow-up. The results of this pilot and feasibility study are discussed. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201511001345372 , registered on 11 November 2015.