Protocol for the Project SAVE randomised controlled trial examining CBT for insomnia among veterans in treatment for alcohol use disorder.

INTRODUCTION: As many as 74% of veterans with alcohol use disorders (AUDS) report symptoms of insomnia. Insomnia represents a barrier to alcohol treatment because insomnia symptoms (1) may lead to relapse among those who use alcohol to help them sleep and may negatively impact (2) executive functions and (3) emotion regulation skills. Cognitive-behavioural therapy for insomnia (CBT-I) is an efficacious first-line treatment for insomnia; however, no research has examined the impact of CBT-I on individuals' response to alcohol treatment. In the Sleep and Alcohol for Veterans (Project SAVE) randomised controlled trial, we hypothesise that CBT-I will enhance the efficacy of alcohol treatment among Veterans with insomnia by enhancing their abilities to attend to treatment, regulate emotions and initiate sleep without alcohol. METHODS AND ANALYSIS: Eighty Veterans enrolled in alcohol treatment at the Veterans Administration (VA) hospital will be randomly assigned to receive either CBT-I or single-session sleep hygiene (SH) education. Individuals will be eligible to participate if they meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for moderate to severe AUD and Insomnia Disorder of at least 1-month duration. Participants will complete assessments at baseline, post-treatment and 6-week follow-up. Preliminary process outcomes include retention/recruitment rates and treatment satisfaction (feasibility and acceptability, respectively). Primary outcomes are insomnia severity, percentage of heavy-drinking days and alcohol-related problems. We will assess a variety of secondary clinical and mechanistic outcomes (eg, post-traumatic stress disorder (PTSD) symptoms, attention and working memory). ETHICS AND DISSEMINATION: Ethics approval was obtained in October 2018. Data collection began in July 2019 and is planned for completion by July 2021. Trial results will be disseminated at local and national conferences, in peer-reviewed publications and through media outlets, as available. Results will also be shared with interested participants and clinical collaborators at the end of the trial. TRIAL REGISTRATION NUMBER: clinicaltrials.gov identifier NCT03806491 (pre-results).

Establishing Concurrent Validity for a Brief PTSD Screen Among Women in a Domestic Violence Shelter.

There is a particular need for valid scales to screen for posttraumatic stress disorder (PTSD) among women who seek safe shelter from intimate partner violence. Screening to identify women who are at risk for PTSD can lead to early intervention that reduces the risk for PTSD-related outcomes such as poor decision making, inconsistent parenting, and behavior dysfunction among their children. The gold standard for diagnosing PTSD is the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) (CAPS-5). A seven-item PTSD screen has been used for in this population and has a well-established cutoff score but has not been validated against the DSM-5 diagnostic criteria for PTSD. The study purpose was to establish concurrent validity for a seven-item screen for PTSD with the CAPS-5. Participants were 75 women, 18 years or older, who were residents of a 120-bed shelter in the southern United States. They spoke English or Spanish. They reported intimate partner physical or sexual violence within 4 months of their entry into the study. Following informed consent, data were collected in individual interviews, conducted in either English or Spanish. In addition to demographic data, the seven-item PTSD screen and the CAPS-5 were administered. A receiver operating characteristic (ROC) curve analysis was conducted to assess the concurrent validity of the seven-item PTSD screen with the CAPS-5. The seven-item PTSD screen results were significantly correlated with the CAPS-5 results in this sample (area under the curve [AUC] = .640, z = 2.670, p = .008). Sensitivity was 96.2, and observed specificity was 31.8. The seven-item PTSD screen demonstrates excellent sensitivity (e.g., 96% of true PTSD cases) and acceptable specificity (32% of non-PTSD cases) and can be used to quickly and accurately identify individuals for diagnostic assessment and intervention.

An Evidence-Based Assessment Tool for Estimating Future Post-Traumatic Stress Disorder: A 7-Year Follow-Up Study.

Background: Intimate partner violence (IPV) affects up to one in three women across the world. Post-traumatic stress disorder (PTSD) is a common outcome. Many, but not all, women suffer long after they first sought help for IPV. Validated tools for estimating the likelihood of future PTSD are lacking. Materials and Methods: Women who sought IPV support services for the first time in 2011-2012 (N = 300) completed a seven-item screen for the presence or absence of clinically significant PTSD symptoms and the first assessment screening tool for post-traumatic stress disorder (FAST-PTSD), a tool designed to estimate future PTSD among women seeking help for IPV. Seven years later, in 2018, 271 (90%) women again completed the seven-item screen for clinically significant PTSD symptoms. A two-step binary logistic regression was conducted to determine the 7-year validity of the FAST for clinically significant symptoms of PTSD while controlling for baseline PTSD symptoms. Results: More than 25% of the women reported clinically significant PTSD at 7 years. Baseline moderate- and high-risk scores on the FAST-PTSD were associated with clinically significant levels of PTSD. Moderate risk was associated with nearly two and one-half times (odds ratio [OR] = 2.4) the risk of clinically significant symptoms of PTSD, and high risk with nearly eight times (OR = 7.8) the risk of PTSD at 7 years. Conclusions: PTSD is commonly associated with IPV and if untreated can compromise functioning of women and their children. The FAST-PTSD is a valid indicator of significant clinical PTSD symptoms 7 years following first contact with IPV support services. Using the FAST-PTSD to triage women at risk for sustained PTSD to early, preventive intervention may improve outcomes for women and their children.

Evaluating an Intergenerational Model to Explain the Path From Violence Against Mothers to Child Behavior and Academic Outcomes.

An intergenerational model to explain the long-term effect of partner violence against mothers on child behavior was evaluated 48 months after 278 mothers first sought safe shelter or justice services. Twelve percent reported recent abuse, and six mothers reported severe or extreme danger. Self-efficacy (-.58, p < .05), social support (-28, p < .05), and financial support (-.25) were inversely associated with mental health concerns. Higher maternal mental health concerns (.55, p < .05) and child witnessing abuse (.70, p < .05) were associated with child behavioral problems. Child behavioral problems were inversely associated with child academic functioning (-.22, p < .05). To improve child outcomes, interventions that establish safety for mothers and children and promote maternal mental health are needed.

Validation of an Expanded Measure of Integrated Care Provider Fidelity: PPAQ-2.

This study aimed to validate the factor structure of the expanded Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ-2), which is designed to assess provider fidelity to both the Primary Care Behavioral Health (PCBH) and collaborative care management (CCM) models of integrated primary care. Two-hundred fifty-three integrated care providers completed self-reports of professional background, perceptions of clinic integration and related practice barriers, and the PPAQ-2. Confirmatory factor analyses were conducted to assess the theorized factor structure and criterion validity was assessed through correlational analysis. Factor analyses demonstrated adequate fit with the data and acceptable to excellent composite reliabilities across five PCBH domains and five CCM domains. Validity was demonstrated by correlations between adherence scores and measures of clinic integration and barriers to fidelity. The PPAQ-2 is a psychometrically sound measure that can be used in future integrated care dismantling studies to identify provider behaviors that best predict patient outcomes.

Mothers' posttraumatic stress and child adjustment problems in families seeking services for intimate partner violence.

OBJECTIVE: This study examines whether fluctuation in mothers' posttraumatic stress symptoms (PTSSs) predicts fluctuation in child adjustment problems in families seeking services for intimate partner violence (IPV). METHOD: Participants were 300 mothers (mean age = 30.65 years) of children (mean age = 6.88 years; 49% female) who were seeking shelter or legal services because of IPV. Most mothers identified as Hispanic (57%), followed by Black/African American (26%). Mothers reported PTSSs on a 7-item screening measure and reported child externalizing and internalizing problems on the Child Behavior Checklist. Mother and child functioning were assessed shortly after the mothers' requested services and then every 4 months for a 5-year period. RESULTS: Eighty-one percent of mothers reported clinical levels of PTSSs at the initial assessment. As hypothesized, fluctuation in mothers' PTSSs predicted fluctuation in child externalizing and internalizing problems during the ensuing 4-month period. These relations, however, occurred within subjects but not between subjects. The within-subject associations emerged after accounting for IPV and mothers' depressive symptoms and were stronger for older children than younger children. The strength of the associations decreased over time. CONCLUSIONS: Addressing women's trauma symptoms at the point of seeking services for IPV has possible implications for child mental health. Attempting to reduce mothers' PTSSs may have positive effects for women as well as their children. (PsycINFO Database Record

Using Baseline Data to Predict Chronic PTSD 48-months After Mothers Report Intimate Partner Violence: Outcomes for Mothers and the Intergenerational Impact on Child Behavioral Functioning.

Worldwide one in three women report intimate partner violence. Many of these women report long term mental health problems, especially PTSD, which is associated with negative problem solving, isolation, somatization, depression, and anxiety. Children are impacted by their exposure to domestic violence and experience internal (i.e., depression, anxiety) and external (i.e., hostility, delinquency) behavioral clinical problems. To predict which women will experience chronic PTSD symptoms, a PTSD predictor tool was developed and applied to PTSD symptom scores four years after 300 mothers with children (age 18 months to 16 years) received assistance for the violence. At four years, 266 (89%) of the 300 mother child dyads were retained. Of those, 245 met inclusion criteria for this study and 53% had scores above the clinical threshold for PTSD. The predictor tool performed well. There was a significant association, χ2 (4) = 11.83, p = .019, Cramer's V = 0.229, between mothers predicted at low/some risk for chronic PTSD and scoring below the cut-off score for diagnostic PTSD symptoms at four years. Mothers predicted to be at extreme risk for chronic PTSD reported PTSD symptoms at or above the diagnostic level at 48 months. Children whose mothers had PTSD were at greater risk for Borderline/Clinical range behavioral problems compared to children whose mothers did not have PTSD. Relative risk values ranged from 2.07 (Externalizing) to 2.30 (Internalizing). When appropriate interventions are available, the PTSD predictor tool can assist with triage and guided referral of women at risk for chronic PTSD.

Exploring the Association of Maternal Adverse Childhood Experiences with Maternal Health and Child Behavior Following Intimate Partner Violence.

BACKGROUND: Adverse childhood experiences (ACEs) have been empirically linked to a host of negative health outcomes, both physical and psychosocial. Exposures to ACEs make individuals more susceptible to conditions such as cardiovascular disease, diabetes, cancers, and depression. Many of these conditions do not appear until sometime in adolescence or adulthood and have been linked to premature death. OBJECTIVE: This study explores the association between the number and type of exposure to ACEs in women (mothers) who experienced intimate partner violence and health outcomes. Specifically, it explores the association between maternal ACEs and maternal perceived health and maternal mental and behavioral health. This study also explores the association between ACEs and child behavior. METHODS: This analysis is part of a 7-year prospective study. A cohort of 300 mother-child pairs was assessed at baseline and every 4 months after reaching out for shelter or justice services for the very first time after being in an abusive intimate relationship. RESULTS: Data document individual mothers' ACE scores and show a trend at 12 months, 24 months, and is most significant at 36 months. Additionally, at 36 months, higher ACE scores were significantly associated with all child behavioral subscales (anxiety, depression, aggressive behavior, attention problems, internalizing, externalizing). CONCLUSION: The women in this study reported ACE scores consistently higher than national rates. Our data highlight the added benefit of using ACE criteria as a global prevention strategy to identify those most at risk for delayed mental and behavioral health issues and to intervene with supportive strategies and guided referrals as indicated.

Developing and Testing of an Economic Index Tool for Abused Women With Children.

Violence and poverty combine to severely compromise the safety, health, and functioning of women with major pass-through effects to their children. To reduce poverty and mitigate violence, measures are needed to assess economic status before and after intervention programs. The purpose of the study was to develop a new tool to assess women's various sources of income, to measure the degree to which the components of the tool are independent, and assess the usefulness of the tool to assess the connection of economic status and mental health functioning among abused women. RESULTS: Using content and face validity techniques and exploratory factor analysis, the 5-item Economic Index Tool was derived that assesses formal and informal employment wages, family and government cash assistance, and child support. Concurrent and predictive validity models for both the raw and weighted scores were significant, χ² (1) = 65.02, p <.001, Nalgelkerke R² =.285 and χ² (1) = 108.44, p <.001, Nalgelkerke R² =.443, respectively. Both the raw and weighted scores were associated with increased odds of being above poverty, Odds Ratios were 1.242 and 1.306, respectively, and all p values were < 0.001. The Economic Index Tool revealed a positive connection of higher economic status and better mental health. The Economic Index Tool offers a rapid assessment of abused women's economic status that can be used to guide multifaceted intervention programs and measure program effectiveness.

Continued Intimate Partner Violence During Pregnancy and After Birth and Its Effect on Child Functioning.

OBJECTIVE: To investigate the effect of intimate partner violence (IPV) during pregnancy with continued IPV up to 6 months after birth and its effect on child functioning. DESIGN: Nonexperimental descriptive design. SETTING: Safe shelters and the District Attorney's office in a large urban community in the United States. PARTICIPANTS: Abused women (N = 284) who reported IPV and reached out for services. METHODS: Abused women who reported IPV answered a questionnaire on the effects of abuse during pregnancy and continued abuse after birth and child behaviors. Women who continued to experience abuse during pregnancy were compared with women who did not report abuse during pregnancy and after birth. The Achenback Child Behavior Checklist was used to evaluate child behavior. Research questions were analyzed through the use of nonparametric analyses. RESULTS: Between the two groups, the relationship between IPV during pregnancy and IPV during the first 6 months after birth was significant (p < .001). The relation between women who reported abuse during pregnancy and conception rape was significant (p < .001). Most abused women (76%) were not screened for IPV during pregnancy (p = .025). Significant findings related to child behaviors and IPV during pregnancy were found for internalizing behaviors (p < .009), externalizing behaviors (p < .001), and total behavioral problems (p < .001). CONCLUSION: Intimate partner violence during pregnancy increases the risk of IPV 6 months after birth. These findings also indicated a negative intergenerational effect of IPV during pregnancy on child behavior. Screening for IPV during pregnancy is vital to interrupt ongoing IPV and possible negative outcomes for mother and child.

Child Brides, Forced Marriage, and Partner Violence in America: Tip of an Iceberg Revealed.

Forced marriage is a violation of human rights and thwarts personal safety and well-being. Child brides are at higher risk of intimate partner violence (IPV) and often are unable to effectively negotiate safe sex, leaving them vulnerable to sexually transmitted infections, including human immunodeficiency virus, and early pregnancy. The prevalence of forced marriage and child marriage in the United States is unknown. The intersection of forced marriage and child marriage and IPV is equally unknown. When 277 mothers who reported IPV to shelter or justice services were asked about a forced marriage attempt, frequency and severity of IPV, mental health status, and behavioral functioning of their child, 47 (17%) reported a forced marriage attempt with 45% of the women younger than 18 years of age at the time of the attempt. Among the 47 women, 11 (23%) reported death threats, 20 (43%) reported marriage to the person, and 28 (60%) reported a pregnancy. Women younger than 18 years reported more threats of isolation and economic deprivation associated with the attempt as well as pressure from parents to marry. Regardless of age, women experiencing a forced marriage attempt reported more intimate partner sexual abuse, somatization, and behavior problems for their children. Forced marriage attempts occurred to one in six women (17%) reporting IPV and are associated with worse functioning for mother and child. The frequent occurrence and associated effect of forced marriage attempts to maternal child functioning indicates routine assessment for a forced marriage attempt as part of comprehensive care for women reporting IPV.

Perceived Fertility Control and Pregnancy Outcomes Among Abused Women.

OBJECTIVE: To describe the degree of perceived fertility control and associated likelihood of unintended pregnancy and poor pregnancy outcomes among women who report intimate partner violence. DESIGN: Cross-sectional cohort study design. SETTING: Five domestic violence shelters and one district attorney's office in a large urban metropolis in the United States. PARTICIPANTS: A total of 282 women who reported intimate partner violence and reached out for the first time to a shelter or district attorney's office for assistance. METHODS: This 7-year prospective longitudinal study began in 2011. Participants in the overarching study are being interviewed every 4 months. During the 32-month interview period, participants responded to a one-time, investigator-developed, fertility control questionnaire in addition to the ongoing repeated measures. RESULTS: Almost one third (29%) of the participants reported at least one unintended pregnancy attributed to their abusers' refusal to use birth control, and 14.3% of the participants reported at least one unintended pregnancy as a result of their abusers' refusal to allow them to use birth control. Participants were 28 times more likely to have abuse-induced miscarriages if their pregnancies resulted because their abusers did not use birth control (OR = 28.70, p < .05). Finally, participants were 8 times more likely to report premature births if they were abused because of their use of birth control (OR = 8.340, p < .05). CONCLUSION: Women in abusive relationships reported compromised fertility control associated with abuse and increased risk for unintended pregnancy as well as the adverse pregnancy outcomes of premature birth and miscarriage.

Parenting in the Wake of Abuse: Exploring the Mediating Role of PTSD Symptoms on the Relationship Between Parenting and Child Functioning.

BACKGROUND: Children whose mothers report partner violence and symptoms of posttraumatic stress disorder (PTSD) are at risk for behavior dysfunctions. AIM: To examine the mediating effects of maternal PTSD symptoms on the relationship of parenting behaviors to child internalizing and externalizing behavior dysfunctions. FINDINGS: Maternal PTSD symptoms have a partial mediating effect on the relationship between inconsistent discipline and child internalizing and externalizing behaviors. Maternal PTSD symptoms have a fully mediating effect on the relationship between poor supervision and child internalizing behaviors. CONCLUSIONS: There is a need to identify women who report partner violence and are at high risk for PTSD and intervene early to prevent problematic parenting and resulting child behavior problems.

A Risk Assessment Tool to Predict Sustained PTSD Symptoms Among Women Reporting Abuse.

BACKGROUND: Nationally and worldwide, 30% or more of women are likely to have experienced intimate partner violence. Maternal mental health symptoms predict child function. When mothers have sustained posttraumatic stress disorder (PTSD), their children at are risk for growth and developmental delays and poor behavioral outcomes that may adversely affect the course of their lives. While many who experience trauma will recover without intervention, a significant proportion will experience PTSD, with negative consequences for their personal lives and the lives of their families. Early identification of those at high risk for PTSD symptoms will support early interventions to prevent PTSD and its negative consequences. METHODS: This paper describes the development of a tool that can predict PTSD symptoms at 8 months in mothers who are primarily of low socioeconomic status and primarily members of underrepresented groups. The tool consists of four key measures. CONCLUSIONS: Using this tool to identify mothers at high risk for sustained PTSD and entering them into early intervention programs may protect mothers and their children from negative outcomes and promote their health and wellbeing.

Predicting Abused Women With Children Who Return to a Shelter: Development and Use of a Rapid Assessment Triage Tool.

To develop a tool to predict risk for return to a shelter, 150 women with children, exiting a domestic violence shelter, were evaluated every 4 months for 24 months to determine risk factors for returning to a shelter. The study identified four risk factors, including danger for murder, woman's age (i.e., older women), tangible support (i.e., access to money, transportation), and child witness to verbal abuse of the mother. An easy to use, quick triage tool with a weighted score was derived, which can identify with 90% accuracy abused women with children most likely to return to shelters.

Modeling the intergenerational impact of partner abuse on maternal and child function at 24 months post outreach: Implications for practice and policy.

OBJECTIVE: Many women are exposed to partner violence during their lifetime which affects mental health and child development. This study revalidates an intergenerational model connecting partner violence to poor functioning for mothers and children using structural equation techniques. METHOD: A longitudinal design collected data on 300 mother-child pairs. Comparisons between the model, tested at study entry and again at 24 months, are reported. Maternal measures included childhood experiences of abuse, partner abuse, chronic pain, and mental health. The Child Behavior Checklist measured child function. RESULTS: Comparison of both models revealed that maternal chronic pain, maternal mental health, and child witnessing of mother's abuse remain strong predictors of child dysfunction. Maternal social support and self-efficacy are significant predictors of more positive maternal mental health with a conduit effect on child behavior. CONCLUSION: Intimate partner violence directly impacts the victim and also has a secondary impact on the children of abuse victims.

Partner Abuse of Mothers Compromises Children's Behavioral Functioning Through Maternal Mental Health Dysfunction: Analysis of 300 Mother-Child Pairs.

Partner violence is associated with numerous negative consequences for victims, especially poor mental health. Children who are exposed to partner violence are more likely to have behavior problems. Nevertheless, research on the relationship between severity of abuse, maternal mental health functioning following partner violence, and child behavior problems is limited. We explored the direct and indirect effects on the child's behavioral functioning of severity of maternal abuse and maternal mental health functioning following abuse. A sample of 300 mothers was recruited when they sought assistance for abuse for the first time at shelters for abused women or at the district attorney's office. Severity of abuse, mothers' mental health functioning, and child behavioral functioning were measured by maternal self-report at entry into the study and 4 months later. In SEM analysis, at both entry and 4 months, severity of abuse had a direct effect on maternal mental health functioning, which in turn had a direct effect on child behavioral functioning. The path from severity of abuse to child behavioral functioning also was significant but became non- significant once maternal mental health functioning was added to the equation, indicating that the path from severity of abuse to child behavioral functioning was indirect and occurred as a result of the mother's mental health functioning, which remained directly linked to child behavioral problems. Intergenerational interventions are needed to address both maternal mental health and child behavioral functioning when a mother reports partner violence and is experiencing mental health problems.

Child Witness to Domestic Abuse: Baseline Data Analysis for a Seven-Year Prospective Study.

Children who witness the abuse of their mother by an intimate partner suffer negative effects on behavioral functioning. In this study, 300 abused women seeking services for abuse were interviewed regarding how often their child had witnessed the abuse. Baseline data for this study found that boys who witnessed abuse had externalizing and internalizing behavioral problems comparable to boys in clinical treatment. Girls did not display clinically significant behaviors. For evidence-based programs to interrupt the effect of witness to violence on children, empirical data that are gender-specific are needed. Findings support the need to screen mothers for abuse during well-child visits and offer education to all mothers on the possible effects of child witness to violence in the home.

Risk of behaviors associated with lethal violence and functional outcomes for abused women who do and do not return to the abuser following a community-based intervention.

BACKGROUND: To determine the differential risk of behaviors associated with lethal violence and functioning outcomes for abused women with children who received an intervention of shelter or justice services and return to the abuser were compared with women who did not return. METHODS: The study was carried out using a matched-pair analysis of 152 women. Measures of risk of behaviors associated with lethal violence, type, and severity of abuse, and poor mental health symptoms were measured every 4 months for 24 months. RESULTS: Irrespective of service used, women returning to the abuser reported significantly (p<0.001) more risk of behaviors associated with lethal violence compared to women who did not return. Additionally, severity of physical abuse was significantly higher (p<0.01) for women returning to the abuser who had been in a shelter but not for women who received a protection order. Similarly, levels of depression, posttraumatic stress disorder, and anxiety were significantly higher (p<0.01) for sheltered women who returned to the abuser but not for women using a protection order who returned. CONCLUSIONS: Risk of behaviors associated with lethal violence increases when abused women return to live with the abuser. Abused women should be informed of the heightened risk and greater probability for poor mental health.

Abused women with children who are first-time users of a shelter or applicants for a protection order: entry data of a 7-year prospective analysis.

Worldwide, two models of care are offered most often to abused women-safe shelter and justice services. No evidence exists on the differential effectiveness of the services. To provide evidence, 300 abused women, 150 first-time users of a shelter and 150 first-time applicants for a protection order, signed informed consent to participate in a 7-year study. Safety, abuse, and functioning of the women and their children were measured. Compared with women seeking justice services, women in shelters reported more abuse and depression and less support. The baseline characteristics of these 300 women are presented with implications for practice and policy.