Mediators of Outcome in Trauma-Focused Psychotherapy with Youth: A Systematic Review.

This article aimed to provide a systematic narrative synthesis of existing studies on the mediators of change in psychotherapy with adolescents (10-19 years) and transition age youth (TAY) (20-29 years) who have experienced trauma-related symptoms or posttraumatic disorder. Additionally, we were interested in identifying psychotherapy-, trauma type-, and clients' age- and gender-specific mediators of treatment outcome. Following the preferred reporting items for systematic reviews and meta-analyses, a total of 3,723 studies published in PubMed and PsycINFO databases were screened against inclusion criteria, revealing 15 eligible studies. No studies with only TAY were found; therefore, all results were limited to therapy with adolescents. Cognitive mediators were tested in 66% of selected studies, followed by parents/family-related, mental-health-related, therapy-related, and behavioral mediators. Moderate evidence was found for posttraumatic cognitions, whereas therapeutic alliance seemed to be a promising candidate for future research. Striking absence of non-cognitive-behavioral therapy interventions, emotional and adolescent-specific mediators, as well as studies with males and in non-Western societies was evident. Future original studies would benefit from applying methodological rigor in respect to mediation testing.

Pre-event attachment anxiety and avoidance predict posttraumatic stress symptom severity - Results from a longitudinal population-based study.

Attachment-related anxiety and avoidance have been identified as risk factors for psychopathology following traumatic events. However, the predictive value of pre-event attachment orientations for PTSD symptoms in the general population remains unclear. Attachment anxiety and avoidance, as well as symptoms of anxiety and depression, were assessed in autumn 2010 (T0) in 270 adult members of a Dutch research panel. PTSD symptoms were assessed in April (T1), August (T2), and December (T3) 2012 for events occurring within one year before T1. The predictive value of attachment orientations for severity and remission of PTSD cluster and total scores was estimated by latent growth curve analyses controlling for gender, age, and pre-event psychopathology. Attachment anxiety predicted higher posttraumatic stress severity at T1, while attachment avoidance predicted lower initial posttraumatic stress levels, together adding 7.4 % independently explained variance. Higher attachment anxiety was related to more remission of PTSD total scores (6.0 % independently explained variance) which might be understood as an effect of regression to the mean. In conclusion, insecure attachment orientation predicts PTSD symptoms in the general population. Our results advocate the significance of pre-traumatic factors for the prediction of posttraumatic stress and the consideration of attachment orientations in clinical work with trauma survivors.

Mediators of outcome in adolescent psychotherapy and their implications for theories and mechanisms of change: a systematic review.

Psychotherapeutic treatment of adolescents requires age-specific approaches and thus plausibly also involves different change mechanisms than adult psychotherapy. To guide further research and improve therapeutic outcomes for adolescents, we reviewed all RCTs investigating mechanisms of change in the psychological treatment of adolescents to identify the most promising age-, disorder- or treatment-specific mediators. Following the preferred reporting items for systematic reviews (PRISMA), 106 studies were included that reported 252 statistical mediation tests assessed with 181 different measures. Most often studied and significant mediators were cognitive, followed by family-related, and behavioral variables. Several mediators were identified to be promising for future investigations: changes in negative thoughts, dysfunctional beliefs and metacognitive skills; family functioning and parenting skills; as well as successful engagement in therapy activities and increased impulse control. Symptom change during therapy was least often a mediator for other therapeutic changes. Relational and emotional mediators were largely understudied, whereas peer-influence appeared a promising mediator for intervention outcomes. Adolescence-specific mediators were most commonly investigated. Majority of studied mediators were not disorder-specific. There was a tendency to mainly test change mechanisms of specific theoretical models without considering other possible change theories. Further, virtually no studies fulfilled all criteria for rigorously investigating mediation and only nine were classified with an overall good study quality. While bearing in mind the current limitations in study designs, methodological rigor and reporting, there appears to be substantial evidence for transdiagnostic age-specific change models in the psychological treatment of adolescents. For future research, need for consensus on a core set of transdiagnostic and transtheoretical mediators and measures is highlighted. These should address likely core mechanisms of change, as well as take into account age-relevant developmental challenges and biological markers.

Guilt is effectively induced by a written auto-biographical essay but not reduced by experimental pain.

Introduction: The aim of the present study was (1) to validate the method of guilt-induction by means of a written auto-biographical essay and (2) to test whether experimental pain is apt to alleviate the mental burden of guilt, a concept receiving support from both empirical research and clinical observation. Methods: Three independent groups of healthy male participants were recruited. Group allocation was not randomized but within group pain/sham administration was counterbalanced over the two test-days. Groups were tested in the following consecutive order: Group A: guilt induction, heat-pain/sham, N = 59; Group B: guilt induction, cold-pressure-pain/sham, N = 43; Group C: emotionally neutral induction, heat-pain/sham, N = 39. Guilt was induced on both test-days in group A and B before pain/sham administration. Visual analog scale (VAS) guilt ratings immediately after pain/sham stimulation served as the primary outcome. In a control group C the identical heat-pain experiment was performed like in group A but a neutral emotional state was induced. Results: A consistently strong overall effect of guilt-induction (heat-pain: p < 0.001, effect size r = 0.71; CPT-pain p < 0.001, r = 0.67) was found when compared to the control-condition (p = 0.25, r = 0.08). As expected, heat- and cold-pressure-stimuli were highly painful in all groups (p < 0.0001, r = 0.89). However, previous research supporting the hypothesis that pain is apt to reduce guilt was not replicated. Conclusion: Although guilt-induction was highly effective on both test-days no impact of pain on behavioral guilt-ratings in healthy individuals could be identified. Guilt induction per se did not depend on the order of testing. The result questions previous experimental work on the impact of pain on moral emotions.

The Role of Strategic Emotional Intelligence in Predicting Adolescents' Academic Achievement: Possible Interplays with Verbal Intelligence and Personality.

As recent meta-analyses confirmed that emotional intelligence (EI), particularly strategic EI, adjoins intelligence and personality in predicting academic achievement, we explored possible arrangements in which these predictors affect the given outcome in adolescents. Three models, with versions including either overall strategic EI or its branches, were considered: (a) a mediation model, whereby strategic EI partially mediates the effects of verbal intelligence (VI) and personality on achievement; the branch-level version assumed that emotion understanding affects achievement in a cascade via emotion management; (b) a direct effects model, with strategic EI/branches placed alongside VI and personality as another independent predictor of achievement; and (c) a moderation model, whereby personality moderates the effects of VI and strategic EI/branches on achievement. We tested these models in a sample of 227 students (M = 16.50 years) and found that both the mediation and the direct effects model with overall strategic EI fit the data; there was no support for a cascade within strategic EI, nor for the assumption that personality merely moderates the effects of abilities on achievement. Principally, strategic EI both mediated the effects of VI and openness, and independently predicted academic achievement, and it did so through emotion understanding directly, "skipping" emotion management.

Sensory-Processing Sensitivity and Pathways to Depression and Aggression: The Mediating Role of Trait Emotional Intelligence and Decision-Making Style-A Pilot Study.

While the link between sensory-processing sensitivity (SPS) and internalizing symptoms has been well-established, a link to externalizing problems is still to be explored. This study aimed to further examine the relation between SPS and behavioral problems by testing the potential mediating roles of trait emotional intelligence (TEI) and decision-making styles. Pathway analyses were conducted on data from 268 community sample participants (Mage = 25.81, SD = 2.41, 61.2% females). Results indicated gender differences in the pathway level outcomes of SPS, as well as potential partial mediators in men and women. SPS both directly and via the mediating effects of the well-being factor (TEI) and avoidant decision-making influenced depression, regardless of gender. Direct effects on aggression were, however, obtained only in the male sample. Indirect effects of SPS on aggression were found in spontaneous decision-making for men and in the self-control and sociability factors of TEI for women. Directions for future research were discussed.

Mediators and Theories of Change in Psychotherapy for Young People With Personality Disorders: A Systematic Review Protocol.

Background: Personality disorders (PDs) are a severe health issue already prevalent among adolescents and young adults. Early detection and intervention offer the opportunity to reduce disease burden and chronicity of symptoms and to enhance long-term functional outcomes. While psychological treatments for PDs have been shown to be effective for young people, the mediators and specific change mechanisms of treatment are still unclear. Aim: As part of the "European Network of Individualized Psychotherapy Treatment of Young People with Mental Disorders" (TREATme), funded by the European Cooperation in Science and Technology (COST), we will conduct a systematic review to summarize the existing knowledge on mediators of treatment outcome and theories of change in psychotherapy for young people with personality disorders. In particular, we will evaluate whether mediators appear to be common or specific to particular age groups, treatment models, or outcome domains (e.g., psychosocial functioning, life quality, and adverse treatment effects). Method: We will follow the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched for prospective, longitudinal, and case-control designs of psychological treatment studies, which examine mediators published in English. Participants will be young people between 10 and 30years of age who suffer from subclinical personality symptoms or have a personality disorder diagnosis and receive an intervention that aims at preventing, ameliorating, and/or treating psychological problems. Results: The results will be published in a peer-reviewed journal and at conference presentations and will be shared with relevant stakeholder groups. The data set will be made available to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives. The review has been registered in PROSPERO (evaluation is pending, registration number ID 248959). Implications: This review will deliver a comprehensive overview on the empirical basis to contribute to the further development of psychological treatments for young people with personality disorders.

Mediators in Psychological Treatments for Anxiety and Depression in Adolescents and Young People: A Protocol of a Systematic Review.

INTRODUCTION: Anxiety and depressive disorders are a significant problem that starts in childhood or adolescence and should be addressed early to avoid chronic mental conditions. There is strong evidence to demonstrate that psychological treatments are effective for these disorders, however, little is known on mediators and mechanisms of change of psychological treatment in adolescents and young adults. Understanding the pathways through which psychological treatments operate will facilitate more effective treatments. AIM: We aim to conduct a systematic review, exploring the available evidence on mediators of psychological treatments for anxiety and depression in adolescents and young adults. METHODS: A systematic search has been performed on PubMed and PsycINFO databases to identify studies from inception to 23rd February 2020. Eligible studies include randomized controlled trials and trials (quasi-experimental) designs that have enrolled adolescents and young adults presenting with depression and/or anxiety and that have examined mediators of psychological treatments. A group of 20 reviewers from the COST-Action TREATme (CA16102) divided into 10 pairs independently screen studies for inclusion, extract information from the included studies, and assess the methodological quality of the included studies and the requirements for mediators. The methodological quality will be assessed by The Mixed Methods Appraisal Tool. Extracted data from the included studies will be collected and presented using a narrative approach. DISCUSSION: This systematic review will summarize and provide a comprehensive overview of the current evidence on mediators of psychological treatments for anxiety and depression for adolescents and young adults. Results will allow the identification of strategies to optimize intervention to enhance clinical outcomes. ETHICS AND DISSEMINATION: Ethics approval is not required. Findings from this systematic review will be published in a peer-reviewed journal and disseminated at conferences and meetings. PROSPERO registration number: CRD42021234641.

Mediators and theories of change in psychotherapy with adolescents: a systematic review protocol.

INTRODUCTION: Approximately 75% of mental disorders emerge before the age of 25 years but less than half receive appropriate treatment. Little is known about the mechanisms underlying the therapeutic change of adolescents in psychotherapy. The 'European Network of Individualised Psychotherapy Treatment of Young People with Mental Disorders', funded by the European Cooperation in Science and Technology, will conduct the first systematic review to summarise the existing knowledge on mediators and theories of change in psychotherapy for adolescents. METHOD: A systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched on 23 February 2020, for prospective, longitudinal and case-control designs which examine mediators of change. Participants will be adolescents between 10 and 19 years of age who suffer from a mental disorder or psychological difficulties and receive an intervention that aims at preventing, ameliorating and/or treating psychological problems. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review as no primary data will be collected. The results will be published in a peer-reviewed journals and at conference presentations and will be shared with stakeholder groups. The whole data set will be offered to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives. PROSPERO REGISTRATION NUMBER: CRD42020177535.

Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review.

BACKGROUND: Externalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old). METHODS: A systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis. RESULTS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent-adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively. CONCLUSIONS: Family variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified. ETHICS AND DISSEMINATION: Ethical approval was not required. PROSPERO registration number: CRD42021231835.

Differences in attachment dimensions and reflective functioning between traumatized juvenile offenders and maltreated non-delinquent adolescents from care services.

BACKGROUND: Adverse childhood experiences, especially maltreatment, are regarded as significant risk factors for the development of antisocial behavior in adolescence. However, possible correlates are still to be investigated after considering the history of criminal records and the experience of institutionalization. OBJECTIVE: In this study, differences in attachment anxiety and avoidance, and reflective functioning (RF) between traumatized incarcerated juvenile offenders and non-delinquent adolescents institutionalized in child services because of domestic violence were examined. PARTICIPANTS, SETTING AND METHOD: Forty-two juvenile offenders (Nfemale = 19) and 43 inmates of institutions for adolescents without parental care (Nfemale = 20) with the history of trauma filled in the childhood trauma and attachment dimensions questionnaires, and were scored on the Reflective Functioning Scale. Groups were matched on age and education. RESULTS: Results indicate that both groups reported equally high levels of attachment anxiety and avoidance. Male juvenile offenders had lower scores on reflective functioning than both female convicted minors (B = 1.06; Odds Ratio = 2.88; Nagelkerkes R2 = 45) and non-delinquent adolescents of both genders (B = -.65; Odds Ratio = .52; Nagelkerkes R2 = 42). In comparison to non-convicted males, male offenders also had higher scores on the control scale of idealization (B = .35; Odds Ratio = 1.42; Nagelkerkes R2 = 42). No differences between females with and without a history of crimes were found. CONCLUSIONS: Results indicate a need for building RF in both traumatized samples, especially in male delinquents, and encourage further research in females.

Psychometric evaluation of the Hamburg Nightmare Questionnaire (HNQ).

Background: Nightmares are a widespread phenomenon. In comparison to the general population, they occur in mentally ill and especially in traumatized individuals with an increased frequency. Despite the high prevalence, there is no short questionnaire in the German language that is able to characterize nightmares, to differentiate between different nightmare types and to assess their impact on daytime functioning. Objective: The Hamburg Nightmare Questionnaire (HNQ) has been developed as a short self-rating instrument to fill this gap. Method: Psychometric characteristics of the HNQ were evaluated in a sample of 707 German soldiers passing through the standard diagnostics of the Center for Mental Health at the German Armed Forces Hospital Hamburg. Results: The results of this study show satisfactory psychometric characteristics as a sound factorial structure and adequate internal consistency for the HNQ as well as initial indications of the construct validity of its subscales. Conclusions: The HNQ is a reliable and economic tool for the assessment of posttraumatic nightmares in clinical as well as research settings.

Antecedentes: Las pesadillas son un fenómeno ampliamente generalizado. En comparación con la población general, las pesadillas ocurren con una mayor frecuencia en personas con enfermedad mental y, especialmente, en personas traumatizadas. A pesar de su alta prevalencia, no existe ningún cuestionario breve en idioma alemán que sea capaz de caracterizar las pesadillas, diferenciarlas en tipos, y evaluar su impacto sobre la funcionalidad durante el periodo de vigilia.Objetivo: Se desarrolló el Cuestionario de Pesadillas de Hamburgo (HNQ, por sus siglas en inglés) como un instrumento de valoración breve auto-aplicado para subsanar esta brecha.Método: Se evaluaron las características psicométricas del HNQ a partir de una muestra de 707 soldados alemanes que eran sometidos a los diagnósticos estándar del Centro para la Salud Mental del Hospital de Hamburgo de las Fuerzas Armadas Alemanas.Resultados: Los resultados de este estudio mostraron características psicométricas satisfactorias, tales como una firme estructura factorial y una adecuada consistencia interna para el HNQ, así como indicadores iniciales de la validez del constructo de sus subescalas.Conclusiones: El HNQ es una herramienta confiable y económica para la evaluación de pesadillas postraumáticas tanto en el ámbito clínico como en el de investigación.

Association of posttraumatic nightmares and psychopathology in a military sample.

OBJECTIVE: Nightmares are among the most frequent and disturbing symptoms of posttraumatic stress disorder (PTSD). However, basic research questions regarding key associations between certain nightmare characteristics, especially replicativeness, and posttraumatic psychopathology need further empirical elaboration. METHOD: Sixty-two German soldiers (mean age 33.8 years, 17.7% females) admitted to a hospital-based treatment program for veterans completed extensive assessments consisting of clinical interviews and self-rating measures with respect to sociodemographic characteristics and psychopathology as well as dream-related variables. RESULTS: Although nightmare distress, frequency, and replicativeness were all linked to PTSD symptomatology, only the latter proved to be a significant predictor of PTSD diagnosis. Moreover, none of these nightmare characteristics predicted a depression diagnosis. CONCLUSIONS: The replicativeness of nightmares appears to be a key variable for understanding the relationship between posttraumatic nightmares and PTSD, whereas nightmare frequency and distress appear to be more aptly defined as generic markers of mental health. (PsycINFO Database Record