PRACTICE makes progress, a self-care course for mental health professionals in the child trauma field: A preliminary investigation.

OBJECTIVE: Mental health professionals who work with clients exposed to trauma commonly experience secondary traumatic stress (STS) and burnout, which have a well-documented negative impact on clinicians as well as clients. As self-care has been identified as a protective factor against STS and burnout, the current study aimed to examine the effects of a self-care course for mental health professionals working with trauma-exposed clients. METHOD: This pretest-posttest pilot study examined the impact of a six-session virtual self-care course on the well-being of 43 mental health professionals previously trained in Trauma-focused Cognitive Behavioral Therapy(TF-CBT), a well-established, evidence-based treatment for childhood trauma. The components of TF-CBT comprise the acronym PRACTICE, and we are referring to this self-care course as PRACTICE Makes Progress (PMP), as participants receive weekly assignments that encourage the use of many of the same PRACTICE skills clients are taught in the context of TF-CBT. RESULTS: Results comparing pre- and postcourse survey responses indicated significant increases in the use of PRACTICE skills (p = .006, d = .44) as well as the utilization of humor as a coping skill (p < .001, d = .53), and significant decreases in STS symptoms (p < .001, d = .63) and burnout (p = .004, d = .47). CONCLUSIONS: These results provide preliminary evidence that mental health professionals working with clients exposed to trauma may benefit from participation in an evidence-informed, standalone virtual self-care course. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Bisphenol-A and phthalate metabolism in children with neurodevelopmental disorders.

BACKGROUND: The etiology of autism spectrum (ASD) and Attention Deficit/Hyperactivity (ADHD) disorders are multifactorial. Epidemiological studies have shown associations with environmental pollutants, such as plasticizers. This study focused on two of these compounds, the Bisphenol-A (BPA) and Diethylhexyl Phthalate (DEHP). The major pathway for BPA and DEHP excretion is via glucuronidation. Glucuronidation makes insoluble substances more water-soluble allowing for their subsequent elimination in urine. HYPOTHESIS: Detoxification of these two plasticizers is compromised in children with ASD and ADHD. Consequently, their tissues are more exposed to these two plasticizers. METHODS: We measured the efficiency of glucuronidation in three groups of children, ASD (n = 66), ADHD (n = 46) and healthy controls (CTR, n = 37). The children were recruited from the clinics of Rutgers-NJ Medical School. A urine specimen was collected from each child. Multiple mass spectrometric analyses including the complete metabolome were determined and used to derive values for the efficiency of glucuronidation for 12 varied glucuronidation pathways including those for BPA and MEHP. RESULTS: (1) Both fold differences and metabolome analyses showed that the three groups of children were metabolically different from each other. (2) Of the 12 pathways examined, only the BPA and DEHP pathways discriminated between the three groups. (3) Glucuronidation efficiencies for BPA were reduced by 11% for ASD (p = 0.020) and 17% for ADHD (p<0.001) compared to controls. DEHP showed similar, but not significant trends. CONCLUSION: ASD and ADHD are clinically and metabolically different but share a reduction in the efficiency of detoxification for both BPA and DEHP with the reductions for BPA being statistically significant.

TF-CBT Training Augmented with a Self-Care Focus: Understanding Facilitators and Barriers to Treatment Implementation.

Clinicians working with youth exposed to trauma may be at increased risk for experiencing elevated levels of stress and symptoms of secondary traumatic stress, which can negatively impact clinician wellbeing and ultimately contribute to reduced access to quality care for clients. An innovative Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training incorporating self-care practices (i.e., Practice What You Preach; PWYP) was developed to help facilitate the implementation of TF-CBT and to enhance clinicians' coping and decrease stress. The primary purpose of this study was to determine whether the PWYP-augmented training met three Objectives: (1) increase clinicians' feelings of TF-CBT competency; (2) improve clinicians' coping abilities/reduce clinicians' stress; and (3) increase clinicians' insight into the benefits and/or challenges clients may experience in treatment. An exploratory aim was also developed to identify additional facilitators and barriers of TF-CBT implementation. The written reflections of 86 community-based clinicians who participated in the PWYP-augmented TF-CBT training were examined using qualitative methods. The majority of clinicians indicated increased feelings of competency and improved coping abilities and/or stress levels; almost half mentioned increased insight into clients' experiences. The most frequently mentioned additional facilitators were related to elements of the TF-CBT treatment model. Anxiety/self-doubt was the barrier most frequently mentioned, though all clinicians who mentioned this barrier indicated it lessened or resolved over the course of the training. Incorporating self-care strategies into trainings may serve as a facilitator for TF-CBT implementation by enhancing the competency and well-being of clinicians. The additional insights into barriers and facilitators can be used to further improve the PWYP initiative and future training and implementation efforts.

Decreased Adiponectin Levels in Early Pregnancy Are Associated with High Risk of Prematurity for African American Women.

The relationship of low maternal serum adiponectin levels with preterm delivery among a multi-ethnic group has not been extensively investigated. We examined ethnic differences in cytokine/adipokine profiles and whether they contribute to several adverse pregnancy outcomes, particularly preterm delivery. Data and samples were from a large prospective observational cohort (n = 1776) of young, generally healthy pregnant women (African American 36.4%, Hispanic 48.0%, Caucasian 15.6%). Serum cytokine/adipokine concentrations were measured at entry (mean gestational age of 16.83 weeks) using the Liminex xMap Technology. Multivariable analyses were performed. A significant difference in adiponectin level was observed among ethnic groups. African Americans had a decreased adiponectin and increased resistin levels compared to Hispanics and Caucasians (p < 0.05 to p < 0.0001 for each). Decreased adiponectin (lowest quartile) was positively associated with preterm delivery independent of usual risk factors (adjusted odds ratio (AOR) 1.46, 95% confidence interval (CI) 1.05, 2.04 for all preterm and AOR 1.84, 95% CI 1.07, 3.17 for early preterm births). The results were unchanged when women with preeclampsia were excluded. Similar results were observed in African Americans. Decreased adiponectin levels were not related to preterm birth in either Hispanics or Caucasians. Lower adiponectin levels were also significantly associated with an increased risk of developing gestational diabetes (AOR 1.72, 95% CI 1.05, 2.84) and preeclampsia (AOR 1.45, 95% CI 1.00, 2.14) in the whole cohort and in Caucasians. We did not find any consistent relationships between the other markers with outcome variables. Dysregulation in maternal adiponectin at early gestation is associated with an increased risk of preterm delivery. An ethnic difference in adiponectin levels may contribute to a higher preterm delivery rate in African American women.

Caregiver Satisfaction and Perceptions of Trauma-Focused Cognitive Behavioral Therapy.

Although caregivers have been found to be critical to children's healing, little has been documented about caregivers' experiences in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). The current study describes caregivers' satisfaction with and perceptions of TF-CBT. Caregivers (n = 431) of children/adolescents (n = 496) who completed TF-CBT filled out pre-treatment questionnaires on demographics and perceived aloneness in facing their child's trauma, and posttreatment questionnaires on treatment satisfaction and perceptions of TF-CBT. Caregivers rated treatment satisfaction an average of 30.59 (SD = 3.15) out of a maximum score of 32 on the Client Satisfaction Questionnaire-8. The majority of caregivers endorsed that talking about their child's trauma was more helpful than discussing other current problems, they spoke frequently with their child's therapist about their child's trauma, they reported information/skill building in therapy were more helpful than support received, they felt understood by their therapist, treatment helped them more effectively parent, and treatment helped improve their relationship with their child. Perceptions were associated with overall treatment satisfaction. There was a significant reduction in caregivers' feelings of aloneness in facing their child's trauma from pre- to posttreatment, which was also related to overall treatment satisfaction. Caregivers reported high satisfaction with TF-CBT, and identified talking about their child's trauma as more helpful than talking about problems not related to the trauma. Caregivers endorsed benefits of participating in TF-CBT, including feeling less alone in facing their child's trauma, improved relationship with their child, and more effective parenting skills. These results have important treatment implications.

Disseminating Trauma-Focused Cognitive Behavioral Therapy with a Systematic Self-care Approach to Addressing Secondary Traumatic Stress: PRACTICE What You Preach.

This pilot study evaluated the effectiveness of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training programs augmented with a systematic "PRACTICE What You Preach" (PWYP) self-care focus, which has trainees personally utilize the coping skills they teach their clients. Participants were 115 clinicians/supervisors who completed a PWYP TF-CBT training program. Pre- to post-training analyses documented significant increases in participants' competency and fidelity in implementing TF-CBT (ps < .001), significantly more frequent use of coping skills including instrumental social support (p < .01), active coping (p < .001), humor (p < .01), and restraint (p < .01), and significant decreases in secondary traumatic stress (STS; p < .001). Children's symptoms of PTSD (ps < .001) and behavior problems (p < .05) also decreased significantly. This preliminary evidence suggests that training augmented with PWYP may enhance clinicians'/supervisors' personal coping and reduce their levels of STS without compromising treatment implementation efforts and client outcomes.

Individual free fatty acids have unique associations with inflammatory biomarkers, insulin resistance and insulin secretion in healthy and gestational diabetic pregnant women.

Objective: We investigated the relationships of maternal circulating individual free fatty acids (FFA) with insulin resistance, insulin secretion and inflammatory biomarkers during mid-pregnancy. Research design and methods: The data were drawn from a prospective cohort of generally healthy pregnant women (n=1368, African-American 36%, Hispanic 48%, Caucasian 16%) in Camden, NJ. We quantitatively determined 11 FFAs, seven cytokine/adipokine, homeostatic model assessment of insulin resistance (HOMA-IR) and C-peptide levels from the fasting blood samples that were collected at 16 weeks of gestation. Multivariate analyses were performed along with separate analyses for each individual FFA. Results: High HOMA-IR (p<0.001) and C-peptide (p<0.0001) levels were positively associated with a twofold to fourfold increased risk for developing gestational diabetes mellitus (GDM). Negative relationships were found with specific FFAs (molecular percentage, palmitoleic, oleic, linolenic, myristic acids) and HOMA-IR and C-peptide levels (p<0.01 to p<0.0001). In contrast, palmitic, stearic, arachidonic, dihomo-γ-linolenic (DGLA) and docosahexaenoic acids were positively associated with HOMA-IR and C-peptide (p<0.01 to p<0.0001). The individual FFAs also predicted cytokine/adipokine levels. For example, women who had elevated DGLA (highest quartile) were twice as (adjusted OR 2.06, 95% CI 1.42 to 2.98) likely to have higher interleukin (IL)-8 (p<0.0001) levels. Conversely, women with high palmitoleic, oleic, and linolenic acid levels had reduced odds (≥2-fold, p<0.01 to p<0.001) for having higher IL-8, IL-6 or tumor necrosis factor-alpha levels. Conclusion: Our results suggest that maternal individual FFAs uniquely affect insulin resistance and secretion. The effects are either direct or indirect via modulation of the inflammatory response. Modifying the composition of FFAs may help in reducing the risk of GDM.

Overall severities of gastrointestinal symptoms in pediatric outpatients with and without autism spectrum disorder.

In order to determine the effectiveness of a Gastrointestinal Severity Index to screen for gastrointestinal disorders, the Gastrointestinal Severity Index was administered to 135 children with autism spectrum disorders and 146 comparisons with and without gastrointestinal disorders. The mean Gastrointestinal Severity Index scores of the groups were 3.53 ± 1.78, 3.15 ± 1.99, 0.81 ± 1.25, and 0.29 ± 0.76 (comparative pediatric patients with gastrointestinal disorder = autism spectrum disorder + gastrointestinal disorder > autism spectrum disorder-gastrointestinal disorder > comparative pediatric patients without gastrointestinal disorder, respectively), Ps < 0.05. Receiver operating characteristic curves and areas under the receiver operating characteristic curves were calculated to ascertain which Gastrointestinal Severity Index cutoff scores yielded the highest sensitivity and specificity rates for the diagnosis of gastrointestinal disorders. The area under the receiver operating characteristic curve (0.97) for the comparison group was higher (P < 0.001) than the area under the receiver operating characteristic curve (0.85) for autism spectrum disorder children indicating that the Gastrointestinal Severity Index was more effective in screening for gastrointestinal disorders in comparisons. However, the same Gastrointestinal Severity Index cutoff score of 2 and above yielded, respectively, sensitivity and specificity rates of 92% and 93% for comparisons and 80% and 79% for autism spectrum disorder children. The negative and positive predictive values based on these sensitivity and specificity rates were calculated for a range of prevalences of gastrointestinal disorders and indicated that the Gastrointestinal Severity Index may be useful for screening children with and without autism spectrum disorder for gastrointestinal symptoms.

A Gut Feeling: A Hypothesis of the Role of the Microbiome in Attention-Deficit/Hyperactivity Disorders.

Attention-deficit/hyperactivity disorder (ADHD) is a neurologic disorder characterized by hyperactivity/impulsivity and/or inattentiveness, with genetic and environmental factors contributing to the disorder. With the growing recognition of the microbiome's role in many neurological disorders, the authors propose that it may also be implicated in ADHD. Here, we describe several evolving areas of research to support this hypothesis. First, a unique composition of gut bacteria has been identified and linked to behaviors in ADHD. Second, our research found an increased incidence of 2 gastrointestinal symptoms (constipation and flatulence) in children with ADHD, as compared to controls. Finally, emerging data may be interpreted to suggest that immune dysregulation in ADHD be associated with an altered microbiome, low-grade inflammation, and gastrointestinal dysfunction. Although more studies are needed to elucidate exact mechanisms and causality, we propose that an altered microbiome, gastrointestinal symptoms, and immune dysregulation may be associated with the ADHD phenotypes.

Improvements in personal resiliency among youth who have completed trauma-focused cognitive behavioral therapy: A preliminary examination.

This preliminary investigation assessed whether different aspects of personal resiliency improved for youth (7-17 years old) impacted by child sexual abuse (CSA) after completing trauma-focused cognitive behavioral therapy (TF-CBT). The Resiliency Scales for Children and Adolescents (RSCA; Prince-Embury, 2007) were administered to 157 youth before and after participating in TF-CBT with their nonoffending caregivers. Hierarchal regression analyses were performed to ascertain whether pretest RSCA resiliency scores moderated decreases in the posttraumatic stress and self-reported depressive symptoms at posttreatment. The RSCA scales did not moderate any of the improvements on the PTSD and depression outcome measures. Paired t-tests between the mean pre- and posttest RSCA Sense of Mastery (MAS), Sense of Relatedness (REL), and Emotional Reactivity (REA) scores demonstrated significant (ps<0.001) improvements on these measures over time. Using residualized posttest scores for the three RSCA scales to assess improvement, significant correlations were found between changes in resiliency and various residualized outcome scores for posttraumatic stress disorder (PTSD) and depression measures. Decreases in the REA scores and increases in the MAS and REL scores were related to fewer symptoms of hypervigilance and less self-reported depression after completing TF-CBT. Only improvements in the REL scores were associated with fewer symptoms of re-experiencing after treatment. The results were discussed as indicating that significant improvements in personal resiliency had occurred over time with effect sizes less than those found for posttraumatic stress symptoms, but comparable to those found for self-reported depression reductions. Limitations and future research recommendations are discussed.

Maternal Circulating Lipid Profile during Early Pregnancy: Racial/Ethnic Differences and Association with Spontaneous Preterm Delivery.

Prior reports on the association between altered maternal serum lipid levels with preterm delivery are inconsistent. Ethnic differences in serum lipids during pregnancy and their relation to preterm delivery have not been studied. We examined the relationships of six maternal lipids during early pregnancy with the risk of spontaneous preterm delivery (SPTD). The design represents a case-control study nested within a large prospective, multiethnic cohort of young, generally healthy pregnant women. SPTD cases (n = 183) and controls who delivered at term (n = 376) were included. SPTD is defined as delivery at <37 completed weeks of gestation without indicated conditions. We found that African-American women had significantly increased levels of high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1 (apoA1), and lower triglyceride (TG) and apolipoprotein B (apoB) levels compared to Hispanic and non-Hispanic Caucasians combined. Elevated HDL-C and apoA1 concentrations were significantly associated with an increased odds of SPTD after controlling for potential confounding factors. The adjusted odds ratio (AOR) was 1.91 (95% confidence interval (CI) 1.15, 3.20) for the highest quartile of HDL-C relative to the lowest quartile, and for apoA1 the AOR was 1.94 (95% CI 1.16, 3.24). When controlling for ethnicity, the results remained comparable. These data suggest that pregnant African-American women had a more favorable lipid profile suggestive of a reduction in cardiovascular risk. Despite this, increased HDL-C and apoA1 were both found to be associated with SPTD.

The Predictive Validity of the Beck Depression Inventory Suicide Item.

OBJECTIVE: The current study examines the predictive validity of the Beck Depression Inventory (BDI) suicide item for death by suicide and suicide attempts. METHOD: The study included 2 samples: (1) 5,200 psychiatric outpatients who were evaluated between 1975 and 1995 and followed prospectively for up to 20 years (all psychiatric diagnoses based on DSM-III and DSM-III-R), and (2) 119 patients who, between 2000 and 2004, participated in a randomized controlled trial of outpatient Cognitive Therapy for Suicide Prevention after a suicide attempt and were followed for 18 months (all psychiatric diagnoses based on DSM-IV-TR). All patients completed structured diagnostic interviews, as well as the BDI and Scale for Suicide Ideation. RESULTS: Cox regression models demonstrated that the BDI suicide item significantly predicted both deaths by suicide (Wald χ(2)1 = 35.67; P < .001 [N = 5,200]) and repeat suicide attempts (Wald χ(2)1 = 8.82; P < .01 [N = 119]), with each successive rating on the item conferring greater risk. Using receiver operating characteristic (ROC) curves, optimal cutoff scores of 1 and above for suicide and 2 and above for suicide attempts were identified as providing the best balance between sensitivity and specificity. CONCLUSIONS: The BDI suicide item is associated with both risk of repeat suicide attempts and death by suicide. The use of the item as a brief, efficient screen for suicide risk in routine clinical care is recommended. Clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen. Future research examining the item's performance in other at-risk groups (ie, older adults, adolescents, inpatients, etc) is encouraged.

Bisphenol A Exposure in Children With Autism Spectrum Disorders.

The etiology of autism spectrum disorders (ASD) is believed to involve genetic and environmental components. This study focused on the plasticizer, Bisphenol-A (BPA). The major pathway for BPA metabolism and excretion is via glucuronidation. To determine whether there was a relationship between BPA exposure and ASD, urine specimens were collected from 46 children with ASD and 52 controls. Free and total BPA concentrations were determined by mass spectrometry. The fraction glucuronidated was calculated from the difference. A metabolomics study was done to investigate metabolite distribution in the urine. (i) Most of the BPA excreted in the urine was as the glucuronide; (ii) about 20% of the ASD children had BPA levels beyond the 90th percentile (>50 ng/mL) of the frequency distribution for the total sample of 98 children; (iii) Mann-Whitney U tests and multiple regression analyses found significant differences (P < 0.05) between the groups in total and % bound BPA; and (iv) the metabolomics analyses showed the number of absolute partial correlations >|0.30| between metabolite concentrations and total BPA was ∼3 times greater with the ASD group than the controls (P < 0.001), and the number of absolute partial correlations > |0.30| for % bound BPA was ∼15 times higher with ASD (P < 0.001). The results suggest there is an association between BPA and ASD.

PTSD symptom cluster profiles of youth who have experienced sexual or physical abuse.

The research examined whether youth (6-17 years old) who were referred for treatment due to sexual, physical, or both types of abuse presented with distinct profiles of PTSD DSM-IV-TR symptom clusters. When examining data for the 749 youth participants, five PTSD symptom cluster profiles were identified with each profile representing approximately 20% of the youth. The five profiles were also differentiated with respect to being referred for physical or sexual abuse, age, parental ratings of internalizing symptoms, and self-reported depression. The youth referred for treatment in the aftermath of child sexual, physical, or both sexual and physical abuse presented with different profiles of PTSD symptom clusters thereby suggesting a need for individualized tailoring of evidenced-based treatments. Two cognitive behavioral approaches, designed for traumatized children and either their nonoffending or offending parents, were described for treating youth with the distinct PTSD profiles.

Depression and parenting by nonoffending mothers of children who experienced sexual abuse.

Parenting may be one mechanism by which depression in nonoffending mothers impacts child emotional and behavioral adjustment after sexual abuse. This study examined the relationship between self-reported maternal depression and parenting behaviors by nonoffending mothers of children who experienced sexual abuse. The participants were 204 nonoffending biological mother-child pairs recruited from a clinic providing services for children who experienced sexual abuse. The mothers completed pretreatment self-report measures of demographic information, depression, and parenting behaviors. Children (7 to 17 years) completed a measure of mothers' parenting behaviors. Mothers with clinically high levels of self-reported depression employed more inconsistent parenting behavior and provided poorer monitoring/supervision of their children than mothers without clinically high levels of self-reported depression. Implications for clinical practice and future research are discussed.

Autism and phthalate metabolite glucuronidation.

Exposure to environmental chemicals may precipitate autism spectrum disorders (ASD) in genetically susceptible children. Differences in the efficiency of the glucuronidation process may substantially modulate substrate concentrations and effects. To determine whether the efficiency of this pathway is compromised in children with ASD, we measured the efficiency of glucuronidation for a series of metabolites derived from the commonly used plasticizer, diethylhexyl phthalate. Spot urines were collected and analyzed for the fraction of each metabolite conjugated by isotope dilution-liquid chromatography mass spectrometry-mass spectrometry. The degree of glucuronidation was lower with the ASD group. The glucuronidation pathway may differ in some children with ASD.

Trauma-focused cognitive-behavioral therapy for children: sustained impact of treatment 6 and 12 months later.

This study presents the findings from 6- and 12-month follow-up assessments of 158 children ages 4-11 years who had experienced sexual abuse and who had been treated with Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) with or without the inclusion of the trauma narrative (TN) treatment module and in 8 or 16 treatment sessions. Follow-up results indicated that the overall significant improvements across 14 outcome measures that had been reported at posttreatment were sustained 6 and 12 months after treatment and on two of these measures (child self-reported anxiety and parental emotional distress) there were additional improvements at the 12-month follow-up. Higher levels of child internalizing and depressive symptoms at pretreatment were predictive of the small minority of children who continued to meet full criteria for posttraumatic stress disorder at the 12-month follow-up. These results are discussed in the context of the extant TF-CBT treatment literature.

Screening for attention-deficit/hyperactivity disorder in adult inpatients with psychiatric disorders.

The purpose was to assess the effectiveness of the adult ADHD Module from the MINI International Neuropsychiatric Interview (MINI) and the Conners' Adult ADHD Rating Scales: Screening Version DSM-IV ADHD Symptoms Total Scale (CAARS-S:SV) in screening for attention-deficit/hyperactivity (ADHD) disorder in patients hospitalized for other psychiatric disorders. Assessment measures were administered to 55 (50%) female and 55 (50%) male adult (>18 yr. old) inpatients. Only six (5%) of the 110 inpatients had been diagnosed with comorbid ADHD according to medical charts. In contrast, 55 (50%) patients met criteria for ADHD according to the MINI, and 39 (36%) patients met criteria on the CAARS-S:SV. The higher rates of prevalence for the MINI and the CAARS-S:SV were attributable to symptom criteria for ADHD being similar to those shared with comorbid disorders.

Self-reported inability to cry as a symptom of anhedonic depression in outpatients with a major depressive disorder.

To ascertain whether self-reported inability to cry would be associated with symptoms of anhedonic depression, the 21-item Beck Depression Inventory-II was administered to 1,050 outpatients diagnosed with a DSM-IV-TR major depressive disorder. 219 (21%) patients reported on the BDI-II Crying item that they were unable to cry, and 831 (79%) patients reported they were able to cry. Only BDI-II Loss of Interest was significantly associated with the inability to cry after the other BDI-II symptoms were controlled for using a multiple logistic-regression analysis. The inability to cry was discussed as an indicator of anhedonic depression.

Trauma-focused cognitive behavioral therapy for children: impact of the trauma narrative and treatment length.

BACKGROUND: Child sexual abuse (CSA) is associated with the development of a variety of mental health disorders, and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an established treatment for children who have experienced CSA. However, there are questions about how many TF-CBT sessions should be delivered to achieve clinical efficacy and whether a trauma narrative (TN) component is essential. This study examined the differential effects of TF-CBT with or without the TN component in 8 versus 16 sessions. METHODS: Two hundred and ten children (aged 4-11 years) referred for CSA and posttraumatic stress disorder symptoms were randomly assigned to one of the four treatment conditions: 8 sessions with no TN, 8 sessions with TN, 16 sessions with no TN, and 16 sessions with TN. RESULTS: Mixed-model ANCOVAs demonstrated that significant posttreatment improvements had occurred with respect to 14 outcome measures across all conditions. Significant main and interactive effect differences were found across conditions with respect to specific outcomes. CONCLUSIONS: TF-CBT, regardless of the number of sessions or the inclusion of a TN component, was effective in improving participant symptomatology as well as parenting skills and the children's personal safety skills. The eight session condition that included the TN component seemed to be the most effective and efficient means of ameliorating parents' abuse-specific distress as well as children's abuse-related fear and general anxiety. On the other hand, parents assigned to the 16 session, no narrative condition reported greater increases in effective parenting practices and fewer externalizing child behavioral problems at posttreatment.