Prolonged exposure treatment for post-traumatic stress disorder: Single case studies in a sample of adults with mild intellectual disabilities.

BACKGROUND: Post-traumatic stress disorder (PTSD) is common in adults with intellectual disabilities. Often there are additional disorders such as substance use, mood and anxiety disorders. The current study focuses on the feasibility and initial efficacy of prolonged exposure (PE) for PTSD in adults with mild intellectual disabilities. The secondary effect of PE on additional mood, anxiety and substance use disorders is also examined. METHODS: A single case experimental design (N = 12) with an A (baseline)-B (intervention) phase including a follow-up measurement after 3 months was conducted. Time series and single time points measurements were performed. RESULTS: Six participants dropped-out. The results showed a significant decrease in PTSD symptoms and a significant decrease in additional symptoms (social avoidance, anxiety and stress), among participants who completed treatment. CONCLUSION: PE appears to be a feasible and effective treatment for PTSD in some adults with mild intellectual disabilities. Suggestions emerge from this study to make standard PE treatment more appropriate for adults with mild intellectual disabilities. Further research is needed to reduce drop-out in trauma treatment. Some suggestions for this are made in this study. Treatment of PTSD with PE did not appear to affect comorbid mood disorders. Further research is needed.

Effectiveness of game-based meditation therapy on neurobiological stress systems in adolescents with posttraumatic symptoms: a randomized controlled trial.

Many adolescents in residential care have experienced traumatic events and suffer from posttraumatic stress. Prolonged activation of neurobiological stress systems as the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis can result in long-lasting maladaptive alternations. This study investigated the effectiveness of Muse, a game-based meditation intervention, on the sympathetic nervous system (SNS), parasympathetic nervous system (PNS), and cortisol basal activity and reactivity to acute stress among adolescents with posttraumatic symptoms in residential care. The intervention consisted of two gameplay sessions a week, for 6 consecutive weeks. Seventy-seven adolescents with clinical levels of posttraumatic symptoms (10-18 years old) received either Muse as an addition to treatment as usual (n = 40) or treatment as usual alone (n = 37). We expected reduced basal activity for the SNS and cortisol and increased basal activity for the PNS. As for the response to acute stress, we expected decreased PNS and increased HPA axis reactivity. The Muse group exhibited lower basal activity for the SNS and increased HPA reactivity to acute stress. There were no differences between conditions on SNS and HPA axis activity during rest and on SNS and PNS reactivity to acute stress. Game-based meditation therapy is a promising intervention for the treatment of adolescents with posttraumatic symptoms in residential care. Implications for clinical relevance and trauma-focused treatment purposes are discussed.

Alterations of autonomic nervous system and HPA axis basal activity and reactivity to acute stress: a comparison of traumatized adolescents and healthy controls.

Alterations in neurobiological stress systems such as the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis contribute to the development and maintenance of psychological and behavioral problems after traumatic experiences. Investigating neurobiological parameters and how these relate to each other may provide insight into the complex mechanisms at play. Whereas the preponderance of studies focuses on either the ANS or the HPA axis separately, the current study is the first to evaluate relations between posttraumatic stress and both basal activity during rest and stress reactivity of the ANS as well as the HPA axis in a sample of traumatized adolescents and healthy controls. The traumatized sample (n = 77), based on clinical levels of posttraumatic stress, was a convenience sample that was recruited within residential institutions, was compared to a healthy control sample (n = 48) recruited within the general community. For the ANS, we expected increased SNS and decreased PNS activity during rest and increased SNS and decreased PNS reactivity to social stress among traumatized adolescents compared to healthy controls. Regarding the HPA axis, we expected increased basal cortisol levels and decreased cortisol reactivity to stress in the traumatized sample. Compared to healthy controls, traumatized adolescents exhibited significantly higher sympathetic and lower parasympathetic activation during rest and increased sympathetic reactivity to acute stress (ANS parameters). Outcomes on the HPA axis (i.e. cortisol) indicated that traumatized adolescents showed increased cortisol levels during rest and blunted cortisol reactivity to acute stress. Implications for clinical relevance and trauma-focused treatment purposes are discussed.

Game-Based Meditation Therapy to Improve Posttraumatic Stress and Neurobiological Stress Systems in Traumatized Adolescents: Protocol for a Randomized Controlled Trial.

BACKGROUND: Many adolescents in residential care have been exposed to prolonged traumatic experiences such as violence, neglect, or abuse. Consequently, they suffer from posttraumatic stress. This not only negatively affects psychological and behavioral outcomes (eg, increased anxiety, depression, and aggression) but also has adverse effects on physiological outcomes, in particular on their neurobiological stress systems. Although current evidence-based treatment options are effective, they have their limitations. An alternative to traditional trauma treatment is meditation-based treatment that focuses on stress regulation and relaxation. Muse is a game-based meditation intervention that makes use of adolescents' intrinsic motivation. The neurofeedback element reinforces relaxation abilities. OBJECTIVE: This paper describes the protocol for a randomized controlled trial in which the goal is to examine the effectiveness of Muse (InteraXon Inc) in reducing posttraumatic stress and normalizing neurobiological stress systems in a sample of traumatized adolescents in residential care. METHODS: This will be a multicenter, multi-informant, and multimethod randomized controlled trial. Participants will be adolescents (N=80), aged 10 to 18 years, with clinical levels of posttraumatic symptoms, who are randomized to receive either the Muse therapy sessions and treatment as usual (intervention) or treatment as usual alone (control). Data will be collected at 3 measurement instances: pretest (T1), posttest (T2), and at 2-month follow-up. Primary outcomes will be posttraumatic symptoms (self-report and mentor report) and stress (self-report) at posttest. Secondary outcomes will be neurobiological stress parameters under both resting and acute stress conditions, and anxiety, depression, and aggression at posttest. Secondary outcomes also include all measures at 2-month follow-up: posttraumatic symptoms, stress, anxiety, depression aggression, and neurobiological resting parameters. RESULTS: The medical-ethical committee Arnhem-Nijmegen (NL58674.091.16) approved the trial on November 15, 2017. The study was registered on December 2, 2017. Participant enrollment started in January 2018, and the results of the study are expected to be published in spring or summer 2021. CONCLUSIONS: Study results will demonstrate whether game-based meditation therapy improves posttraumatic stress and neurobiological stress systems, and whether it is more effective than treatment as usual alone for traumatized adolescents. TRIAL REGISTRATION: Netherlands Trial Register NL6689 (NTR6859); https://www.trialregister.nl/trial/6689. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19881.

Validity of the Empatica E4 Wristband to Measure Heart Rate Variability (HRV) Parameters: a Comparison to Electrocardiography (ECG).

Wearable monitoring devices are an innovative way to measure heart rate (HR) and heart rate variability (HRV), however, there is still debate about the validity of these wearables. This study aimed to validate the accuracy and predictive value of the Empatica E4 wristband against the VU University Ambulatory Monitoring System (VU-AMS) in a clinical population of traumatized adolescents in residential care. A sample of 345 recordings of both the Empatica E4 wristband and the VU-AMS was derived from a feasibility study that included fifteen participants. They wore both devices during two experimental testing and twelve intervention sessions. We used correlations, cross-correlations, Mann-Whitney tests, difference factors, Bland-Altman plots, and Limits of Agreement to evaluate differences in outcomes between devices. Significant correlations were found between Empatica E4 and VU-AMS recordings for HR, SDNN, RMSSD, and HF recordings. There was a significant difference between the devices for all parameters but HR, although effect sizes were small for SDNN, LF, and HF. For all parameters but RMSSD, testing outcomes of the two devices led to the same conclusions regarding significance. The Empatica E4 wristband provides a new opportunity to measure HRV in an unobtrusive way. Results of this study indicate the potential of the Empatica E4 as a practical and valid tool for research on HR and HRV under non-movement conditions. While more research needs to be conducted, this study could be considered as a first step to support the use of HRV recordings provided by wearables.

A novel approach to improve stress regulation among traumatized youth in residential care: Feasibility study testing three game-based meditation interventions.

AIM: Many youth in residential care suffer from post-traumatic symptoms that have adverse effects on a range of psychological, behavioural and physiological outcomes. Although current evidence-based treatment options are effective, they have their limitations. Meditation interventions are an alternative to traditional trauma-focused treatment. This pilot study aimed to evaluate three game-based meditation interventions in a sample of traumatized youth in residential care. METHODS: Fifteen participants were randomly divided over three conditions (Muse, DayDream and Wild Divine) that all consisted of twelve 15-minute game-play sessions. Physiological measurements (heart rate variability) were conducted at baseline, post-treatment and during each intervention session. Post-traumatic symptoms, stress, depression, anxiety and aggression were assessed at baseline, post-treatment and 1-month follow-up. RESULTS: Physiological stress regulation was improved during the meditation sessions of all three interventions. User evaluations were in particular high for Muse with a rating of 8.42 out of 10 for game evaluation. Overall, outcomes on psychopathology demonstrated the most robust effect on stress. Muse performed best, with all participants showing reliable improvements (reliable change indexes [RCIs]) in post-traumatic symptoms, stress and anxiety. Participants who played Daydream or Wild Divine showed inconsistent progression: some participants improved, whereas others remained stable or even deteriorated based on their RCIs. CONCLUSIONS: Preliminary findings show promising outcomes on physiology, psychopathology and user evaluations. All indicate the potential of this innovative form of stress regulation intervention, and the potential of Muse in particular, although findings should be considered preliminary due to our small sample size. Further studies are warranted to assess intervention effectiveness effects of Muse or other game-based meditation interventions for traumatized youth.

Emotional valence detection in adolescents with oppositional defiant disorder/conduct disorder or autism spectrum disorder.

Oppositional defiant disorder, conduct disorder (ODD/CD), and autism spectrum disorder (ASD) share poor empathic functioning and have been associated with impaired emotional processing. However, no previous studies directly compared similarities and differences in these processes for the two disorders. A two-choice emotional valence detection task requiring differentiation between positive, negative, and neutral IAPS pictures was administered to 52 adolescents (12-19 years) with ODD/CD, 52 with ASD and 24 typically developing individuals (TDI). Callous-unemotional (CU) traits were assessed by self- and parent reports using the Inventory of callous-unemotional traits. Main findings were that adolescents with ODD/CD or ASD both performed poorer than TDI in terms of accuracy, yet only the TDI-not both clinical groups-had relatively most difficulty in discriminating between positive versus neutral pictures compared to neutral-negative or positive-negative contrasts. Poorer performance was related to a higher level of CU traits. The results of the current study suggest youth with ODD/CD or ASD have a diminished ability to detect emotional valence which is not limited to facial expressions and is related to a higher level of CU traits. More specifically, youth with ODD/CD or ASD seem to have a reduced processing of positive stimuli and/or lack a 'positive perception bias' present in TDI that could either contribute to the symptoms and/or be a result of having the disorder and may contribute to the comorbidity of both disorders.

Using a Videogame Intervention to Reduce Anxiety and Externalizing Problems among Youths in Residential Care: an Initial Randomized Controlled Trial.

Residential care is among the most intensive forms of treatment in youth care. It serves youths with severe behavioral problems and is primarily focused on targeting externalizing problems. Despite best efforts, effect sizes remain moderate, which may be due to the disregarding of internalizing symptoms - in particular anxiety - and to limitations regarding the delivery model of interventions. This initial randomized controlled trial (n = 37) aimed to examine the effectiveness of a biofeedback videogame intervention (Dojo) as an addition to treatment as usual for youths with and without intellectual disability (ID) in residential care with clinical levels of anxiety and externalizing problems. Dojo targets both anxiety and externalizing problems, and incorporates the principles of conventional treatment, while addressing its limitations. Youths were randomly assigned to play Dojo (eight 30-min gameplay sessions) or to treatment as usual (TAU). Measurements of anxiety and externalizing problems were conducted at baseline, posttreatment, and 4-months follow-up through youths' self-report and mentor-report. Completers-only analyses revealed decreases in self-reported anxiety and externalizing problems, and mentor-reported anxiety at posttreatment for participants in the Dojo condition compared to the control condition. Only mentor-reported anxiety was maintained at follow-up. No effect was found for mentor-reported externalizing problems. These findings provided preliminary evidence that Dojo is a promising, innovative intervention that engages high-risk youths. Practical implications are discussed.

Beck's cognitive theory and the response style theory of depression in adolescents with and without mild to borderline intellectual disability.

AIM: This study tests the validity of Beck's cognitive theory and Nolen-Hoeksema's response style theory of depression in adolescents with and without MBID. METHODS: The relationship between negative cognitive errors (Beck), response styles (Nolen-Hoeksema) and depressive symptoms was examined in 135 adolescents using linear regression. RESULTS: The cognitive error 'underestimation of the ability to cope' was more prevalent among adolescents with MBID than among adolescents with average intelligence. This was the only negative cognitive error that predicted depressive symptoms. There were no differences between groups in the prevalence of the three response styles. In line with the theory, ruminating was positively and problem-solving was negatively related to depressive symptoms. Distractive response styles were not related to depressive symptoms. The relationship between response styles, cognitive errors and depressive symptoms were similar for both groups. CONCLUSION: The main premises of both theories of depression are equally applicable to adolescents with and without MBID. The cognitive error 'Underestimation of the ability to cope' poses a specific risk factor for developing a depression for adolescents with MBID and requires special attention in treatment and prevention of depression. WHAT THIS PAPER ADDS?: Despite the high prevalence of depression among adolescents with MBID, little is known about the etiology and cognitive processes that play a role in the development of depression in this group. The current paper fills this gap in research by examining the core tenets of two important theories on the etiology of depression (Beck's cognitive theory and Nolen-Hoeksema's response style theory) in a clinical sample of adolescents with and without MBID. This paper demonstrated that the theories are equally applicable to adolescents with MBID, as to adolescents with average intellectual ability. However, the cognitive bias 'underestimation of the ability to cope' was the only cognitive error related to depressive symptoms, and was much more prevalent among adolescents with MBID than among adolescents with average intellectual ability. This suggests that underestimating one's coping skills may be a unique risk factor for depression among adolescents with MBID. This knowledge is important in understanding the causes and perpetuating mechanisms of depression in adolescents with MBID, and for the development of prevention- and treatment programs for adolescents with MBID.

A Pilot Study Evaluating "Dojo," a Videogame Intervention for Youths with Externalizing and Anxiety Problems.

OBJECTIVE: Externalizing problems, which are the main reason for youth referrals to mental health agencies, are highly persistent and predict a range of negative outcomes. Youths with externalizing problems are also frequently comorbid with anxiety. Among the most widely recognized evidence-based treatments is cognitive behavioral therapy (CBT). Although CBT principles seem to be sound, effect sizes remain moderate, suggesting improvements could be made to this conventional treatment approach. The main premise of the current pilot study is to investigate the feasibility of implementing a videogame intervention ("Dojo" [Gamedesk, Los Angeles, CA]) that incorporates CBT principles and aims to address the limitations of conventional CBT delivery models, with the ultimate goal of improving outcomes for this difficult-to-treat population. MATERIALS AND METHODS: "Dojo" is an emotion management game that helps youths to recognize and control their physiological and emotional arousal. We explored the implementation and user experience of "Dojo" in a sample of eight adolescents in residential treatment for both externalizing and anxiety problems. RESULTS: Participants attended all sessions without complaints. They evaluated "Dojo" very positively and exhibited high compliance during the training sessions. We encountered some problems with session scheduling and obtaining mentor reports. Quantitative data show the predicted decrease in three out of four measurements. CONCLUSIONS: The smooth implementation, high user satisfaction, high self-reported compliance during training sessions, and initial outcome results all indicate the high potential "Dojo" holds as an innovative intervention. If additional rigorously designed randomized controlled trials prove to be successful, "Dojo" can be a cost-effective way to engage high-risk youths in effective intervention.

Study protocol: a randomised controlled trial testing the effectiveness of 'Op Volle Kracht' in Dutch residential care.

BACKGROUND: Although adolescents are often referred to residential treatment centres because of severe externalizing behaviours, a vast majority demonstrated comorbid symptoms of depression and anxiety. Covert internalizing symptoms in these adolescents might be easily unrecognized and therefore untreated. Adolescents with mild intellectual disability (MID) are overrepresented among youth with both externalizing and internalizing problems. There are yet few treatment programs available for adolescents with both externalizing and internalizing problems. METHODS/DESIGN: The CBT-based resiliency program, Op Volle Kracht (OVK), which is based on the US Penn Resiliency Program (PRP), was adapted to suit the needs of adolescents with both externalizing and internalizing problems, either with or without MID, in Dutch residential treatment centres. The effectiveness of this group intervention program of eight sessions will be tested in a randomised controlled trial (RCT) with N = 182 adolescents aged 12-16, allocated to either the target intervention plus treatment as usual (OVK + TAU) or treatment as usual only (TAU). The main outcome variables include depressive symptoms (primary), anxiety, behavioural problems, and group therapeutic climate. Cognitive styles and coping styles will be included as possible mediators. Assessments take place at baseline (T1), one week before the start of the program (T2), immediately after the program (T3), and at three months follow-up (T4). DISCUSSION: The program assets include its wide implementation possibilities due to low costs, the short duration of the program and the delivery by group care workers, and its suitability for adolescents with MID. Further strengths of the present study design include its robust method (RCT), the ecological validity, and the inclusion of possible mediators of treatment effect. The program emphasizes individual risk factors for depression rather than social and family factors. Implications for practice and future research are discussed. TRIAL REGISTRATION: Dutch Trial Register NTR4836.

The Associations between Structural Treatment Characteristics and Post-Treatment Functioning in Compulsory Residential Youth Care.

BACKGROUND: In 2005 a new compulsory residential treatment program was developed for adolescents in need for protection against themselves or their environment. OBJECTIVE: The aim of the present study was to examine the association of structural treatment characteristics of this new residential treatment program (i.e., duration of treatment, discharge status, and group composition in terms of sex) with post-treatment functioning. Additionally, the number of pre-treatment risk factors was included in the model. METHOD: A total of 301 adolescents (174 boys, 127 girls), with a mean age at time of admittance of 15.50 (SD = 1.26) participated in this study. The number of risk factors was derived from treatment files of the adolescents at time of entrance. Six months after discharge, adolescents participated in a telephone interview to measure ten post-treatment variables indicating how well they were doing. RESULTS: The results showed that duration of treatment was related to post-treatment living situation, in that adolescents who were in treatment for shorter durations were more likely to live on their own after treatment. For discharge status, findings suggested that adolescents who were regularly discharged had more frequent contact with their family; however, they also showed higher alcohol consumption 6 months after treatment. Group composition was related to the girls' official offending, indicating that girls placed in mixed-sex groups showed significantly fewer official police contacts than did girls in girls-only treatment groups. CONCLUSION: Overall, structural treatment characteristics were hardly related to the adolescents' functioning after treatment. Suggestions for future research are discussed.

Psychopathic traits of Dutch adolescents in residential care: identifying subgroups.

The present study examined whether a sample of 214 (52.8% male, M age = 15.76, SD = 1.29) institutionalized adolescents could be classified into subgroups based on psychopathic traits. Confirmatory Factor Analyses revealed a relationship between the subscales of the Youth Psychopathic traits Inventory (YPI) and the three latent constructs of the original model on which it is based. Latent Class Analyses showed that adolescents showing psychopathic traits could be classified into three subgroups. The first group showed low scores on the grandiose/manipulative dimension, the callous/unemotional dimension, and the impulsive/irresponsible dimension (normal group). The second group scored moderate on the grandiose/manipulative dimension and the callous/unemotional dimension and high on the impulsive/irresponsible dimension (impulsive, non-psychopathic-like group). The third group scored high on all three dimensions (psychopathy-like group). The findings revealed that the impulsive, non-psychopathic like group scored significantly higher on internalizing problem behavior compared to the normal group, while the psychopathy-like and the impulsive, non-psychopathic-like group both scored higher on externalizing problem behavior compared to the normal group. Based on a self-report delinquency measure, it appeared that the psychopathy-like group had the highest delinquency rates, except for vandalism. Both the impulsive and psychopathy-like group had the highest scores on the use of soft drugs.

Frequency and seriousness of parental offending and their impact on juvenile offending.

The present study investigated to what extent the frequency and seriousness of parental offending were related to their offspring offending. Police officers in one Dutch province completed a form to register risk factors and the actions undertaken when they came into contact with offenders aged 8-14 years. These juveniles were followed for 18 months to establish whether or not they committed more crimes. In addition, the parents of these children were traced in the police criminal record systems. Data were gathered from 577 children and their parents. Of these children, 34% were exposed to parental criminality, of which 33 delinquents had two criminal parents and 163 had one criminal parent. If both parents were criminal, the child had the highest frequency of offending. Further, the frequency of parental offending was positively related to the frequency of the child's offending. Concerning the seriousness of juvenile crimes, the seriousness of the committed offences of the father showed a positive relation with the seriousness of his child's offending. Unexpectedly, a negative association was found between the seriousness of maternal offending and the seriousness of her child offending. These results offered a better understanding of the influence that parents with a criminal history have on their children. Further research is needed to identify mechanisms underlying this relationship in order to provide appropriate prevention and intervention strategies.

Short-term criminal pathways: type and seriousness of offense and recidivism.

In this longitudinal study, the authors investigated short-term criminal pathways of children and early adolescents starting under the age of 14 years and the extent to which characteristics of the 1st crime influenced criminal pathways. Participants were 387 juvenile offenders with a mean age of 12.1 years (SD = 2.05 years). The authors followed all participants in the police systems for 2 years to get insight into the crimes that they committed. Then, 2 years after the 1st police contact, 46.5% of these offenders were still considered 1st offenders, and 53.5% had become recidivists. Most of the children began their criminal pathway with less serious covert crimes. Further analyses showed that when the 1st crime was a serious overt crime, the risk of recidivism within 1 year increased. The likelihood of committing a serious overt crime increased with age. The results supported the authors' hypotheses in that juvenile offenders who committed both overt and covert delinquent acts had the highest rates of offense, were more aggressive, and committed more serious offenses. Furthermore, children who committed only overt crimes developed even more serious criminal pathways.

Parenting styles, coping strategies, and the expression of homesickness.

The present study examined the role of parenting styles in the experience and expression of homesickness, and the way of coping with the feelings involved. Using a sample of 670 first year college and university students, aged 16 to 25, we tested three hypotheses: (1) authoritarian, permissive as well as uninvolved parenting are associated with the experience of homesickness, contrary to students with authoritative parents who are less likely to have feelings of homesickness; (2) students with authoritarian, permissive or uninvolved parents show their homesickness by internalizing and externalizing problems; and (3) students raised by authoritative or permissive parents use more effective coping strategies to deal with homesickness. Results indicated that students raised by authoritative and permissive parents experienced more homesickness with stronger feelings of homesickness than students raised by authoritarian or uninvolved parents. However, they hardly express homesickness by internalizing or externalizing problems when they use effective ways of coping, namely support-seeking and/or problem-solving. Students with parents endorsing an authoritarian or uninvolved parenting style, on the other hand, showed more internalizing and externalizing problems in reaction to feelings of homesickness. They also use less effective coping strategies. The results revealed the importance of a loving and accepting home environment for the development and expression of homesickness, as well as the importance of the way in which students learn to cope with their problems.