A network analysis of Hurricane Maria-related traumatic stress and substance use among Puerto Rican youth.

Youth exposed to natural disasters are at risk of developing trauma-related symptoms as well as engaging in substance use. Although previous research has established associations between disaster-related stressors and substance use in youth, less has focused on how symptoms of posttraumatic stress disorder (PTSD) may underpin this association. The current study used network analysis to identify specific PTSD symptoms associated with substance use following a natural disaster. Participants were 91,732 youths (Grades 3-12) from across Puerto Rico who completed a needs assessment 5-9 months after Hurricane Maria made landfall in September 2017. We examined associations between PTSD symptoms and substance use, identified clusters of symptoms and bridges between them, and explored age- and binary gender-related differences in associations between specific PTSD symptoms and substance use. Analyses identified two symptom communities: (a) arousal and reactivity, negative alterations in cognition and mood, and substance use, and (b) avoidance and intrusion. Broader findings suggested that substance use was most strongly associated with PTSD-related irritability and angry outbursts among youths. Surrounding nodes explained only 4.1% of the variance in substance use, but this was higher among youths who reported not having a supportive adult, R2 = 8.5; friend, R2 = 7.9; or teacher/counselor, R2 = 7.7, in their life. The bridge symptoms of sleep disruption and physiological reactivity were identified as potentially critical intervention targets for disrupting PTSD symptom networks after a natural disaster. Implications for triaged mental health care following natural disasters and directions for future research are discussed.

Disaster exposure and mental health among Puerto Rican teachers after Hurricane Maria.

The purpose of the study was to assess the prevalence rates of anxiety, depression, and posttraumatic stress disorder (PTSD) outcomes among teachers (N = 8,167) exposed to Hurricane Maria in Puerto Rico. The findings indicate that the rates of likely significant symptoms of anxiety, depression, and PTSD were 13.1%, 8.7%, and 5.4%, respectively. There were no significant disparities in psychopathological symptoms based on sex, except that female participants were more likely to exhibit anxiety symptoms than their male counterparts, odds ratio (OR) = 1.53. Key disaster-related factors, such as perceived threat, actual threat, and disruption of life were found to significantly influence all psychopathology outcomes, ORs = 1.20-3.57, whereas increased social support significantly buffered the manifestation of clinically significant psychopathology symptoms across all domains, ORs = 0.30-0.46. These outcomes, strongly linked to peritraumatic consequences, were not constrained by geographical or socioeconomic boundaries, highlighting the wide-ranging impact of the hurricane. Nevertheless, social support emerged as a significant counteracting force, reducing the likelihood of detrimental mental health symptoms. Consistent with prior studies, this study emphasizes the crucial role of social support in nurturing posttraumatic resilience and curbing the severity of posttraumatic stress outcomes, thus underscoring the need for incorporating robust social support systems within disaster response strategies.

Patient perceptions of trauma-focused telemental health services using the Telehealth Satisfaction Questionnaire (TSQ).

Telehealth services can address many barriers to traditional office-based mental health services. Few studies have assessed youth and caregiver perceptions of and satisfaction with trauma-focused interventions delivered via telemental health. The present study reports data collected using the Telehealth Satisfaction Questionnaire (TSQ), which was developed to measure child and caregiver satisfaction with services, comfort with the telehealth equipment, and barriers to traditional office-based services. Thirteen clinicians delivered home- and school-based Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) via videoconferencing on tablets and computers to 60 child patients (71.7% Latinx, 18.3% Black, and 10.0% non-Hispanic White). Patients and caregivers completed the TSQ at treatment discharge via telephone, videoconferencing, or in-person interviews. There was a high level of satisfaction among patients and caregivers receiving TF-CBT via telemental health. Furthermore, most youth and caregivers felt comfortable using the telehealth equipment from the outset of therapy, and all participants who were not initially comfortable using the equipment reported feeling more comfortable over time. The most common barriers to traditional office-based services were caregiver work schedule (57.7%), distance to mental health clinic (55.8%), and lack of transportation (44.2%). Patients and caregivers expressed a preference for telemental health services if given the option between receiving therapy via videoconferencing versus going to an office-based clinic. Findings indicated telemental health treatment addressed barriers that would have otherwise prevented families from accessing office-based services. The TSQ can be used to help clinics and providers assess patient and caregiver satisfaction with telehealth services in various settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Trauma-focused cognitive behavioral therapy with Puerto Rican youth in a post-disaster context: Tailoring, implementation, and program evaluation outcomes.

PURPOSE: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has not yet been systematically evaluated in the Caribbean context, particularly with Hispanic youth exposed to multiple disasters. The objective of this project was twofold: 1) to train mental health providers in Puerto Rico in TF-CBT as part of a clinical implementation project within the largest managed behavioral health organization (MBHO) on the island, and 2) to conduct a program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. METHOD: Fifteen psychologists were trained in TF-CBT. These psychologists then provided TF-CBT to 56 children and adolescents, ages 5-18, in community-based mental health clinics and one primary care clinic with a co-located psychologist in Puerto Rico. The mean number of traumatic events reported by youth referred for TF-CBT was 4.11. RESULTS: Thirty-six out of 56 children enrolled in the project (64.3%) successfully completed all components of TF-CBT. Results demonstrated large effect sizes for reduction in youth-reported posttraumatic stress symptoms (PTSS) (Cohen's d = 1.32), depressive symptoms (Cohen's d = 1.32), and anxiety symptoms (Cohen's d = 1.18). CONCLUSIONS: These results suggest that it was feasible to train providers in TF-CBT, that providers were able to deliver TF-CBT in community-based settings both in person and via telehealth (due to the COVID-19 pandemic), and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in Puerto Rico in a post-disaster context. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for Hispanic youth and disaster-affected youth in the Caribbean.

Psychometric properties of the Spanish Child PTSD Symptom Scale for DSM-5-Self-Report in El Salvador.

Conducting research in global applied settings necessitates the use of easily administered, brief, and evidentiary measures. One widely used, brief self-report measure of posttraumatic stress disorder (PTSD) symptoms in children and adolescents is the Child PTSD Symptom Scale for DSM-5-Self-Report (CPSS-5-SR). The present study examined the factor structure, measurement invariance, reliability, and convergent validity of the Spanish translation of the CPSS-5-SR in a sample of 1,296 third- through 12th-graders in El Salvador (Mage = 12.73 years, SD = 2.67, 55.2% female, 100.0% Latinx). This sample was collected as part of a government-led initiative to conduct broad school-based psychopathology screening, with the wider goal of introducing trauma-informed services into El Salvador's school system. Consistent with prior research, confirmatory factor analysis indicated that the four-factor DSM-5 model displayed a strong fit with the data. Measurement invariance by gender was also examined, with results showing invariance at the configural, metric, and scalar levels, indicating strong evidence that participants' patterns of response did not differ by gender. The results also indicated strong reliability, Cronbach's α = .91, and convergent validity with measures of commonly comorbid psychopathology, rs = .43-.68. Total scale norms derived from the current sample are provided. These findings highlight the considerable levels of posttraumatic stress experienced by Salvadorian youth and the importance of establishing evidentiary measures of psychopathology that can be used in diverse global populations. In particular, psychometric research represents the first step in augmenting efforts to screen, refer, and treat youth impacted by violence across the globe.

Implementation of an Evidence-Based Psychotherapy for Trauma-Exposed Children in a Lower-Middle Income Country: the Use of Trauma-Focused Cognitive Behavioral Therapy in El Salvador.

Central American youth are at a high risk for experiencing trauma and related psychosocial problems. Despite this, few studies of evidence-based trauma-focused interventions with this population exist. The objective of this project was twofold: 1) to train providers in El Salvador in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) as part of a clinical implementation project within a non-governmental organization, and 2) to conduct program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. Fifteen Salvadoran psychologists were trained in TF-CBT who then provided TF-CBT to 121 children and adolescents ages 3-18 in community-based locations. The mean number of traumas reported by youth was 4.39. Results demonstrated large effect sizes for reduction in youth-reported trauma symptoms (Cohen's d = 2.04), depressive symptoms (Cohen's d = 1.68), and anxiety symptoms (Cohen's d = 1.67). Our program evaluation results suggest that it was feasible to train providers in TF-CBT, that providers were in turn able to deliver TF-CBT in community-based settings, and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in El Salvador. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for youth in Latin American countries.

A Pilot Trial of Universal School-Based Mental Health Screening in El Salvador: Traumatic Stress in an Underresourced School Environment.

Salvadoran youth have an elevated risk of trauma exposure and related mental health problems. However, investigations of childhood trauma exposure and mental health sequelae in El Salvador are limited. The present study aimed to (a) explore the prevalence of exposure to potentially traumatic events and symptoms of posttraumatic stress, anxiety, and depression and (b) evaluate the associations between specific trauma types and emotional functioning among Salvadoran youth. A total of 1,296 youth aged 8-21 years from seven public schools completed self-report measures of trauma exposure, posttraumatic stress symptoms (PTSS), anxiety, and depression. Participants reported high levels of trauma exposure, endorsing an average of 3.62 (SD = 2.32) trauma types. In total, 34.5% of participants reported clinically elevated PTSS; fewer youths reported elevated depressive (8.7%) and anxiety symptoms (8.6%). Although boys reported exposure to more trauma types than girls, d = 0.22, girls were more likely to endorse elevated PTSS, V = .11; anxiety, V = .06; and depression, V = .10. Adolescents reported exposure to more trauma types than younger children, d = 0.23, and were more likely to endorse elevated PTSS, V = .07; anxiety, V = .13; and depression, V = .16. Undergoing a frightening medical procedure, OR = 2.30; female sex, OR = 1.92; witnessing domestic violence, OR = 1.70; and experiencing war between gangs, OR = 1.61, were strong predictors of elevated PTSS. This broad, school-based screening was a critical step toward better understanding the rate of trauma exposure and trauma-related symptoms among Salvadoran youth.

Leveraging Technology and Cultural Adaptations to Increase Access and Engagement Among Trauma-Exposed African American Youth: Exploratory Study of School-Based Telehealth Delivery of Trauma-Focused Cognitive Behavioral Therapy.

African American youth are disproportionately represented among trauma-exposed youth; yet, they are significantly less likely to access and complete mental health services. Research suggests that barriers to accessing and engaging in trauma-focused treatment include both logistical factors and engagement factors. This multiple case study sought to illustrate the initial feasibility and acceptability of delivering culturally tailored, trauma-focused cognitive behavioral therapy (TF-CBT) via telehealth in a school setting with three African American youth presenting with multiple barriers to accessing treatment. Barriers to treatment, telehealth modifications, and cultural tailoring are described for each participant. The UCLA Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) was completed at pretreatment and posttreatment. Results demonstrated significant decreases in symptoms of posttraumatic stress, as evidenced by a reduction in total UCLA PTSD-RI scores to nonclinical levels for all participants at posttreatment (UCLA scores posttreatment = 8-12). In addition, at posttreatment no participants met diagnostic criteria for PTSD or adjustment disorder. This multiple case study provides preliminary support for school-based, culturally tailored TF-CBT delivered via telehealth with African American youth.

Listen, don't tell: Partnership and adaptation to implement trauma-focused cognitive behavioral therapy in low-resourced settings.

Clinical psychological science has developed many efficacious treatments for diverse emotional and behavioral difficulties encountered by children and adolescents, although randomized trials investigating these treatments have disproportionally been conducted by American, university-based research labs. The subsection of the world population involved in these studies, however, represents very few people among those in need of psychological services whose voices, perspectives, and orientations to therapy have not generally been reflected in well-funded research trials. Dissemination and implementation of evidence-based services designed to meet the needs of this broader global population, therefore, may require cultural and contextual adaptation to be successful. The current article describes the implementation of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in 3 separate low-resourced settings (rural South Carolina, Puerto Rico, and El Salvador) utilizing the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and guided by a community-based participatory research framework. Emphasis is placed on description of program development, building collaborative and responsive partnerships, and the use of implementation strategies to guide continuous quality improvement. Program evaluation data comparing baseline to posttreatment trauma symptoms and treatment completion rates for all sites are also presented, which suggests that treatment was associated with a large reduction in symptoms, exceeding that noted in many TF-CBT randomized trials. The implications of attention to context, adaptation, and methods of building partnerships with global communities are discussed, with a particular focus on propelling more refined models and controlled studies in the future. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Disaster Exposure and Mental Health Among Puerto Rican Youths After Hurricane Maria.

Importance: Quantifying the magnitude of disaster exposure and trauma-related symptoms among youths is critical for deployment of psychological services in underresourced settings. Hurricane Maria made landfall in Puerto Rico on September 20, 2017, resulting in massive destruction and unprecedented mortality. Objective: To determine the magnitude of disaster exposure and mental health outcomes among Puerto Rican youths after Hurricane Maria. Design, Setting, and Participants: Survey study in which a school-based survey was administered to each public school student at all schools in Puerto Rico between February 1 and June 29, 2018 (5-9 months after Hurricane Maria). Of the 226 808 students eligible to participate, 96 108 students completed the survey. Main Outcomes and Measures: Participants were assessed for exposure to hurricane-related stressors, posttraumatic stress disorder (PTSD), and depressive symptoms, using standardized self-report measures administered in Spanish. Descriptive statistics were compiled for all outcome variables, as was the frequency of individuals reporting clinically elevated symptoms of PTSD or depression. Differences in these statistics across sexes were also examined via t tests. Correlations between demographic, geographic, and main outcome variables were also calculated, and regressions were conducted to examine their association with symptoms of PTSD. Results: A total of 96 108 students participated in the study (42.4% response rate; 50.3% female), representative of grades 3 to 12 across all 7 educational regions of Puerto Rico. As a result of the hurricane, 83.9% of youths saw houses damaged, 57.8% had a friend or family member leave the island, 45.7% reported damage to their own homes, 32.3% experienced shortages of food or water, 29.9% perceived their lives to be at risk, and 16.7% still had no electricity 5 to 9 months after the hurricane. Overall, 7.2% of youths (n = 6900) reported clinically significant symptoms of PTSD; comparison of the frequency of reporting clinically elevated symptoms of PTSD across sex yielded a significant difference (t = 12.77; 95% CI of the difference, 0.018-0.025; P < .001), with girls (8.2%) exceeding the clinical cutoff score more often than boys (6.1%). Finally, similar analysis of differences in depression between sexes was also significant (t = 17.56; 95% CI of the difference, 0.31-0.39; P < .001), with girls displaying higher mean (SD) scores (2.72 [3.14]) than boys (2.37 [2.93]). Demographic and risk variables accounted for approximately 20% of variance in symptoms of PTSD (r2 = 0.195; 95% CI, 0.190-0.200). Conclusions and Relevance: Survey results indicate that Hurricane Maria exposed Puerto Rican youths to high levels of disaster-related stressors, and youths reported high levels of PTSD and depressive symptoms. Results are currently being used by the Puerto Rico Department of Education to inform targeted and sustainable evidence-based practices aimed at improving mental health outcomes for Puerto Rico's youths.

A Pilot Study of Trauma-Focused Cognitive-Behavioral Therapy Delivered via Telehealth Technology.

Significant barriers exist in access to evidence-based, trauma-focused treatment among youth from economically disadvantaged backgrounds, those living in rural areas, and belonging to a racial and ethnic minority group, despite the high prevalence rates of trauma exposure among these underserved groups. The present study is proof-of-concept pilot of trauma-focused cognitive-behavioral therapy (TF-CBT) delivered to underserved trauma-exposed youth ( N = 15) via telehealth technology (i.e., via one-on-one videoconferencing), aimed at addressing barriers in access to TF treatment. This pilot study provides preliminary evidence of the ability to successfully deliver TF-CBT via a telehealth delivery format. Results demonstrated clinically meaningful symptom change posttreatment (large effect sizes for youth-reported ( d = 2.93) and caregiver-reported ( d = 1.38) reduction in posttraumatic stress disorder symptoms), with no treatment attrition (0% dropout). These findings are promising in showing treatment effects that are comparable with TF-CBT delivered in an in-person, office-based setting and an important first step in determining how to best address the mental health needs of trauma-exposed youth with barriers in access to care.

The Child PTSD Symptom Scale: An Investigation of Its Psychometric Properties.

The current study addresses the need for accurate measurement of posttraumatic stress disorder (PTSD) symptoms in youth by investigating the psychometric properties of the Child PTSD Symptom Scale (CPSS). The factor structure, reliability, and concurrent and discriminant validity of the CPSS were investigated in a sample of 206 6th- to 12th-grade adolescents. Exploratory and confirmatory factor analysis supported a single-factor structure, which was contrary to the hypothesized three-factor structure. Scores comprising this one-factor structure were also associated with high reliability (α = .93), and tests of concurrent and discriminant validity were also strong. The implications of these findings are discussed, with particular emphasis on future directions for research on self-report measures for adolescent PTSD symptoms.

A decision-tree approach to the assessment of posttraumatic stress disorder: Engineering empirically rigorous and ecologically valid assessment measures.

Structured diagnostic interviews are widely considered to be the optimal method of assessing symptoms of posttraumatic stress; however, few clinicians report using structured assessments to guide clinical practice. One commonly cited impediment to these assessment approaches is the amount of time required for test administration and interpretation. Empirically keyed methods to reduce the administration time of structured assessments may be a viable solution to increase the use of standardized and reliable diagnostic tools. Thus, the present research conducted an initial feasibility study using a sample of treatment-seeking military veterans (N = 1,517) to develop a truncated assessment protocol based on the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (CAPS). Decision-tree analysis was utilized to identify a subset of predictor variables among the CAPS items that were most predictive of a diagnosis of PTSD. The algorithm-driven, atheoretical sequence of questions reduced the number of items administered by more than 75% and classified the validation sample at 92% accuracy. These results demonstrated the feasibility of developing a protocol to assess PTSD in a way that imposes little assessment burden while still providing a reliable categorization.

The Development and Psychometric Investigation of the Cyberbullying Scale.

Accurate assessment of cyberbullying is essential for intervention planning and evaluation. Limitations to many currently available self-report measures of cyberbullying victimization include a lack of psychometric information and a limited scope (i.e., not assessing multiple electronic mediums of cybervictimization). To address these limitations, we developed and investigated the psychometric properties of a broad self-report measure of cyberbullying, the Cyberbullying Scale (CBS). We examined the factor structure and reliability of the CBS across 736 students in Grades 6 to 12 in six Northern Mississippi schools. Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) results indicated that the structure of the CBS was best represented by a one-factor model. The finding of a single-factor structure suggests that cyberbullying is a unidimensional construct, which is consistent with previous research. In the current sample, the CBS demonstrated strong psychometric properties, including excellent internal consistency (Cronbach's α = .94) and significant positive correlations with related constructs of anxiety, depression, and loneliness. Results from the present study provide initial support for the CBS as a measure of cybervictimization among adolescents.