Utilizing screening as a trauma-responsive approach in pediatric health care settings.

Given the widespread impact of child trauma, it is important that child- and family-serving systems adopt trauma-informed care. Because of their integral relationships with families, pediatricians and family medicine physicians play critical roles in disrupting negative societal and developmental cascades for trauma-exposed youth through their potential for early identification and intervention. When implemented alongside organization-wide trauma-informed care practices, trauma screening is one concrete trauma-informed care practice that has shown both feasibility and positive impacts on pediatric healthcare. In support of this practice, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS) helps pediatric care providers to identify and respond to children and adolescents who may need trauma-focused supports. In this paper we discuss the importance of pediatric physicians adopting trauma-informed care and how evidence-based screening practices in pediatric settings is a trauma-responsive approach with great potential for meeting unmet needs among trauma-exposed children and families.

Trajectory of external implementation support activities across two states in the United States: A descriptive study.

Background: Reporting on strategies to advance implementation outcomes is imperative. The current study reports descriptive information about external implementation support (EIS) provided over 5 years to 13 regions in North Carolina and South Carolina scaling an evidence-based system of parenting and family supports. Regional support teams operating through the Implementation Capacity for Triple P (ICTP) projects employed core practice components (CPCs) for EIS as proposed by Aldridge et al. and further operationalized by members of The Impact Center at FPG Child Development Institute, UNC-Chapel Hill. Method: Practice activities associated with CPCs were developed and iteratively refined across the study period. ICTP regional support teams systematically tracked their use of CPCs and related activities following each substantive support interaction. Tracking included the duration of time a CPC was employed and the use of specific practice activities associated with that CPC. Data were aggregated by month of the relationship to account for differential start dates across regions. Results: From November 2016 through December 2021, ICTP support teams tracked 749 support interactions with Triple P regions in North Carolina and South Carolina. Monthly support decreased year over year, though dose varied considerably. Patterns of CPC use indicated a high dose of "foundational" and "co-design" CPCs early, followed by a blended and more diverse use thereafter, with some notable trends. Practice activities considered essential to influencing intended practice outcomes were characterized by higher rates of use. Like CPCs, practice activities were used dynamically across the study period. Conclusions: This descriptive study offers a case study for how EIS might be operationalized, tracked, and employed. Findings suggest several interpretations that might refine our understanding and use of EIS. Although the nature of this practical report precludes generalizability of findings, directions for future research and practice are discussed.

More needs to be known about how external support providers work with organizational, system, and community partners to improve their efforts to implement innovative programs and practices. Although a handful of models of external support have emerged in the literature, support strategies or activities are not often tracked systematically or prospectively. In the current study, we report on the adoption, operationalization, and use of a recently proposed model of external support across 13 regions in North Carolina and South Carolina scaling an evidence-based system of parenting and family interventions. Teams of external support providers tracked their activities using the model across more than 5 years. Results provide a description of what external support might look like across long-term support engagements, noting key patterns about dose of support and use of activities that might be responsible for influencing intended support outcomes. The study offers several findings that might refine our understanding and use of external support strategies. In addition, the study lays groundwork for examining additional research questions, such as the feasibility of support processes and whether and how support activities influence support outcomes.

Youth Dually-Involved in the Child Welfare and Juvenile Justice Systems: Varying Definitions and Their Associations with Trauma Exposure, Posttraumatic Stress, & Offending.

Recently, scholars have placed increasing effort on better understanding the unique needs of youth involved in both the child welfare and juvenile justice systems. This study drew from the Developmental Cascade of Multisystem Involvement Framework to examine group differences in trauma exposure, posttraumatic stress symptoms, and offending among youth solely involved in the juvenile justice system and youth with varying degrees of dual-system involvement, including crossover youth (i.e., youth with a history of maltreatment and offending regardless of system involvement), dual-contact youth (i.e., youth who had a history of a substantiated CW maltreatment petition prior to their involvement in the current study), and dually-involved youth (i.e., youth under the care and custody of the state's child welfare system at the time of study participation). Four-hundred adolescents (25% girls, Mage = 15.97) who were recruited from a detention center and completed self-report measures assessing trauma exposure, posttraumatic stress, and offending. Juvenile justice and child welfare records also were collected. Results indicated that, compared to youth solely involved in the juvenile justice system, crossover youth reported significantly more exposure to traumatic events, more severe posttraumatic stress symptoms, and more self-reported offending. In contrast, results indicated few differences between dual-contact youth and youth solely involved in the juvenile justice system; these groups only differed in age and in recidivism charges. There also were few differences between dually-involved youth and youth solely involved in the juvenile justice system; these groups only differed in age and exposure to non-Criterion A traumatic events. The current results suggest that categorizing youth as crossover youth based on their own self-reported history of child maltreatment exposure resulted in more observed differences between dual-system youth and youth solely involved in juvenile justice. The present results have valuable implications for how we operationalize youth's system involvement and highlight the importance of examining child maltreatment as a point of prevention and intervention efforts for these youth.

Advancing Our Understanding of the Risk Factors Associated with Crossover Youth in the Child Welfare and Juvenile Justice Systems: A Trauma-Informed Research Agenda.

Previous research has provided robust evidence demonstrating that a notable proportion of youth become involved in both the child welfare (CW) system and the juvenile justice (JJ) system, a population often referred to as crossover youth. Prior work has identified a number of risk factors associated with crossing over between these systems. However, there are limitations to the extant literature, key among which is a lack of systematic attention to the influence of trauma exposure and posttraumatic sequelae on the crossover trajectory. In contrast, viewing this research through a trauma-informed lens promises to enhance our ability to integrate findings across studies and to derive theoretically derived hypotheses about underlying mechanisms which will better inform future research and the development of effective prevention and intervention efforts. Accordingly, the purpose of this article is to present a trauma-informed research agenda that would strengthen future research in the field. After providing a brief critique of the existing studies that has documented known risk factors associated with the crossover population, we outline ways in which future research could apply relevant theoretical trauma-informed approaches, including developmental traumatology, to further advance our knowledge of risk factors and mechanisms associated with the crossover trajectory. We conclude by discussing policy and system-wide implications related to the proposed research agenda.

Development and Validation of the Moral Injury Scales for Youth.

This paper describes the development and preliminary psychometric properties of the Moral Injury Scales for Youth (MISY). Although to date, the construct of moral injury has been focused on studies of samples of adult military personnel, the MISY was developed to extend the study of moral injury to interpersonal relationship stressors and transgressions among emerging adults, adolescents, and children. Participants in a validation study included 473 undergraduate students (78.6% female, age range: 18-25 years) recruited from a psychology participant pool at a large university in the Western United States as well as a second sample of 185 students recruited from the same pool, to assess reliability. Results of exploratory factor analysis and confirmatory factor analysis (CFA) indicated that the MISY demonstrated a five-factor latent structure with good internal consistencies. Correlational analyses indicated that the MISY subscales demonstrated good convergent validity, divergent validity, and test-retest reliability. The findings suggest that the MISY is a psychometrically reliable and valid measure of moral injury in emerging adults, with utility for examining moral injury in nonmilitary youth populations.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Desarrollo y validación de la escala de daños morales para jóvenes ESCALA DE DAÑO MORAL PARA JÓVENES Este artículo describe el desarrollo y las propiedades psicométricas preliminares de la escala de daño moral para jóvenes (MIY en sus siglas en inglés). A pesar que a la fecha el concepto de daño moral se ha centrado en estudios de muestras de personal militar adulto, el MIY se desarrolló para ampliar el estudio del daño moral a factores de estrés interpersonales y transgresiones entre adultos emergentes, adolescentes y niños. Los participantes para el estudio de validación incluyeron a 473 estudiantes de pregrado (78.6% mujeres, rango de edad: 18 a 25 años) reclutados de un grupo de participantes de psicología en una universidad grande en el oeste de los Estados Unidos, así como una segunda muestra de 185 estudiantes reclutados del mismo grupo, para evaluar la fiabilidad. Los resultados del análisis factorial exploratorio y el análisis factorial confirmatorio (AFC) indicaron que el MIY demostró una estructura de cinco factores latentes con buena consistencia interna. Los análisis correlacionales indicaron que las subescalas de MIY demostraron una buena validez convergente, validez divergente y confiabilidad de test- retest. Los hallazgos sugieren que el MIY es una medida psicométricamente confiable y válida de daño moral en adultos emergentes, con utilidad para examinar daño moral en poblaciones no militares de jóvenes.

Trauma exposure, posttraumatic overmodulation and undermodulation, and nonsuicidal self-injury in traumatized justice-involved adolescents.

OBJECTIVE: Previous research has established associations among childhood trauma exposure, posttraumatic stress symptoms (PTSSs), and adolescent nonsuicidal self-injury (NSSI). In fact, numerous studies have suggested that PTSSs may serve as a mechanism linking trauma exposure and NSSI. However, studies to date have not utilized newer models of PTSSs that differentiate between symptoms of overmodulation and undermodulation. This study investigated associations among interpersonal and noninterpersonal trauma exposure, posttraumatic overmodulation and undermodulation, and NSSI in a sample of justice-involved youth. METHOD: Participants were 566 youth (2 transgender youth, 142 girls, and 422 boys). On average, youth were 16 years old (SD = 1.27), and approximately half self-identified as an ethnic minority. Participants completed measures of lifetime trauma exposure and NSSI, and past-month PTSSs. RESULTS: Structural equation modeling demonstrated that interpersonal trauma exposure was associated with symptoms of overmodulation (95% confidence interval [CI] [.180, .340]) and undermodulation (95% CI [.179, .338]) as well as NSSI (95% CI [.156, .572]). Additionally, symptoms of overmodulation were differentially associated with NSSI (95% CI [.158, .720]), and there was a significant indirect effect between interpersonal trauma exposure and NSSI via overmodulation (95% CI [.015, .095]). CONCLUSIONS: This study highlights the utility of conceptualizing posttraumatic stress disorder as a disorder of emotion regulation characterized by symptoms of overmodulation and undermodulation, and has clinical implications for mental health professionals who interact with youth in the justice system. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Promoting trauma-informed parenting of children in out-of-home care: An effectiveness study of the resource parent curriculum.

The Resource Parent Curriculum (RPC) is a workshop designed to promote trauma-informed parenting among foster, adoptive, and kinship caregivers (i.e., resource parents). The ultimate goal of RPC is to improve placement stability and promote healing from traumatic stress in children who have been placed in out-of-home care. The current study examined data from multiple RPC implementation sites throughout the United States. This study used a pre- versus postworkshop design to assess resource parents' (n = 314) improvement on trauma-informed parenting, perceived self-efficacy for parenting a child who experienced trauma, tolerance of child misbehavior, and whether parent characteristics moderated the impact of RPC on these outcomes. A repeated measures multivariate analysis of variance (MANOVA) demonstrated improvement from pre- to postworkshop on trauma-informed parenting F(1, 259) = 11.96, p = .001, η2 = .044; parenting self-efficacy F(1, 259) = 17.41, p = .000, η2 = .063; and tolerance of child misbehavior F(1, 259) = 3.94, p = .048, η2 = .015, regardless of parent characteristics (e.g., age, gender race/ethnicity, and resource parent type). The results of the current study support prior work showing the effectiveness of RPC in improving resource parents' trauma-informed knowledge and attitudes and further demonstrates the effectiveness of RPC with a diverse range of resource parents. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Screening for PTSD among detained adolescents: Implications of the changes in the DSM-5.

OBJECTIVE: Screening for posttraumatic stress disorder (PTSD) is highly relevant for youth involved in the juvenile justice system given their high rates of trauma exposure and posttraumatic stress symptoms. However, to date, no studies have investigated the implications of the recent revisions to the Diagnostic and Statistical Manual for Mental Disorders (5th ed., DSM-5; American Psychiatric Association [APA], 2013) diagnostic criteria for PTSD for screening in this population. To this end, the present study compared PTSD screening rates using the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR; APA, 2013) versus DSM-5 criteria in a group of detained adolescents. METHOD: Participants included 209 youth (60 girls) aged 13-19 (M = 15.97, SD = 1.24). Youth completed measures of lifetime trauma exposure and past-month posttraumatic stress symptoms. RESULTS: Over 95% of youth in the sample reported exposure to at least 1 type of traumatic event. Approximately 19.60% of the sample screened positive for PTSD according to the DSM-5 compared to 17.70% according to the DSM-IV-TR. Girls were more likely than boys to screen positive for PTSD according to the DSM-IV-TR compared to the DSM-5. CONCLUSION: The main factors accounting for the differences in screening rates across the versions of PTSD criteria involved the removal of Criterion A2 from the DSM-5, the separation of avoidance symptoms (Criterion C) into their own cluster, the addition of a cluster involving negative alterations in cognitions and mood (Criterion D), and revisions to the cluster of arousal symptoms (Criterion E). Future research should continue to investigate gender differences in PTSD symptoms in youth and consider the implications of these diagnostic changes for the accurate diagnosis and referral to treatment of adolescents who demonstrate posttraumatic stress reactions. (PsycINFO Database Record

Numbing of Positive, Negative, and General Emotions: Associations With Trauma Exposure, Posttraumatic Stress, and Depressive Symptoms Among Justice-Involved Youth.

Increasing attention has been drawn to the symptom of emotional numbing in the phenomenology of posttraumatic stress disorder (PTSD), particularly regarding its implications for maladaptive outcomes in adolescence such as delinquent behavior. One change in the definition of emotional numbing according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) was the limitation to the numbing of positive emotions. Previous research with youth, however, has implicated general numbing or numbing of negative emotions in PTSD, whereas numbing of positive emotions may overlap with other disorders, particularly depression. Consequently, the goal of this study was to investigate whether numbing of positive emotions was associated with PTSD symptoms above and beyond numbing of negative emotions, general emotional numbing, or depressive symptoms among at-risk adolescents. In a sample of 221 detained youth (mean age = 15.98 years, SD = 1.25; 50.7% ethnic minority), results of hierarchical multiple regressions indicated that only general emotional numbing and numbing of anger accounted for significant variance in PTSD symptoms (total R(2) = .37). In contrast, numbing of sadness and positive emotions were statistical correlates of depressive symptoms (total R(2) = .24). Further tests using Hayes' Process macro showed that general numbing, 95% CI [.02, .45], and numbing of anger, 95% CI [.01, .42], demonstrated indirect effects on the association between trauma exposure and PTSD symptoms.

Validation of the factor structure of the adolescent dissociative experiences scale in a sample of trauma-exposed detained youth.

OBJECTIVE: The inclusion of a dissociative subtype in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM­5) criteria for the diagnosis of posttraumatic stress disorder (PTSD) has highlighted the need for valid and reliable measures of dissociative symptoms across developmental periods. The Adolescent Dissociative Experiences Scale (A-DES) is 1 of the few measures validated for young persons, but previous studies have yielded inconsistent results regarding its factor structure. Further, research to date on the A-DES has been based upon nonclinical samples of youth or those without a known history of trauma. To address these gaps in the literature, the present study investigated the factor structure and construct validity of the A-DES in a sample of highly trauma-exposed youth involved in the juvenile justice system. METHOD: A sample of 784 youth (73.7% boys) recruited from a detention center completed self-report measures of trauma exposure and the A-DES, a subset of whom (n = 212) also completed a measure of PTSD symptoms. RESULTS: Confirmatory factor analyses revealed a best fitting 3-factor structure comprised of depersonalization or derealization, amnesia, and loss of conscious control, with configural and metric invariance across gender. Logistic regression analyses indicated that the depersonalization or derealization factor effectively distinguished between those youth who did and did not likely meet criteria for a diagnosis of PTSD as well as those with PTSD who did and did not likely meet criteria for the dissociative subtype. CONCLUSIONS: These results provide support for the multidimensionality of the construct of posttraumatic dissociation and contribute to the understanding of the dissociative subtype of PTSD among adolescents. (PsycINFO Database Record

Investigating the dissociative subtype of posttraumatic stress disorder in a sample of traumatized detained youth.

In this study, we tested the validity of a dissociative subtype in a sample of 225 detained adolescents (142 boys, 83 girls) likely meeting full or partial criteria for posttraumatic stress disorder (PTSD). Competing theories of dissociation pose controversy regarding dissociation as a taxon versus a continuum, and results of the current study contribute to this debate by providing evidence of distinct group differences between those high and low in dissociation. Mixture modeling revealed 2 groups of youth with differing levels of depersonalization/derealization dissociative symptoms. Differences between the 2 groups of youth were investigated regarding trauma exposure and several posttraumatic reactions: posttraumatic stress symptoms (PTSS), emotion dysregulation, and emotional numbing. Compared with youth classified in the low-dissociation group, youth who exhibited high levels of dissociation demonstrated higher levels of total PTSS, posttraumatic symptom clusters of emotional numbing, intrusion, and associated features, as well as reporting more difficulties with emotion dysregulation. To test theory regarding the factors that increase the likelihood of persistent dissociation, bootstrapped regression analyses were performed to examine the possibility of an indirect effect of peritraumatic dissociation. Results consistent with statistical mediation suggested that the presence of peritraumatic dissociation at the time of trauma may contribute to the continuation of dissociative symptoms as a more generalized pattern. The results of the current study have implications for clinical treatment with traumatized youth.

The roles of emotion dysregulation and dissociation in the association between sexual abuse and self-injury among juvenile justice-involved youth.

To date, scholars have established associations among nonsuicidal self-injury and sexual abuse, posttraumatic stress symptoms, and dissociation. However, leading theoretical models of the mechanisms underlying the association between trauma and negative outcomes suggest a more parsimonious explanation in that deficits in emotion regulation may underlie these various risk factors for self-injury. This study examined whether sexual abuse was differentially associated with nonsuicidal self-injury over and above other forms of traumatic experiences and whether the association between sexual abuse and self-injury was statistically mediated by emotion dysregulation and dissociation. Participants included 525 youth (392 boys, 133 girls) recruited from the U.S. juvenile justice system who completed measures of self-reported trauma exposure, posttraumatic stress symptoms, dissociation, and emotion dysregulation. Results of a hierarchical regression demonstrated that sexual abuse predicted posttraumatic stress symptoms and self-injury over and above other forms of traumatic experiences. Results of bootstrapped mediation analyses indicated that emotion dysregulation and dissociation in combination were implicated in self-injury among youth. The results suggest that youth in the juvenile justice system who experience sexual abuse may be at risk for higher rates of posttraumatic stress symptoms and that self-injury may be particularly salient for youth who experience sexual abuse. Furthermore, the results shed light on the role that dissociation and emotion dysregulation play in the relation between sexual abuse and self-injury, suggesting that a larger framework of self-regulation may have both empirical and clinical utility in helping to understand the underlying processes at play in these associations.