Sensory processing challenges as a novel link between early caregiving experiences and mental health.

Early caregiving adversity (ECA) is associated with elevated psychological symptomatology. While neurobehavioral ECA research has focused on socioemotional and cognitive development, ECA may also increase risk for "low-level" sensory processing challenges. However, no prior work has compared how diverse ECA exposures differentially relate to sensory processing, or, critically, how this might influence psychological outcomes. We examined sensory processing challenges in 183 8-17-year-old youth with and without histories of institutional (orphanage) or foster caregiving, with a particular focus on sensory over-responsivity (SOR), a pattern of intensified responses to sensory stimuli that may negatively impact mental health. We further tested whether sensory processing challenges are linked to elevated internalizing and externalizing symptoms common in ECA-exposed youth. Relative to nonadopted comparison youth, both groups of ECA-exposed youth had elevated sensory processing challenges, including SOR, and also had heightened internalizing and externalizing symptoms. Additionally, we found significant indirect effects of ECA on internalizing and externalizing symptoms through both general sensory processing challenges and SOR, covarying for age and sex assigned at birth. These findings suggest multiple forms of ECA confer risk for sensory processing challenges that may contribute to mental health outcomes, and motivate continuing examination of these symptoms, with possible long-term implications for screening and treatment following ECA.

Leveraging Leadership in Child Welfare Systems: Large-scale Trauma- and Resilience-informed Training Initiative.

Strengthening the infrastructure of public health systems around trauma-informed principles is crucial to addressing the needs of traumatized children in the child welfare system. In fact, many local and state initiatives have focused on large-scale evaluation studies to determine the value of training direct service staff on trauma foundations. Less yet is known about the benefits of training leaders on trauma foundations, which is crucial given their unique influence on implementation decisions. The current study evaluates a trauma training delivered to leadership-level stakeholders through a large-scale training initiative for the Los Angeles County Department of Children and Family Services. Findings indicated that leaders improved in trauma knowledge from baseline to post-training and reported changes in their professional wellbeing and leadership approach after the reflective training component. The leadership trauma program may have positive downstream implications for direct service staff, organizational culture, and child and family outcomes.

Long-term effects of pre-adoptive risk on emotional and behavioral functioning in children adopted from foster care.

BACKGROUND: Children adopted from foster care are at heightened risk for emotional and behavioral challenges, potentially due to early trauma exposure and related risk factors. Research has demonstrated that adoptees with greater pre-adoptive risk exhibit higher rates of internalizing and externalizing problems across childhood and into adulthood. However, these studies have been limited by their use of individual risk factors or sum scores of cumulative risk and their measurement of internalizing and externalizing behaviors separately. OBJECTIVE: The current study aimed to examine effects of pre-adoptive risk on long-term functioning in children adopted from foster care. METHOD: In a longitudinally-followed sample of 82 adoptees, we utilized latent growth curve modeling to examine effects of two latent indices of pre-adoptive risk, postnatal (i.e., trauma-related) risk and prenatal risk (not including prenatal substance exposure, since it was nearly ubiquitous in this sample), on adoptee internalizing, externalizing, and latent scores of dysregulation across childhood. Additionally, in three separate models, we tested whether baseline levels and change across childhood in internalizing, externalizing, and dysregulation mediated effects of prenatal and postnatal risk on adolescent/young-adult functioning. RESULTS: Greater postnatal risk, but not prenatal risk, predicted higher levels of internalizing and dysregulation across childhood. However, only dysregulation mediated the effect of postnatal risk on adolescent/young-adult functioning. CONCLUSIONS: These results are consistent with prior research evidencing long-term effects of postnatal pre-adoptive risk, but not prenatal risk, in adoptees. Furthermore, they suggest that trauma exposure in this population may result in a profile of broad dysregulation that increases risk for maladjustment into adulthood.

Developmental Outcomes of Infants Adopted from Foster Care: Predictive Associations from Perinatal and Preplacement Risk Factors.

Infants adopted domestically from foster care often present with prenatal substance exposure and risky birth outcomes such as prematurity and low birth weight. Because few longitudinal studies of foster-adoptive infants exist, it is unclear how these preplacement risk factors influence development over time. The present study examined associations between perinatal risk factors and developmental outcomes among an ethnically/racially-diverse sample of 97 infants in foster-care (56% boys) placed into adoptive homes at ages 0-19 months. Relative to population-norms, foster-adoptive infants showed comparable cognitive but lower language and motor functioning at baseline and one-year follow-up. Age-adjusted language scores significantly improved one year following placement, consistent with a developmental "catch-up" effect. Low birth weight uniquely predicted lower language scores at baseline, but this association was no longer significant at follow-up. Prenatal substance exposure was associated with lower baseline cognitive scores, but only for infants placed after six months of age. In contrast, infants with low birth weight and later placement age (>12 months) showed the most accelerated motor development. Sex differences emerged at follow-up when predicting motor and language outcomes, suggesting potential sex-specific pathways of risk. Overall, results support adoption as an early intervention that may buffer vulnerability to perinatal risk on development.

Leveraging a public-public partnership in Los Angeles County to address COVID-19 for children, youth, and families in underresourced communities.

There is growing concern about the mental health and social impact of COVID-19 on underresourced children, youth, and families given widespread social disruption, school closures, economic impact, and loss of lives. In this commentary we describe how an existing public-public partnership between a large county mental health department and a state university responded to COVID-19. This partnership, originally designed to address workforce needs, rapidly pivoted to support providers through a trauma- and resilience-informed approach to mitigating adverse mental health effects among youth and families in Los Angeles County. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mediators of youth anxiety outcomes 3 to 12 years after treatment.

OBJECTIVE: Test changes in perceived coping efficacy, negative self-statements, and interpretive biases to threat during treatment as potential mediators of the relationship between randomly assigned treatment conditions and long-term anxiety follow-ups. Age at randomization was also tested as a moderator of mediational relationships. METHOD: Participants included 319 youth (ages 7-17) from the Child/Adolescent Multimodal Study (CAMS) who participated in a naturalistic follow-up beginning an average of 6.5 years after the end of the CAMS intervention. The intervention conditions included cognitive behavioral therapy (CBT; Coping Cat), pharmacotherapy (sertraline), combined CBT and sertraline, and pill placebo. Putative mediators were measured four times during the intervention phase. Follow-up consisted of four annual assessments of current anxiety. RESULTS: Reductions on a measure of interpretive bias to threat over the course of the combined condition intervention, as compared to the placebo condition, mediated anxiety outcomes at the first follow-up visit. This mediated effect was not significant for the CBT-only or sertraline-only conditions when compared to the placebo condition. No other significant mediated effects were found for putative mediators. Age did not significantly moderate any mediated effects. CONCLUSION: Changes in youth-reported interpretive biases to threat over the course of combined youth anxiety interventions, as compared to a placebo intervention, may be associated with lower anxiety an average of 6.5 years following treatment.

A Cross-Site Partnership to Examine Implementation and Sustainability of a School-Based Trauma Program.

Objectives: Schools have been identified as an ideal setting for increasing access to mental health services particularly for underserved minority youth. The emerging field of implementation science has begun to systematically investigate strategies for more efficiently integrating evidence-based practices into community settings. Significantly less translational research has focused specifically on the school setting. To address this need, we examined the implementation of a school-based trauma intervention across three distinct regions. Design: We conducted key informant interviews guided by Mendel's Framework of Dissemination in Health Services Intervention Research with multiple school stakeholders to examine what school organizational characteristics influence the adoption and implementation process and sustainability of Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Participants were selected from schools in three geographic regions in the United States: Western, Midwestern, and Southern. Results: Our findings reveal that while sites had some common organizational factors that appeared to facilitate implementation, regions differed in how they compensated for less robust implementation domains. Across all regions, school stakeholders recognized the need for services to support students impacted by trauma. In the Western region, there was no centralized district policy for implementation; therefore, implementation was facilitated by school-level change agents and supervision support from the district mental health unit. In the Midwestern region, centralized district policies drove implementation. In both the Midwestern and Southern regions, implementation was facilitated by collaboration with a local mental health agency. Conclusions: This study contributes to the paucity of empirical information on the organizational factors that influence the implementation of evidence-based mental health interventions in schools. Our findings reveal that different implementation strategies across policies, structures, and resources can result in implementation of a school-based intervention. Frameworks such as Mendel's can be helpful in identifying areas of strength and improvement of implementation within a school organization.

Applying a Trauma Informed School Systems Approach: Examples from School Community-Academic Partnerships.

Objectives: Schools can play an important role in addressing the effects of traumatic stress on students by providing prevention, early intervention, and intensive treatment for children exposed to trauma. This article aims to describe key domains for implementing trauma-informed practices in schools. Design: The Substance Abuse and Mental Health Administration (SAMHSA) has identified trauma-informed domains and principles for use across systems of care. This article applies these domains to schools and presents a model for a Trauma-Informed School System that highlights broad macro level factors, school-wide components, and tiered supports. Community partners from one school district apply this framework through case vignettes. Results: Case 1 describes the macro level components of this framework and the leveraging of school policies and financing to sustain trauma-informed practices in a public health model. Case 2 illustrates a school founded on trauma-informed principles and practices, and its promotion of a safe school environment through restorative practices. Case 3 discusses the role of school leadership in engaging and empowering families, communities, and school staff to address neighborhood and school violence. Conclusions: This article concludes with recommendations for dissemination of trauma-informed practices across schools at all stages of readiness. We identify three main areas for facilitating the use of this framework: 1) assessment of school staff knowledge and awareness of trauma; 2) assessment of school and/or district's current implementation of trauma-informed principles and practices; 3) development and use of technology-assisted tools for broad dissemination of practices, data and evaluation, and workforce training of clinical and non-clinical staff.

Implementing the Bounce Back trauma intervention in urban elementary schools: A real-world replication trial.

The current study provides the first replication trial of Bounce Back, a school-based intervention for elementary students exposed to trauma, in a different school district and geographical area. Participants in this study were 52 1st through 4th graders (Mage = 7.76 years; 65% male) who were predominately Latino (82%). Schools were randomly assigned to immediate treatment or waitlist control. Differential treatment effects (Time × Group Interaction) were found for child-reported posttraumatic stress disorder (PTSD) and parent-reported child coping, indicating that the immediate treatment group showed greater reductions in PTSD and improvements in coping compared with the delayed group. Differential treatment effects were not significant for depression or anxiety. Significant maintenance effects were found for both child-reported PTSD and depression as well as parent-reported PTSD and coping for the immediate treatment group at follow-up. Significant treatment effects were also found in the delayed treatment group, showing reductions in child-reported PTSD, depression, and anxiety as well as parent-reported depression and coping upon receiving treatment. In conclusion, the current study suggests that Bounce Back is an effective intervention for reducing PTSD symptoms and improving coping skills, even among a sample experiencing high levels of trauma and other ongoing stressors. (PsycINFO Database Record

Temperamental sensitivity to early maltreatment and later family cohesion for externalizing behaviors in youth adopted from foster care.

Children in foster care frequently have histories of physical/sexual abuse and neglect, increasing their risk for externalizing behaviors (EB; e.g., aggression). According to the differential susceptibility theory, children with reactive temperaments (e.g., negative emotionality) may be particularly vulnerable to early maltreatment, but may also benefit the most from environmental enrichment such as family cohesion. In a high-risk longitudinal sample of 82 children adopted from foster care in Los Angeles County from 1996 and 2001, we examined predictions of EB from childhood to adolescence/young adulthood from temperament, preadoption maltreatment, and adoptive family cohesion. Overall, results from generalized linear models and generalized estimating equations (GEE) did not support differential susceptibility theory - specifically, youth with early reactive temperament did not exhibit heightened sensitivity to maltreatment nor to later adoptive family cohesion. Instead, reactive temperament was associated with higher EB at initial adoptive placement and escalating EB across childhood, controlling for age, gender, race-ethnicity, preadoption maltreatment, and adoptive family cohesion. Preadoption maltreatment history was unrelated to baseline EB, although sexual abuse history predicted escalating childhood EB post-adoption, whereas exposure to family violence (e.g., domestic violence) inversely predicted EB over time. By late adolescence/young adulthood 11-15 years post-adoption, rates of arrest and substance use in this sample were relatively comparable to normative populations of youth, although older age of adoption predicted more substance use in late adolescence/young adulthood. Findings highlight early reactive temperament and preadoption maltreatment as important risk factors to target for ameliorating patterns of EB growth in the first few years of adoption.

Social Interpretation Bias in Children and Adolescents with Anxiety Disorders: Psychometric Examination of the Self-report of Ambiguous Social Situations for Youth (SASSY) Scale.

BACKGROUND: Anxiety disorders are among the most common mental health problems in youth, and faulty interpretation bias has been positively linked to anxiety severity, even within anxiety-disordered youth. Quick, reliable assessment of interpretation bias may be useful in identifying youth with certain types of anxiety or assessing changes on cognitive bias during intervention. OBJECTIVE: This study examined the factor structure, reliability, and validity of the Self-report of Ambiguous Social Situations for Youth (SASSY) scale, a self-report measure developed to assess interpretation bias in youth. METHODS: Participants (N=488, age 7 to 17) met diagnostic criteria for Social Phobia, Generalized Anxiety Disorder, and/or Separation Anxiety Disorder. An exploratory factor analysis was performed on baseline data from youth participating in a large randomized clinical trial. RESULTS: Exploratory factor analysis yielded two factors (Accusation/Blame, Social Rejection). The SASSY full scale and Social Rejection factor demonstrated adequate internal consistency, convergent validity with social anxiety, and discriminant validity as evidenced by non-significant correlations with measures of non-social anxiety. Further, the SASSY Social Rejection factor accurately distinguished children and adolescents with Social Phobia from those with other anxiety disorders, supporting its criterion validity, and revealed sensitivity to changes with treatment. Given the relevance to youth with social phobia, pre- and post-intervention data were examined for youth social phobia to test sensitivity to treatment effects; results suggested that SASSY scores reduced for treatment responders. CONCLUSIONS: Findings suggest the potential utility of the SASSY Social Rejection factor as a quick, reliable, and efficient way of assessing interpretation bias in anxious youth, particularly as related to social concerns, in research and clinical settings.

Developmental Differences in Functioning in Youth With Social Phobia.

Social phobia (SoP) in youth may manifest differently across development as parent involvement in their social lives changes and social and academic expectations increase. This cross-sectional study investigated whether self-reported and parent-reported functioning in youth with SoP changes with age in social, academic, and home/family domains. Baseline anxiety impairment data from 488 treatment-seeking anxiety-disordered youth (ages 7-17, N = 400 with a SoP diagnosis) and their parents were gathered using the Child Anxiety Impact Scale and were analyzed using generalized estimating equations. According to youth with SoP and their parents, overall difficulties, social difficulties, and academic difficulties increased with age, even when controlling for SoP severity. These effects significantly differed for youth with anxiety disorders other than SoP. Adolescents may avoid social situations as parental involvement in their social lives decreases, and their withdrawn behavior may result in increasing difficulty in the social domain. Their avoidance of class participation and oral presentations may increasingly impact their academic performance as school becomes more demanding. Implications are discussed for the early detection and intervention of SoP to prevent increased impairment over the course of development.

Trauma exposure in elementary school children: Description of screening procedures, level of exposure, and posttraumatic stress symptoms.

Traumatic childhood events can have a significant impact on overall child functioning. Early identification and intervention could offer significant benefits for children's mental health and educational trajectories, but how to effectively identify young children is a challenge. In this paper, we describe screening for exposure to traumatic events and associated symptoms of posttraumatic stress, and examine differences by child gender and grade level. A total of 402 elementary school children in grades 1-5 participated across four elementary schools. We describe modified administration procedures of screening instruments for these young children. Children who endorsed exposure to one or more traumatic events were individually assessed for posttraumatic stress symptom severity. Thirty-four percent (n=138) of children screened experienced one or more traumatic events, and 75.4% of those exposed to at least one traumatic event endorsed moderate levels or higher of posttraumatic stress symptoms. Internal consistency of the symptom self-report instrument was adequate for children of all grade levels. Posttraumatic stress symptom severity increased for children exposed to more types of events. No gender/grade differences were found in symptom severity. Findings suggest that young children are impacted by traumatic events in relatively high numbers, that they can reliably report their posttraumatic stress symptoms, and that a large portion of those exposed to trauma experience significant distress. These results highlight the importance of early screening and identification of these children to curtail potential risk for future academic, social, and psychological maladjustment.

Bounce back: Effectiveness of an elementary school-based intervention for multicultural children exposed to traumatic events.

OBJECTIVE: To evaluate the feasibility and acceptability of a school-based intervention for diverse children exposed to a range of traumatic events, and to examine its effectiveness in improving symptoms of posttraumatic stress, depression, and anxiety. METHOD: Participants were 74 schoolchildren (Grades 1-5) and their primary caregivers. All participating students endorsed clinically significant posttraumatic stress symptoms. School clinicians were trained to deliver Bounce Back, a 10-session cognitive-behavioral group intervention. Children were randomized to immediate or delayed (3-month waitlist) intervention. Parent- and child-report of posttraumatic stress and depression, and child report of anxiety symptoms, were assessed at baseline, 3 months, and 6 months. RESULTS: Bounce Back was implemented with excellent clinician fidelity. Compared with children in the delayed condition, children who received Bounce Back immediately demonstrated significantly greater improvements in parent- and child-reported posttraumatic stress and child-reported anxiety symptoms over the 3-month intervention. Upon receipt of the intervention, the delayed intervention group demonstrated significant improvements in parent- and child-reported posttraumatic stress, depression, and anxiety symptoms. The immediate treatment group maintained or showed continued gains in all symptom domains over the 3-month follow-up period (6-month assessment). CONCLUSIONS: Findings support the feasibility, acceptability, and effectiveness of the Bounce Back intervention as delivered by school-based clinicians for children with traumatic stress. Implications are discussed.

Preventing secondary traumatic stress in educators.

Teachers can be vulnerable to secondary traumatic stress (STS) because of their supportive role with students and potential exposure to students' experiences with traumas, violence, disasters, or crises. STS symptoms, similar to those found in posttraumatic stress disorder, include nightmares, avoidance, agitation, and withdrawal, and can result from secondary exposure to hearing about students' traumas. This article describes how STS presents, how teachers can be at risk, and how STS can manifest in schools. A US Department of Education training program is presented, and thoughts on future directions are discussed.

A web-based platform to support an evidence-based mental health intervention: lessons from the CBITS web site.

OBJECTIVE: To explore the role of Web-based platforms in behavioral health, the study examined usage of a Web site for supporting training and implementation of an evidence-based intervention. METHODS: Using data from an online registration survey and Google Analytics, the investigators examined user characteristics and Web site utilization. RESULTS: Site engagement was substantial across user groups. Visit duration differed by registrants' characteristics. Less experienced clinicians spent more time on the Web site. The training section accounted for most page views across user groups. Individuals previously trained in the Cognitive-Behavioral Intervention for Trauma in Schools intervention viewed more implementation assistance and online community pages than did other user groups. CONCLUSIONS: Web-based platforms have the potential to support training and implementation of evidence-based interventions for clinicians of varying levels of experience and may facilitate more rapid dissemination. Web-based platforms may be promising for trauma-related interventions, because training and implementation support should be readily available after a traumatic event.

The child anxiety impact scale: examining parent- and child-reported impairment in child anxiety disorders.

The purpose of the current investigation was to examine the factor structure, reliability, and construct validity of both the Child and Parent version of the Child Anxiety Impact Scale (CAIS) using data obtained from the Child/Adolescent Anxiety Multimodal Study (Walkup et al., 2008 ). The CAIS child and parent versions measure anxiety-related functional impairment in school, social, and family domains. Participants were 488 children ages 7 to 17 (M age = 10.7, SD = 2.8 years) enrolled as part of the CAMS study across 6 sites and their primary parent or caregiver. Families participated in a structured diagnostic interview and then completed the CAIS along with other measures. Confirmatory factor analysis revealed that the a priori three-factor structure (school, social, and home/family) for the CAIS parent- and CAIS child-report was a reasonable fit, with a comparative fit index of .88 and root mean square error of approximation of .05. Internal consistency was very good for total score and subscales of both versions of the scale (Cronbach's α = .70-.90). The CAIS total scores demonstrated good construct validity, showing predicted significant correlations with the Child Behavior Checklist (CBCL) Internalizing Scale, the Multidimensional Anxiety Scale for Children (MASC) and Screen for Child Anxiety Related Emotional Disorders (SCARED) Total Scores, the Pediatric Anxiety Rating Scale, and the Children's Global Assessment Scale. In addition, CAIS Social and School subscales were significantly related to similar subscales on the CBCL, SCARED, and MASC. The results provide support that the CAIS is a reliable and valid measure for the assessment of the impact of anxiety on child and adolescent functioning.

Improving implementation of mental health services for trauma in multicultural elementary schools: stakeholder perspectives on parent and educator engagement.

Although more schools are offering mental health programs, few studies have involved the school community in research to improve their successful implementation. In this community-partnered study, focus groups were conducted with school staff and parents to explore issues related to community engagement and feasibility of a mental health intervention for elementary school students exposed to trauma. Four educator focus groups, including 23 participants, and 2 parent focus groups, consisting of 9 Spanish-speaking and 7 English-speaking parents were conducted. Participants discussed facilitators and barriers to successful implementation of the program. Participants identified the importance of pre-implementation parent education, raising awareness of the impact of student mental health among educators, maintaining ongoing communication during the intervention, and addressing logistical concerns. Participants described clear considerations for parent and educator engagement, both at the pre-implementation phase and during implementation of the program. Implications for next steps of this community-partnered approach are described.

Parental and Family Factors as Predictors of Threat Bias in Anxious Youth.

The present study examined the relative predictive value of parental anxiety, parents' expectation of child threat bias, and family dysfunction on child's threat bias in a clinical sample of anxious youth. Participants (N = 488) were part of the Child/Adolescent Anxiety Multi-modal study (CAMS), ages 7-17 years (M = 10.69; SD = 2.80). Children met diagnostic criteria for generalized anxiety disorder, separation anxiety and/or social phobia. Children and caregivers completed questionnaires assessing child threat bias, child anxiety, parent anxiety and family functioning. Child age, child anxiety, parental anxiety, parents' expectation of child's threat bias and child-reported family dysfunction were significantly associated with child threat bias. Controlling for child's age and anxiety, regression analyses indicated that parents' expectation of child's threat bias and child-reported family dysfunction were significant positive predictors of child's self-reported threat bias. Findings build on previous literature by clarifying parent and family factors that appear to play a role in the development or maintenance of threat bias and may inform etiological models of child anxiety.

Family factors predict treatment outcome for pediatric obsessive-compulsive disorder.

OBJECTIVE: To examine family conflict, parental blame, and poor family cohesion as predictors of treatment outcome for youths receiving family-focused cognitive behavioral therapy (FCBT) for obsessive-compulsive disorder (OCD). METHOD: We analyzed data from a sample of youths who were randomized to FCBT (n = 49; 59% male; M age = 12.43 years) as part of a larger randomized clinical trial. Youths and their families were assessed by an independent evaluator (IE) pre- and post-FCBT using a standardized battery of measures evaluating family functioning and OCD symptom severity. Family conflict and cohesion were measured via parent self-report on the Family Environment Scale (Moos & Moos, 1994), and parental blame was measured using parent self-report on the Parental Attitudes and Behaviors Scale (Peris, Benazon, et al., 2008b). Symptom severity was rated by IEs using the Children's Yale-Brown Obsessive Compulsive Scale (Scahill et al., 1997). RESULTS: Families with lower levels of parental blame and family conflict and higher levels of family cohesion at baseline were more likely to have a child who responded to FCBT treatment even after adjusting for baseline symptom severity compared with families who endorsed higher levels of dysfunction prior to treatment. In analyses using both categorical and continuous outcome measures, higher levels of family dysfunction and difficulty in more domains of family functioning were associated with lower rates of treatment response. In addition, changes in family cohesion predicted response to FCBT, controlling for baseline symptom severity. CONCLUSION: Findings speak to the role of the family in treatment for childhood OCD and highlight potential targets for future family interventions.