The Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions.

Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle-Out Approach is a novel, integrative, contextually informed framework for organizing and applying existing empirical methods to evaluate current and alternative traumatic stress reactions. Rather than beginning to identify traumatic stress reactions from the top-down (i.e., disorder-first approach) or bottom-up (i.e., symptom-first approach), constructs are evaluated from the middle out (i.e., presentation-first approach), unconstrained by higher-order disorders or lower-order diagnostic symptoms. This approach provides innovation over previous methods at multiple levels, including the conceptualization of traumatic stress reactions as well as the type of assessments and data sources used and how they are used in statistical analyses. Conceptualizations prioritize the identification of middle-order phenotypes, representing person-centered clinical presentations, which are informed by the integration of multidimensional, transdiagnostic, and multimodal (e.g., psychosocial, physiological) assessments and/or data sources. Integrated data are then analyzed concurrently using person-centered statistical models to identify precise, discrete, and representative health outcomes within broader heterogeneous samples. Subsequent variable-centered analyses are then used to identify culturally sensitive and contextually informed correlates of phenotypes, their clinical utility, and the differential composition within and between broader traumatic stress reactions. Examples from the moral injury literature are used to illustrate practical applications that may increase clinical utility and the accurate representation of health outcomes for diverse individuals and communities.

Caregiver behaviors and childhood maladaptive grief: Initial validation of the Grief Facilitation Inventory.

The Grief Facilitation Inventory (GFI) is a newly-developed measure of caregiver behaviors theorized to facilitate or hinder children's adaptive grief reactions. We examine its factor structure, reliability, and validity. An exploratory factor analysis identified four factors: Ongoing Connection, Existential Continuity/Support, Caregiver Grief Expression, and Grief Inhibition/Avoidance. Both child- and caregiver-report versions had adequate-to-good internal consistency. The child-report GFI showed evidence of criterion-referenced validity via significant correlations with measures of child maladaptive grief and other psychological symptoms. Results provide preliminary evidence of the reliability, validity, and clinical utility of the GFI as a measure of caregiver grief-facilitation behaviors.

Measurement Invariance of the Persistent Complex Bereavement Disorder Checklist With Respect to Youth Gender, Race, Ethnicity, and Age.

The Persistent Complex Bereavement Disorder (PCBD) Checklist was constructed to facilitate the developmentally sensitive assessment of proposed PCBD criteria in bereaved children and adolescents 8-18 years of age. Initial analyses of the PCBD Checklist provided support for the hypothesized two-factor model. The purpose of the present study was to evaluate the measurement invariance of the PCBD Checklist with respect to gender (boys and girls), race/ethnicity (White, Black, and Hispanic youth), and age (school age, preadolescent, and adolescent youth). Participants were 594 youth (50.4% female) aged 7-18 years (M = 11.91, SD = 2.80) who were evaluated as part of standard care at a community-based grief support center. Youth self-identified as Hispanic (n = 184, 30.8%), non-Hispanic white (n = 179, 30.0%), and African American/Black (n = 136, 22.8%). A series of stepwise, multigroup confirmatory factor analyses provided evidence in support of the PCBD Checklist's measurement invariance for all three groups concerning configural invariance, metric invariance, and scalar invariance. These results suggest that PCBD Checklist Criterion B and C scores are measuring similar latent variables, to a similar degree, across gender, race/ethnicity, and age. Establishing the cross-group equivalence of the PCBD Checklist is an important endorsement of its generalizability and clinical utility in that it can be administered to diverse populations with confidence that it is measuring proposed PCBC diagnostic criteria similarly across subgroups.

Initial Validation and Measurement Invariance of the Active Inhibition Scale Among Traumatized and Grieving Youth.

The Active Inhibition Scale (AIS; Ayers, Sandler, & Twohey, 1998) is an 11-item, self-report measure of emotional suppression among children and adolescents. Previous research with the AIS has linked emotional suppression to several clinically significant outcomes, such as posttraumatic stress symptoms (PTSS) and suicide, among trauma-exposed and bereaved youth; however, there are no published evaluations of its psychometric properties. We examined the factor structure and criterion validity of the AIS in two samples. Sample 1 included youth (M = 12.22 years, SD = 2.96, range: 6-18 years; 55.4% female) referred to an outpatient psychology clinic specializing in childhood trauma and grief. Sample 2 included youth (M = 13.18 years, SD = 2.58, range: 8-18 years; 61.8% female) referred to a community grief counseling center. Confirmatory factor analytic results supported a one-factor solution, Cronbach's α = .94. Additionally, AIS scores correlated positively with PTSS, depression, and maladaptive grief, rs = .43-.64. Evidence of factorial invariance was found across gender, race/ethnicity, and age group. Emotional suppression scores were higher among girls compared to boys, Black and Hispanic youth compared to White youth, and older compared to younger age groups. The magnitude of correlations between AIS and symptom measure scores was comparable across groups. These results support the reliability and criterion validity of the AIS with diverse youth populations and underscore the role that emotional suppression may play in explaining group differences in mental health symptoms.

Calculating the incidence rate of sibling bereavement among children and adolescents across the United States: A proposed method.

This study proposes a method for calculating the annual incidence rate of sibling bereavement among US youth using national epidemiological data. The proposed model combines data on family household size with national death statistics to calculate the number of siblings affected by the death of a child annually. From 2012 to 2015, an average of 61,389 children per year experienced the death of a sibling, resulting in an estimate of 0.0832% of children bereaved by the death of a sibling annually. Data indicate a need for greater awareness and dialog concerning the frequency with which children experience the death of a sibling.

Understanding grief reactions, thwarted belongingness, and suicide ideation in bereaved adolescents: Toward a unifying theory.

OBJECTIVE: Childhood bereavement is linked to suicide-related behaviors in adolescence and adulthood, but candidate mechanisms through which bereavement may lead to suicide-related behaviors have not been explored. One candidate pathway is that grief reaction arising from bereavement lead to increased perceived burdensomeness and/or thwarted belongingness, resulting in increased suicide ideation. This cross-sectional study of bereaved adolescents explored indirect effects between grief reactions as distal predictors, perceived burdensomeness and thwarted belongingness as proximal predictors, and suicide ideation. METHOD: Participants were 58 bereaved youth, 12-17 years of age (mean = 14.21, SD = 1.65; 81.0% female; 51.7% Hispanic, 17.2% African American, and 22.4% Caucasian), and their parents/guardians seeking services at a trauma and grief specialty outpatient clinic. RESULTS: The indirect effect of grief reactions on suicide ideation via thwarted belongingness, but not perceived burdensomeness, was statistically significant. CONCLUSIONS: Clinicians may wish to consider signs of thwarted belongingness as possible indicators of suicide risk among bereaved youth.

Out of the Mouths of Babes: Links Between Linguistic Structure of Loss Narratives and Psychosocial Functioning in Parentally Bereaved Children.

This study examined links between the language bereaved children use to describe the death of their caregiver and children's psychological/behavioral functioning and coping strategies. Participants included 44 children (54.5% male) aged 7 to 12 (M = 9.05) years who were bereaved by the death of a caregiver. Children were assessed via self- and caregiver-report measures and an in-person interview regarding the loss of their caregiver. Children's loss narratives gathered through in-person interviews were transcribed and subjected to textual analysis. Linguistic categories included pronouns and verb tense. Drawing from linguistic and self-distancing theories, we hypothesized that children's use of language reflecting self-distancing (third-person pronouns and past tense) or social connectedness (first-person plural pronouns) would be negatively associated with psychological/behavioral distress and avoidant coping. Similarly, we expected that children's use of self-focused language (first-person singular pronouns and present tense) would be positively associated with psychological/behavioral distress and avoidant coping. As hypothesized, preliminary findings suggest that children who employed more self-distancing language and used more social connectedness words reported less avoidant coping, rs = .40-.42. Also as hypothesized, children who employed more self-focused language had higher levels of self-reported posttraumatic stress symptoms, r = .54, and avoidant coping, r = .54, and higher parent-reported psychological/behavioral distress, r = .43. Implications for theory-building, risk screening, and directions for future research with bereaved youth are discussed.

Validation of the Persistent Complex Bereavement Disorder (PCBD) Checklist: A Developmentally Informed Assessment Tool for Bereaved Youth.

The inclusion of Persistent Complex Bereavement Disorder (PCBD) in the DSM-5 appendix signifies a call for research regarding the distinguishing features and clinical utility of proposed PCBD criteria. Rigorously constructed tools for assessing PCBD are lacking, especially for youth. This study evaluated the validity and clinical utility of the PCBD Checklist, a 39-item measure designed to assess PCBD criteria in youth aged 8 to18 years. Test construction procedures involved: (a) reviewing the literature regarding developmental manifestations of proposed criteria, (b) creating a developmentally informed item pool, (c) surveying an expert panel to evaluate the clarity and developmental appropriateness of candidate items, (d) conducting focus groups to evaluate the comprehensibility and acceptability of items, and (e) evaluating psychometric properties in 367 bereaved youth (Mage = 13.49, 55.0% female). The panel, clinicians, and youth provided favorable content validity and comprehensibility ratings for candidate items. As hypothesized, youth who met full PCBD criteria, Criterion B (e.g., preoccupation with the deceased and/or circumstances of the death), or Criterion C (e.g., reactive distress and/or social/identity disruption) reported higher posttraumatic stress and depressive symptoms than youth who did not meet these criteria, ηp2 = .07-.16. Youth who met Criterion C reported greater functional impairment than youth who did not, ηp2 = .08-.12. Youth who qualified for the "traumatic bereavement specifier" reported more frequent posttraumatic stress symptoms than youth who did not, ηp2 = .04. Findings support the convergent, discriminant, and discriminant-groups validity, developmental appropriateness, and clinical utility of the PCBD Checklist.

Comparing Trauma Exposure, Mental Health Needs, and Service Utilization Across Clinical Samples of Refugee, Immigrant, and U.S.-Origin Children.

Most mental health services for trauma-exposed children and adolescents were not originally developed for refugees. Information is needed to help clinicians design services to address the consequences of trauma in refugee populations. We compared trauma exposure, psychological distress, and mental health service utilization among children and adolescents of refugee-origin, immigrant-origin, and U.S.-origin referred for assessment and treatment by U.S. providers in the National Child Traumatic Stress Network (NCTSN). We used propensity score matching to compare trauma profiles, mental health needs, and service use across three groups. Our sample comprised refugee-origin youth (n = 60, 48.3% female, mean age = 13.07 years) and propensity-matched samples of immigrant-origin youth (n = 143, 60.8% female, mean age = 13.26 years), and U.S.-origin youth (n = 140, 56.1% female, mean age = 12.11 years). On average, there were significantly more types of trauma exposure among refugee youth than either U.S.-origin youth (p < .001) or immigrant youth (p ≤ .001). Compared with U.S.-origin youth, refugee youth had higher rates of community violence exposure, dissociative symptoms, traumatic grief, somatization, and phobic disorder.  In contrast, the refugee group had comparably lower rates of substance abuse and oppositional defiant disorder (ps ranging from .030 to < .001).This clinic-referred sample of refugee-origin youth presented with distinct patterns of trauma exposure, distress symptoms, and service needs that merit consideration in services planning.

Predicting Grief Reactions One Year Following a Mass University Shooting: Evaluating Dose-Response and Contextual Predictors.

This study identifies risk factors for grief following a mass school shooting. Participants (N = 1,013) completed online questionnaires 3-4 months (Time 1) and 1 year (Time 2) post-shootings. We tested models predicting Time 2 grief reactions, exploring direct and indirect predictive effects of exposure variables (physical and social proximity) through hypothesized peritraumatic mediators (peritraumatic perceived threat to self or others) while controlling for Time 1 grief and posttraumatic stress (PTS) reactions, pretrauma vulnerabilities. Findings demonstrate that closer social proximity predicted higher levels of Time 2 grief, directly and indirectly through increasing peritraumatic perceived threat to others' safety. Physical proximity and peritraumatic threat to self did not predict Time 2 grief reactions. Implications for grief screening instruments and theory building research through identifying risk factors and causal mechanisms are discussed.

Narrative Focus Predicts Symptom Change Trajectories in Group Treatment for Traumatized and Bereaved Adolescents.

Growing evidence supports the effectiveness of Trauma and Grief Component Therapy for Adolescents (TGCT-A) in reducing posttraumatic stress disorder (PTSD) symptoms and maladaptive grief (MG) reactions. This pilot study explored whether the specific focus of students' narratives (i.e., focus on trauma vs. focus on loss) as shared by TGCT-A group members would predict initial pretreatment levels, as well as pre- to posttreatment change trajectories, of PTSD symptoms and MG reactions. Thirty-three adolescents from three middle schools completed a 17-week course of group-based TGCT-A. PTSD and MG symptoms were assessed at pretreatment, twice during treatment, and at posttreatment. The focus (trauma vs. loss) of each student's narrative was coded using transcripts of members' narratives as shared within the groups. The reliable change index showed that 61% of students reported reliable pre-post improvement in either PTSD symptoms or MG reactions. Students whose narratives focused on loss both reported higher starting levels and showed steeper rates of decline in MG reactions than students whose narratives focused on trauma. In contrast, students whose narratives focused on trauma reported higher starting levels of PTSD than students who narrated loss experiences. However, narrative focus was not significantly linked to the rate at which PTSD symptoms declined over the course of treatment. This study provides preliminary evidence that TGCT-A treatment components are associated with reduced PTSD symptoms and MG reactions. Loss-focused narratives, in particular, appear to be associated with greater decreases in MG reactions.

Do circumstances of the death matter? Identifying socioenvironmental risks for grief-related psychopathology in bereaved youth.

We examined bereaved children's and surviving caregivers' psychological responses following the death of the other caregiver as a function of the stated cause of death. Participants included 63 parentally bereaved children and 38 surviving caregivers who were assessed using self-report instruments and in-person interviews. Surviving caregivers reported the causes of death as resulting from sudden natural death (34.9%), illness (33.3%), accident (17.5%), and suicide (14.3%). Results revealed differences between caregiver-reported versus child-reported cause of death, particularly in cases of suicide. Children who lost a caregiver due to a prolonged illness exhibited higher levels of both maladaptive grief (d = 3.13) and posttraumatic stress symptoms (PTSS; d = 3.33) when compared to children who lost a caregiver due to sudden natural death (e.g., heart attack). In contrast, surviving caregivers did not differ in their levels of maladaptive grief and PTSS as a function of the cause of death; however, caregivers bereaved by sudden natural death reported higher levels of depression than those bereaved by prolonged illness (d = 1.36). Limited sample size prevented analysis of outcomes among those bereaved by suicide or accident. These findings suggest that anticipated deaths may contain etiologic risk factors for maladaptive grief and PTSS in children.

Using the core curriculum on childhood trauma to strengthen clinical knowledge in evidence-based practitioners.

The high prevalence of trauma exposure in mental health service-seeking populations, combined with advances in evidence-based practice, competency-based training, common-elements research, and adult learning make this an opportune time to train the mental health workforce in trauma competencies. The Core Curriculum on Childhood Trauma (CCCT) utilizes a five-tiered conceptual framework (comprising Empirical Evidence, Core Trauma Concepts, Intervention Objectives, Practice Elements, and Skills), coupled with problem-based learning, to build foundational trauma knowledge and clinical reasoning skills. We present findings from three studies: Study 1 found that social work graduate students' participation in a CCCT course (N = 1,031) was linked to significant pre-post increases in self-reported confidence in applying core trauma concepts to their clinical work. Study 2 found significant pre-post increases in self-reported conceptual readiness (N = 576) and field readiness (N = 303) among social work graduate students participating in a "Gold Standard Plus" educational model that integrated classroom instruction in core trauma concepts, training in evidence-based trauma treatment (EBTT), and implementation of that EBTT in a supervised field placement. Students ranked the core concepts course as an equivalent or greater contributor to field readiness compared to standard EBTT training. Study 3 used qualitative methods to "distill" common elements (35 intervention objectives, 59 practice elements) from 26 manualized trauma interventions. The CCCT is a promising tool for educating "next-generation" evidence-based practitioners who possess competencies needed to implement modularized, individually tailored trauma interventions by strengthening clinical knowledge, clinical reasoning, and familiarity with common elements.

Psychometric properties of the UCLA PTSD reaction index. part II: investigating factor structure findings in a national clinic-referred youth sample.

We examined the underlying factor structure of the UCLA PTSD Reaction Index (PTSD-RI) using data from 6,591 children/adolescents exposed to trauma, presenting for treatment at any of 54 National Child Traumatic Stress Network (NCTSN) centers. Using confirmatory factor analysis, we tested the 3-factor DSM-IV PTSD model, 2 separate 4-factor models (Dysphoria vs. Emotional Numbing) and a recently conceptualized 5-factor Dysphoric Arousal model. We found a slight, but significant advantage for the Dysphoria model over the Emotional Numbing model on the PTSD-RI, with a difference in Bayesian information criterion (BIC) values of 81 points. As with several recent studies of adult trauma victims, we found a slight advantage for the Dysphoric Arousal model over the other models on the PTSD-RI, with BIC differences exceeding 300 points. Retaining the Dysphoric Arousal model, we tested the convergent validity of the PTSD-RI factors against subscales of the Trauma Symptom Checklist for Children. Supporting the convergent validity of the PTSD-RI, in the Dysphoric Arousal model, the dysphoric arousal factor related most strongly to anger, whereas the emotional numbing factor related most strongly to depression, and anxious arousal factor related most strongly to anxiety. Results support the use of the PTSD-RI for evaluating PTSD among youth.

Trauma history and psychopathology in war-affected refugee children referred for trauma-related mental health services in the United States.

There is an increasing need to deliver effective mental health services to refugee children and adolescents across the United States; however, the evidence base needed to guide the design and delivery of services is nascent. We investigated the trauma history profiles, psychopathology, and associated behavioral and functional indicators among war-affected refugee children presenting for psychological treatment. From the National Child Traumatic Stress Network's Core Data Set, 60 war-affected refugee children were identified (51.7% males, mean age = 13.1 years, SD = 4.13). Clinical assessments indicated high rates of probable posttraumatic stress disorder (30.4%), generalized anxiety (26.8%), somatization (26.8%), traumatic grief (21.4%), and general behavioral problems (21.4%). Exposure to war or political violence frequently co-occurred with forced displacement; traumatic loss; bereavement or separation; exposure to community violence; and exposure to domestic violence. Academic problems and behavioral difficulties were prevalent (53.6% and 44.6%, respectively); however, criminal activity, alcohol/drug use, and self-harm were rare (all < 5.45%). These findings highlight the complex trauma profiles, comorbid conditions, and functional problems that are important to consider in providing mental health interventions for refugee children and adolescents. Given the difficulties associated with access to mental health services for refugees, both preventive and community-based interventions within family, school, and peer systems hold particular promise.

Training experienced mental health practitioners to deliver foundational trauma education: The core curriculum on childhood trauma.

OBJECTIVE: The majority of U.S. mental health practitioners receive little to no foundational trauma education, and instead rely on in-service or continuing education to fill this deficit. Consequently, it is essential to have experienced mental health practitioners capable of delivering trauma education. Since 2009; experienced mental health practitioners have been trained to use the Core Curriculum on Childhood Trauma (CCCT) to deliver trauma education to other mental health practitioners. Despite prior evidence that the CCCT increases the trauma skills of trainees, to date no evaluation has been conducted on developing facilitators' skills, a crucial element in ensuring effective education. METHOD: Longitudinal, multiinstrument data were collected from 85 CCCT facilitators trained between October 2016-January 2020; along with learning outcome data from 1646 mental health practitioners trained by those facilitators through March 2021. RESULTS: High facilitator skill levels were seen across all instruments, including statistically significant change between preand posttraining measures for 7 core facilitator skills (effect sizes: .90 to 2.25). The data also identified challenges in facilitator development and retention. CONCLUSIONS: CCCT facilitator training effectively imparts skills needed to increase workforce trauma capacity; however, modifications to the facilitator development model are needed to maximize impact of scale-up efforts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Building a trauma-informed national mental health workforce: Learning outcomes from use of the core curriculum on childhood trauma in multidisciplinary practice settings.

OBJECTIVE: The impact of trauma on mental and physical health has long been recognized as a significant public health issue, yet there has been little unanimity about how to best develop a trauma-capable national workforce. The Core Curriculum on Childhood Trauma (CCCT) is being used to train a wide variety of mental health professionals and child-serving staff; however, prior data on its effectiveness have been limited to small pilot studies with master's in social work students. METHOD: We used 1,908 retrospective pre-post-training evaluations collected from 168 CCCT trainings delivered in multidisciplinary or practice settings between October 2016 and August 2019. RESULTS: CCCT participants reported high levels of satisfaction and statistically significant change between pre- and postscores for 8 self-reported child trauma skills (p < .001), with effect sizes ranging from .78 to 1.45. CONCLUSIONS: The consistency of positive outcomes across a wide variety of training formats and audiences demonstrates that the CCCT can be implemented successfully in diverse practice settings and thus can be a useful tool for building a trauma-capable, multidisciplinary national mental health workforce. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Parenting self-efficacy as a predictor of child psychotherapy outcomes in usual care: a multi-dimensional approach.

Three theorized dimensions of perceived parenting self-efficacy (Parental Connection, Psychological Autonomy, and Behavioral Influence) were used to predict psychotherapy outcomes in 271 youth (age = 4-17 years, mean age = 10.4, 42% girls) receiving routine outpatient services in a community mental health setting. We used individual growth curve modeling to examine patterns of change in self-efficacy domains and corresponding changes in parent-reported child symptoms. Parenting self-efficacy scores at pre-treatment did not predict treatment outcomes. Parenting self-efficacy scores for Parental Connection and Psychological Autonomy increased over the course of therapy, and increases in parenting self-efficacy dimensions (particularly Psychological Autonomy) were significantly associated with improvements in child symptoms over the course of treatment. Parenting self-efficacy appears to merit further study as a candidate mechanism of therapeutic change in child mental health treatment.

Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network.

Many children in the child welfare system (CWS) have histories of recurrent interpersonal trauma perpetrated by caregivers early in life often referred to as complex trauma. Children in the CWS also experience a diverse range of reactions across multiple areas of functioning that are associated with such exposure. Nevertheless, few CWSs routinely screen for trauma exposure and associated symptoms beyond an initial assessment of the precipitating event. This study examines trauma histories, including complex trauma exposure (physical abuse, sexual abuse, emotional abuse, neglect, domestic violence), posttraumatic stress, and behavioral and emotional problems of 2,251 youth (age 0 to 21; M = 9.5, SD = 4.3) in foster care who were referred to a National Child Traumatic Stress Network site for treatment. High prevalence rates of complex trauma exposure were observed: 70.4% of the sample reported at least two of the traumas that constitute complex trauma; 11.7% of the sample reported all 5 types. Compared to youth with other types of trauma, those with complex trauma histories had significantly higher rates of internalizing problems, posttraumatic stress, and clinical diagnoses, and differed on some demographic variables. Implications for child welfare practice and future research are discussed.

How do we get to trauma-informed practice? Retention and application of learning by practitioners trained using the core curriculum on childhood trauma.

Objective: Most mental health practitioners receive minimal trauma training in their degree curriculum and rely on supplemental training to build additional skills. Since 2016, the Core Curriculum on Childhood Trauma (CCCT) has been used for brief in-service training of more than 2,000 mental health practitioners. Prior evaluation showed statistically significant learning outcomes posttraining, yet little was known about retention of learning or impact on clinical practice. Method: We collected 100 mixed-method follow-up surveys from participants completing CCCT training between October 2016 and August 2019. Results: Statistically significant increases were seen between pretraining and follow-up self-report (6-24 months later) for four child trauma skills (effect sizes: 0.90-1.07). Qualitative data identified four key impacts on clinical practice: increased empathy, understanding of trauma complexity, systematic approach to case conceptualization, and catalyzing further trauma learning. Conclusions: Positive learning outcomes 6-24 months posttraining suggest that the CCCT is an effective tool for in-service training and that retained learning can translate into improved trauma-informed clinical practice. (PsycInfo Database Record (c) 2021 APA, all rights reserved).