Parents' Perception of Stepped Care and Standard Care Trauma-Focused Cognitive Behavioral Therapy for Young Children

Stepping Together for Children After Trauma (ST-CT): Feasibility and Predictors of Outcome of a Parent-led, Therapist Assisted Treatment

Stepping Together for Children after Trauma (ST-CT) is the first step of the promising intervention Stepped Care CBT for Children after Trauma. In ST-CT, the task of leading treatment is partially shifted to the parents, and the child and parent work together to complete therapeutic tasks from a workbook with therapist supervision. We aimed to investigate the feasibility of ST-CT in Norwegian first line services and explore child factors predicting outcome. Eighty-two children (mean age 9.9 years, 56% girls) participated. Feasibility was defined by treatment completion, reductions of child posttraumatic stress symptoms (PTSS) mid- and post-treatment, and client treatment satisfaction. Predictors included child baseline PTSS, depressive symptoms, posttraumatic cognitions, externalizing symptoms, number of different traumatic events, and type of trauma. Results showed that rates of completion (78.0%) and response (81% of completers/59.8% intention-to-treat) were comparable to previous studies by the ST-CT developer. Overall treatment effect was d = 2.46 and client treatment satisfaction was high (mean score child: 8.3, parent: 9.0, on a scale from 0 - 10). Higher baseline PTSS and depressive symptoms predicted poorer outcome at both mid- and post-treatment, while more posttraumatic cognitions, and exposure to interpersonal trauma predicted poorer outcome at mid-treatment only. These associations were no longer significant in the fully adjusted models. In conclusion, ST-CT shows promise as an effective first line treatment in this new context, with two of three children responding to the treatment. Baseline PTSS, depression, post-traumatic cognitions and type of trauma may be related to outcomes and should be explored further. (Trial registration:  ClinicalTrials.gov Identifier: NCT04073862. Retrospectively registered June 3rd 2019, first patient recruited May 19th 2019).

Parent-Led Stepped Care Trauma Treatment: Parents' Experiences With Helping Their Child Recover

Purpose

There is a need for interventions for traumatized children that are easily accessible and effective, and that involve parents directly in the recovery process. To meet this challenge, stepped care trauma-focused cognitive behavioral treatment (SC TF-CBT), which consists of a parent-led therapist-assisted intervention as the first step, was developed. Parent-led trauma-treatment is a promising, but novel approach. The aim of this study was therefore to gain knowledge on how parents experience the model.

Methods

Parents who participated in a SC TF-CBT feasibility study were consecutively recruited and interviewed with semi-structured interviews, which were then analysed using interpretative phenomenological analysis.

Results

The parents described that the intervention gave them insights that led to a sense of parental agency. Through the analysis we identified and labelled four themes: (i) understanding my child: how the trauma has affected my child and our relationship; (ii) understanding myself: how my reactions have stood in the way of helping my child; (iii) gaining competence: how to learn specific tasks that were not part of my normal parenting skills; and (iv) receiving support: how guidance, warmth and encouragement was necessary.

Conclusions

The results from this study show how the shifting of therapeutic tasks to parents may facilitate parental empowerment and improve the parent-child relationship. This knowledge may guide clinicians on how to provide support to parents so they can take a leading role in their child's recovery process after trauma.

Trial registration

ClinicalTrials.gov, NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019), https://clinicaltrials.gov/ct2/show/NCT04073862.

Parent-led stepped care for traumatised children: parental factors that predict treatment completion and response

Background: Stepped care cognitive behavioural therapy for children after trauma (SC-CBT-CT; aged 7-12 years) can help to increase access to evidence-based trauma treatments for children. SC-CBT-CT consists of a parent-led therapist-assisted component (Step One) with an option to step up to standard therapist-led treatment (Step Two). Studies have shown that SC-CBT-CT is effective; however, less is known about what parent variables are associated with outcome of Step One.Objective: To examine parent factors and their relationship with completion and response among children receiving Step One.Method: Children (n = 82) aged 7-12 (M = 9.91) received Step One delivered by their parents (n = 82) under the guidance of SC-CBT-CT therapists. Logistic regression analyses were used to investigate whether the following factors were associated with non-completion or non-response: the parents' sociodemographic variables, anxiety and depression, stressful life experiences and post-traumatic symptoms, negative emotional reactions to their children's trauma, parenting stress, lower perceived social support, and practical barriers to treatment at baseline.Results: Lower level of educational achievement among parents was related to non-completion. Higher levels of emotional reactions to their child's trauma and greater perceived social support were related to non-response.Conclusions: The children seemed to profit from the parent-led Step One despite their parents` mental health challenges, stress, and practical barriers. The association between greater perceived social support and non-response was unexpected and warrants further investigation. To further increase treatment completion and response rates among children, parents with lower education may need more assistance on how to perform the interventions, while parents who are very upset about their child's trauma may need more emotional support and assurance from the therapist.Trial registration: ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019).

Development and validation of the parents' cognitive perception inventory of disaster effects on children's well-being (PCP-DCWB)

BACKGROUND

Parents' cognition about the type and nature of consequences a disaster may pose on the children's psychosocial health, could be a major protective factor against the long-term overwhelming complications. Given the lack of a reliable instrument to measure parents' cognition about disasters' effects on children's well-being, this study was conducted to develop and validate the parents' cognitive perception inventory of disaster effects on children's well-being (PCP-DCWB).

METHODS

In this cross-sectional study 300 parents of the survived primary school aged children from the Iran's northwest earthquake on August 2012 were recruited in the city of Varzegan. Exploratory factor analysis (EFA) was applied to identify the subcomponents and Cronbach's alpha and Guttmann Split-half coefficients were calculated to assess the internal consistency reliability of the scale.

RESULTS

Structural indicators of the Kaiser-Meyer-Olkin measure (0.69) and Bartlett's test of Sphericity (P < 0.001, df = 153, X² = 618.35) verified interpretability of the EFA output. Applying principal component analysis and direct oblimin rotation in the EFA four latent factors were identified (i.e., perception about child overall mental health, coping with trauma's long-term effects, children or parents' continuing memory of past disaster and perception about behavioral and educational problems) which explained 49.32% of the total variance. The estimated Cronbach's alpha and split-half reliability coefficients (0.71 and 0.52 respectively) supported good internal consistency of the instrument.

CONCLUSION

The study findings revealed sound psychometric attributes of the PCP-DCWB to be applied in assessment of parents' cognition about psychological impacts of a traumatic event on the survived children. The instrument application can shed light on level of pre-disaster preparations in local, national and international scales and help effectiveness assessment of interventions that target maintenance of psycho-social well-being among disaster-affected survivors over time.

Stepped Care Versus Standard Care for Children After Trauma: A Randomized Non-Inferiority Clinical Trial

OBJECTIVE

Trauma-focused cognitive-behavioral therapy (TF-CBT) is an evidence-based therapist-led treatment for children after trauma. Parents often experience barriers to treatment engagement, including cost. Stepped care TF-CBT (SC-TF-CBT) was developed as an alternative delivery system. Step One is a parent-led therapist-assisted treatment. Step Two provides therapist-led TF-CBT for children who did not benefit from Step One and require more intensive treatment. This study compared SC-TF-CBT to standard TF-CBT in a community-based non-inferiority trial.

METHOD

A total of 183 children (aged 4-12 years) experiencing posttraumatic stress symptoms (PTSS) and their caregivers were randomly assigned to SC-TF-CBT or standard TF-CBT within 6 community clinics. Assessments occurred at baseline, mid- and posttreatment, and 6 and 12 months. Primary outcomes included PTSS and impairment. Secondary outcomes included severity, diagnostic status, remission, and response. Treatment cost, acceptability, and satisfaction were measured. Difference and non-inferiority tests were applied.

RESULTS

SC-TF-CBT participants changed at rates comparable to participants in TF-CBT for primary and secondary measures. SC-TF-CBT was non-inferior to TF-CBT for PTSS, impairment, and severity at all time points except for impairment at the 6-month assessment. Attrition did not differ between treatment arms (132 participants were completers). Baseline treatment acceptability was lower for SC-TF-CBT parents, although there was no difference in expected treatment improvements or treatment satisfaction at posttreatment. Based on regression estimates, total costs were 38.4% lower for SC-TF-CBT compared to TF-CBT, whereas recurring costs were 53.7% lower.

CONCLUSION

Stepped Care TF-CBT provides an alternative way to deliver treatment for some children and parents, with reduced cost for providers and parents.

CLINICAL TRIAL REGISTRATION INFORMATION

Stepped Care for Children after Trauma: Optimizing Treatment; https://clinicaltrials.gov; NCT02537678.

"Like a huge weight lifted off my shoulders": Exploring young peoples' experiences of treatment in a pilot trial of trauma-focused cognitive behavioral therapy

Background: The efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) is well-established, yet little work has been done to understand how young people experience this intervention.Method: Semi-structured interviews were conducted with 13 young people aged 17-25 years (M = 20.0, SD = 2.61) who received TF-CBT as part of a pilot trial. Transcripts were analyzed via interpretative phenomenological analysis.Results: Four super-ordinate themes were identified: (i) experience of authentic care, (ii) personal role in therapy and recovery, (iii) talking about trauma is difficult but important, and (iv), transformative change. Young people described authenticity on behalf of the therapist, which seemed to foster emotional connection and comfort discussing trauma. They emphasized the importance of retaining autonomy and control during therapy, and a degree of personal responsibility in their recovery. Talking about trauma was described as difficult and potentially distressing, but also as critical for recovery. Transformative life changes were noted, which had a significant impact on young peoples' future outlook and self-perception.Conclusions: This study suggests that therapists should be attuned to the interpersonal needs of clients, attempt to foster self-determination throughout therapy, and simultaneously recognize the difficulty and importance of trauma work for young people when delivering TF-CBT.

Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions

OBJECTIVE

Treatment for childhood anxiety disorders is insufficient in many cases. Parent involvement has been examined to augment child-based cognitive-behavioral therapy (CBT), but no studies have compared the efficacy of stand-alone parent-based treatment to CBT. Research implicates family accommodation in the maintenance and course of childhood anxiety. Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based treatment that reduces accommodation of childhood anxiety. This study compared SPACE to CBT in a noninferiority trial.

METHOD

Participants were children with primary anxiety disorders (N = 124; 7-14 years of age; 53% female participants; 83% white), randomly assigned to either SPACE (n = 64) with no direct child-therapist contact, or CBT (n = 60) with no parent treatment. A total of 97 participants (78%) completed all treatment sessions and assessments. Attrition did not differ significantly between groups. Primary anxiety outcomes included diagnostic interview and clinician-rated scales. Secondary outcomes included parent and child ratings of anxiety severity, family accommodation, and parenting stress. Noninferiority margins were determined based on statistical and clinical considerations. Change in family accommodation and parenting stress were examined using mixed models analyses.

RESULTS

SPACE was noninferior, relative to CBT, on primary and secondary anxiety outcomes, and based on ratings provided by independent evaluators, parents, and children. Family accommodation and parenting stress were significantly reduced in both treatments, with significantly greater reduction in family accommodation following SPACE compared to CBT. Treatment credibility and satisfaction were high.

CONCLUSION

SPACE is an acceptable and efficacious treatment for childhood anxiety disorders, is noninferior to CBT, and provides an alternative strategy for treating anxiety in children.

CLINICAL TRIAL REGISTRATION INFORMATION

Explanatory Clinical Trial of a Novel Parent Intervention for Childhood Anxiety (SPACE); https://clinicaltrials.gov; NCT02310152.

The Role of Context in the Implementation of Trauma-Focused Treatments: Effectiveness Research and Implementation in Higher and Lower Income Settings

In recent years, the implementation of trauma-focused treatments has expanded across settings that vary widely in the availability of resources, infrastructure, and personnel. The present review aims to inform researchers, policy makers, trainers, and administrators about this diverse range of research. Taking a global health perspective, this review of effectiveness trials and implementation studies compares strategies used in high-income countries to those in low- and medium-income countries. A primary difference between studies in high-income and low- and medium-income countries is the relative emphasis placed on fidelity or adaptation. Adaptations used in low- and medium-income countries might offer useful ideas for increasing the portability, impact, and accessibility of evidence-based interventions in high-income countries.