Cognitive-behavioral treatment for pediatric posttraumatic stress disorder: Protocol and application in school and community settings

A wellbeing program to promote mental health in paediatric burn patients: Study protocol

BACKGROUND

One of the most traumatic injuries a child can experience is a severe burn. Despite improvements in medical treatments which have led to better physical outcomes and reduced mortality rates for paediatric burns patients, the psychological impact associated with experiencing such a traumatic injury has mostly been overlooked. This is concerning given the high incidence of psychopathology amongst paediatric burn survivors.

OBJECTIVES

This project will aim to pilot test and evaluate a co-designed trauma-focused intervention to support resilience and promote positive mental health in children and adolescents who have sustained an acute burn injury. Our first objective is to collect pilot data to evaluate the efficacy of the intervention and to inform the design of future trauma-focussed interventions. Our second objective is to collect pilot data to determine the appropriateness of the developed intervention by investigating the changes in mental health indicators pre- and post-intervention. This will inform the design of future interventions.

METHODS

This pilot intervention study will recruit 40 children aged between 6-17 years who have sustained an acute burn injury and their respective caregivers. These participants will have attended the Stan Perron Centre of Excellence for Childhood Burns at Perth Children's Hospital. Participants will attend a 45-minute weekly or fortnightly session for six weeks that involves building skills around information gathering, managing reactions (behaviours and thoughts), identifying, and bolstering coping skills, problem solving and preventing setbacks. The potential effects and feasibility of our intervention will be assessed through a range of age-appropriate screening measures which will assess social behaviours, personal qualities, mental health and/or resilience. Assessments will be administered at baseline, immediately post-intervention, at 6- and 12-months post-intervention.

CONCLUSION

The results of this study will lay the foundation for an evidence-based, trauma-informed approach to clinical care for paediatric burn survivors and their families in Western Australia. This will have important implications for the design of future support offered to children with and beyond burn injuries, and other medical trauma populations.

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents' mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.

A multi-tiered systems of support blueprint for re-opening schools following COVID-19 shutdown

The COVID-19 pandemic will create enormous disruptions for youth and families with respect to economic and health status, social relationships, and education for years to come. The process of closing and intermittently reopening schools adds to this disruption and creates confusion for parents and school officials who must balance student educational progress with health and safety concerns. One framework that may serve as a roadmap in this regard is a multi-tiered systems of support (MTSS) model. This article briefly addresses four main domains of functioning (adjustment, traumatic stress, academic status, health and safety) across three tiers of support (universal, targeted, intensive). Each section draws on existing literature bases to provide specific recommendations for school officials who must address various and changing logistical, academic, and health-based challenges. The recommendations are designed to be flexible given fluctuations in the current crisis as well as focused on maximum-value targets. An MTSS approach adapted for contemporary circumstances can also be used to help address longstanding disparities that have been laid bare by the pandemic.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

What the MAYSI-2 Can Tell Us About Anger-Irritability and Trauma

The rate of experiencing trauma can be quite high for juvenile offenders and those experiences can lead to feelings of anger and irritability. This study uses Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) data to examine the relationship between the Traumatic Experiences (TE) and Angry-Irritable (AI) scales for juvenile offenders (N = 1,348) from a Midwest detention center. Chi-square analyses revealed statistically significant relationships between the AI scale and gender, race, and the TE scale. In addition, ordinal logistic regression results showed that as the number of traumatic experiences increased, so did the odds of scoring Caution or Warning on the AI scale. Recommendations are that juvenile justice systems utilize a trauma-informed process throughout the adjudicatory process and there be improved efforts to coordinate services across multiple systems, such as child welfare and special education, where juvenile offenders are often engaged.

Meta-analytic review of psychological interventions for children survivors of natural and man-made disasters

Although many post-disaster interventions for children and adolescent survivors of disaster and terrorism have been created, little is known about the effectiveness of such interventions. Therefore, this meta-analysis assessed PTSD outcomes among children and adolescent survivors of natural and man-made disasters receiving psychological interventions. Aggregating results from 24 studies (total N=2630) indicates that children and adolescents receiving psychological intervention fared significantly better than those in control or waitlist groups with respect to PTSD symptoms. Moderator effects were also observed for intervention package, treatment modality (group vs. individual), providers' level of training, intervention setting, parental involvement, participant age, length of treatment, intervention delivery timing, and methodological rigor. Findings are discussed in detail with suggestions for practice and future research.

State of the science: group therapy interventions for sexually abused children

Research investigating the use of group therapy treatment for sexually abused children is limited. This paper aims to review the current state of the science of group therapy and its outcomes with children and adolescents under age 18 who have experienced sexual abuse. A literature review was conducted which located eight articles meeting the inclusion criteria of this paper. These outcome studies utilized a wide array of theoretical orientations and intervention delivery, as well as an assortment of outcomes measurement. While the studies lacked consistency, there is some support that group therapy formats to treat sexually abused children and adolescents may be effective across a range of symptoms. Implications for practice, policy, and future research are discussed.

Perceptions of trauma research with a sample of at-risk youth

Growing body of research demonstrates that participants generally report favorable perceptions of participating in trauma research. However, questions remain on the long-term impact of asking at-risk youth about trauma in settings where such questions are unexpected. Perceptions of participation were examined in the current longitudinal study comprising a sample of adolescent girls recruited from the child welfare system to participate in a healthy relationship project. Over a year, teens (n = 180) completed four research sessions during which they were interviewed about interpersonal trauma exposure and trauma-related symptoms. Results indicated that adolescents reported stable, favorable benefit-to-cost ratios over time. Perceptions of research participation and symptom severity did not impact retention.

School intervention related to school and community violence

Schools are well positioned to facilitate recovery for students exposed to community or school violence or other traumatic life events affecting populations of youth. This article describes how schools can circumvent several key barriers to mental health service provision, outcomes that school interventions target, and the role of the family in school-based services. It includes a description of the history of schools in facilitating recovery for students exposed to traumatic events, particularly related to crisis intervention, and the current status of early intervention and strategies for long-term recovery in the school setting. Challenges and future directions are also discussed.

Cue-centered treatment for youth exposed to interpersonal violence: a randomized controlled trial

This study provides preliminary evidence of the feasibility and efficacy of the Stanford cue-centered treatment for reducing posttraumatic stress, depression, and anxiety in children chronically exposed to violence. Sixty-five youth aged 8–17 years were recruited from 13 schools. Participants were randomly assigned to cue-centered treatment or a waitlist control group. Assessments were conducted at 4 discrete time points. Self-report measures assessed youth symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression.Self-report ratings of caregiver anxiety and depression as well as caregiver report of child PTSD were also obtained. Therapists evaluated participants’ overall symptom improvement across treatment sessions. Hierarchal linear modeling analyses showed that compared to the waitlist group, the cue-centered treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as caregiver anxiety. Cue-centered treatment, a hybrid trauma intervention merging diverse theoretical approaches, demonstrated feasibility,adherence, and efficacy in treating youth with a history of interpersonal violence.

Practice parameter on disaster preparedness

This Practice Parameter identifies best approaches to the assessment and management of children and adolescents across all phases of a disaster. Delivered within a disaster system of care, many interventions are appropriate for implementation in the weeks and months after a disaster. These include psychological first aid, family outreach, psychoeducation, social support, screening, and anxiety reduction techniques. The clinician should assess and monitor risk and protective factors across all phases of a disaster. Schools are a natural site for conducting assessments and delivering services to children. Multimodal approaches using social support, psychoeducation, and cognitive behavioral techniques have the strongest evidence base. Psychopharmacologic interventions are not generally used but may be necessary as an adjunct to other interventions for children with severe reactions or coexisting psychiatric conditions.

A school based study of psychological disturbance in children following the Omagh bomb

OBJECTIVE

To assess the extent and nature of psychiatric morbidity among children (aged 8 to 13 years) 15 months after a car bomb explosion in the town of Omagh, Northern Ireland.

METHOD

A survey was conducted of 1945 school children attending 13 schools in the Omagh district. Questionnaires included demographic details, measures of exposure, the Horowitz Impact of Events Scale, the Birleson Self-Rating Depression Scale, and the Spence Children's Anxiety Scale.

RESULTS

Children directly exposed to the bomb reported higher levels of probable PTSD (70%), and psychological distress than those not exposed. Direct exposure was more closely associated with an increase in PTSD symptoms than in general psychiatric distress. Significant predictors of increased IES scores included being male, witnessing people injured and reporting a perceived life threat but when co-morbid anxiety and depression are included as potential predictors anxiety remains the only significant predictor of PTSD scores.

CONCLUSIONS

School-based studies are a potentially valuable means of screening and assessing for PTSD in children after large-scale tragedies. Assessment should consider type of exposure, perceived life threat and other co-morbid anxiety as risk factors for PTSD.

Posttraumatic stress disorder: shifting toward a developmental framework

This article reviews the current classification of posttraumatic stress disorder and its limitations when applied to youth. Distinctions are made between single-event and multiple-event traumas. Diagnosis, neurobiology, treatment development, and treatment outcomes are presented. A summary of current empirical interventions is provided. The authors present implications for future research and for clinical practice.

Responding to students with posttraumatic stress disorder in schools

The prevalence of trauma exposure among youth is a major public health concern. Students who have experienced a traumatic event are at increased risk for academic, social, and emotional problems. School can be an ideal setting for mental health professionals to intervene with traumatized students, school staff, and parents both immediately following a traumatic event and when symptoms of posttraumatic stress disorder and other trauma-related mental health problems develop. This article describes evidence-based treatments for posttraumatic stress disorder and outlines practical approaches to use in schools.

Cognitive-behavioral treatment for posttraumatic stress disorder in children and adolescents

Several cognitive-behavioral therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). These treatments include common elements (eg, psychoeducation, gradual exposure, relaxation). This review (1) delineates common elements in CBT approaches for treating child and adolescent PTSD; (2) provides a detailed review of three CBT approaches with substantial evidence of effectiveness; and (3) describes promising practices in the area of CBT approaches to treating child and adolescent PTSD. Cultural and implementation considerations are also included.

Sports and games for post-traumatic stress disorder (PTSD)

BACKGROUND

Traumatic experiences evoke emotions such as fear, anxiety and distress and may encourage avoidance of similar situations in the future. For a proportion of those exposed to a traumatic event, this emotional reaction becomes uncontrollable and can develop into Post Traumatic Stress Disorder (PTSD) (Breslau 2001). Most of those diagnosed with PTSD fully recover while a small proportion develop a chronic PTSD a year after the event (First 2004). Sports and games may be able to alleviate symptoms of PTSD.

OBJECTIVES

PRIMARY OBJECTIVE

1. To assess the effectiveness of sports, and games in alleviating and/or diminishing the symptoms of PTSD when compared to usual care or other interventions.

SECONDARY OBJECTIVE

2. To assess the effectiveness of different types of sports and games in alleviating and/or diminishing symptoms of PTSD.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDAN-CTR) were searched up to June 2008.The following databases were searched up to June 2008: the Cochrane Central registry of Controlled Trials; MEDLINE; EMBASE; CINAHL; PsycINFO. Reference lists of relevant papers were searched and experts in the field were contacted to determine if other studies were available.

SELECTION CRITERIA

To be included, participants had to be diagnosed with PTSD using criteria outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) and/or ICD criteria. Randomised controlled trials (RCTs) that considered one or more well-specified sports or games for alleviating and/or diminishing symptoms of PTSD were included.Sports, and games were defined as any organized physical activity done alone or with a group and non-physical activities such as computer games and card games done alone or with a group. Psychological interventions such as music therapy, art therapy and play therapy and behavioural therapy were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers (SL and MD) separately checked the titles and abstracts of the search results to determine which studies met the pre-determined inclusion criteria. A flow chart was used to guide the selection process. No studies met the inclusion criteria.

MAIN RESULTS

The search strategy identified five papers but none of the studies met inclusion criteria.

AUTHORS' CONCLUSIONS

No studies met the inclusion criteria. More research is therefore required before a fair assessment can be made of the effectiveness of sports and games in alleviating symptoms of PTSD.

Cognitive behavioral therapy for symptoms of trauma and traumatic grief in refugee youth

The diverse clinical presentation of refugee children and adolescents after their traumatic experiences requires a treatment model that can mitigate a number of internalizing and externalizing symptoms. Refugee populations also require interventions that can adjust to the wide-ranging experiences likely encountered during preflight, flight, and resettlement. There is some evidence that immigration stressors or social stressors, such as discrimination, are associated with symptoms of posttraumatic stress disorder in refugee youth. Therefore refugee youth may benefit from multiple levels of services, ideally integrated. This article focuses on the mental and behavioral health component of services for refugee youth.

School-based intervention for prevention and treatment of elementary-students' terror-related distress in Israel: a quasi-randomized controlled trial

A school-based intervention for preventing and reducing children's posttraumatic stress-related symptoms, somatic complaints, functional impairment, and anxiety due to exposure to terrorism was evaluated. In a quasi-randomized controlled trial, elementary school students were randomly assigned to an eight-session structured program, "Overshadowing the Threat of Terrorism" or to a waiting list control comparison group. Two months postintervention, the study group reported significant improvement on all measures. The authors conclude that a school-based universal intervention may significantly reduce posttraumatic stress disorder- (PTSD-) related symptoms in children repeatedly exposed to terrorist attacks and propose that it serve as a component of a public mental health approach dealing with children exposed to ongoing terrorism in a country ravaged by war and terrorism.

Psychosocial treatment of pediatric posttraumatic stress disorder: the neglected field of single-incident trauma

Despite the prevalence of childhood trauma, studies regarding psychotherapy for children suffering from posttraumatic stress disorder (PTSD) are scarce, especially regarding the treatment for pediatric PTSD following single-incident trauma. Treatment practices for this population rely mainly on the paradigms of therapy for adult PTSD and pediatric PTSD following sexual abuse. This review outlines the studies published in the last 10 years pertaining to the treatment of pediatric PTSD following single-incident trauma. This is done in the context of available literature on the paradigms mentioned above. Of 742 articles dealing with treatment of pediatric trauma, 10 were found relevant to the treatment of pediatric PTSD following single-incident trauma. The modalities of treatment most frequently reported in this context were cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and play therapy. As a whole, CBT studies were methodologically more rigorous, used manualized, reproducible treatment, and were group, school-based therapies. EMDR treatments were usually short and individual. Most studies showed statistically significant improvement but were still methodologically lacking. We conclude that research on the subject of treatment for pediatric PTSD following single-incident trauma constitutes a neglected part of the study of pediatric PTSD. This stands in contrast to the obvious prevalence of this type of trauma. We encourage future research that will address issues such as clarifying the role of pharmacotherapy, comparing different modes of treatment, dismantling treatment "packages," researching developmentally sensitive treatments, conducting long-term follow-up, and comparing different PTSD populations.

Intergenerational transmission of sexual abuse? Motherhood in the shadow of incest

The aim of the study was to understand why the dynamic of sexual abuse is perpetuated across successive generations. A qualitative analysis was conducted on therapy session transcripts and diaries written during the therapy of 24 mothers who were survivors of incest, and whose children were the victims of incest. Four types of mothers were defined: the Unaware mother, characterized by a complete lack of cognitive knowledge of the sexual abuse occurring in her home; the Unwitting Accomplice, characterized by latent cooperation with the sexual abuse perpetrated by her husband; the Enabler, characterized by overtly or covertly encouraging her spouse in the raping of her daughter; and the Common Fate mother, characterized by sharing a common fate with her daughters.