The effectiveness of psychological interventions for post-traumatic stress disorder in children, adolescents and young adults: a systematic review and meta-analysis

Mediators of Outcome in Trauma-Focused Psychotherapy with Youth: A Systematic Review

This article aimed to provide a systematic narrative synthesis of existing studies on the mediators of change in psychotherapy with adolescents (10-19 years) and transition age youth (TAY) (20-29 years) who have experienced trauma-related symptoms or posttraumatic disorder. Additionally, we were interested in identifying psychotherapy-, trauma type-, and clients' age- and gender-specific mediators of treatment outcome. Following the preferred reporting items for systematic reviews and meta-analyses, a total of 3,723 studies published in PubMed and PsycINFO databases were screened against inclusion criteria, revealing 15 eligible studies. No studies with only TAY were found; therefore, all results were limited to therapy with adolescents. Cognitive mediators were tested in 66% of selected studies, followed by parents/family-related, mental-health-related, therapy-related, and behavioral mediators. Moderate evidence was found for posttraumatic cognitions, whereas therapeutic alliance seemed to be a promising candidate for future research. Striking absence of non-cognitive-behavioral therapy interventions, emotional and adolescent-specific mediators, as well as studies with males and in non-Western societies was evident. Future original studies would benefit from applying methodological rigor in respect to mediation testing.

Savoir détecter l'exposition des enfants à la violence entre partenaires intimes, qu'elle soit présumée ou divulguée, et savoir intervenir

L'exposition des enfants à la violence entre partenaires intimes (EEVPI), qu'il s'agisse des parents ou d'autres proches, représente près de la moitié de tous les cas qui font l'objet d'une enquête et sont corroborés par les services de protection de l'enfance du Canada. Les atteintes affectives, physiques et comportementales associées à l'EEVPI sont semblables aux effets d'autres formes de maltraitance envers les enfants. Il peut être difficile d'établir quels enfants et adolescents sont exposés à la violence entre partenaires intimes (VPI) en raison des comportements non spécifiques parfois associés à une telle exposition, de même que de la stigmatisation et du secret entourant souvent ce type de violence. Par ailleurs, une intervention en toute sécurité auprès des enfants et des adolescents chez qui on présume une exposition à la VPI peut être compliquée par la nécessité d'également tenir compte de la sécurité et du bien-être d'un proche non contrevenant. Le présent document de principes propose une approche fondée sur des données probantes mise au point par le projet VEGA (Violence, Evidence, Guidance, Action ou violence, données probantes, conseils, action) pour détecter l'exposition des enfants et des adolescents à la VPI et intervenir en toute sécurité auprès d'eux.

Recognizing and responding to children with suspected exposure to intimate partner violence between caregivers

Children's exposure to intimate partner violence (CEIPV) between parents and other caregivers accounts for nearly half of all cases investigated and substantiated by child welfare authorities in Canada. The emotional, physical, and behavioural impairments associated with CEIPV are similar to effects of other forms of child maltreatment. The identification of children and youth who have been exposed to intimate partner violence (IPV) can be challenging due to the non-specific behaviours sometimes associated with such exposure, and the stigma and secrecy that often characterize IPV. Also, responding safely to children and youth with suspected CEIPV can be complicated by the need to consider the safety and well-being of a non-offending caregiver. This position statement presents an evidence-informed approach developed by the Violence, Evidence, Guidance, Action (VEGA) Project for the safe recognition and response to children and youth who are suspected of being exposed to IPV.

Can a web application foster emotional competence in children and adolescents? The case of PandHEMOT®

The COVID-19 pandemic has had many traumatic consequences for the physical and psychological functioning of children and adolescents. Internet-based interventions can reach a large audience and be a potentially powerful resource for promoting well-being among young people. We tested the efficacy of the web application PandHEMOT®, developed ad hoc for increasing knowledge about pandemics, emotions, and emotion regulation. We involved a sample of 147 Italian third and seventh graders. The sample was assigned to an experimental (participating in the training) and a waitlist condition (who participated following a waitlist design). All the participants completed pretest and posttest measures. The intervention was structured into three units. The training took place between November and December 2021. Generalized linear mixed models and linear mixed models revealed that knowledge about pandemics, emotions, emotion regulation, and metacognitive awareness increased for the experimental condition. Moreover, adolescents performed better than children. The findings supported the efficacy of an Internet-based training for increasing children and adolescents' resilience, according to the standards of evidence-based research.

Practitioner Review: Neurobiological consequences of childhood maltreatment - clinical and therapeutic implications for practitioners

BACKGROUND

Childhood maltreatment is one of the most important preventable risk factors for a wide variety of psychiatric disorders. Further, when psychiatric disorders emerge in maltreated individuals they typically do so at younger ages, with greater severity, more psychiatric comorbid conditions, and poorer response to established treatments, resulting in a more pernicious course with an increased risk for suicide. Practitioners treating children, adolescents, and young adults with psychiatric disorders will likely encounter the highest prevalence of clients with early-onset maltreatment-associated psychiatric disorders. These may be some of their most challenging cases.

METHOD

In this report, we explore key validated alterations in brain structure, function, and connectivity associated with exposure to childhood maltreatment as potential mechanisms behind their patients' clinical presentations.

RESULTS

We then summarize key behavioral presentations likely associated with neurobiological alterations and propose a toolkit of established trauma and skills-based strategies that may help diminish symptoms and foster recovery. We also discuss how some of these alterations may serve as latent vulnerability factors for the possible development of future psychopathology.

CONCLUSIONS

Research on the neurobiological consequences of childhood adversity provides a vastly enriched biopsychosocial understanding of the developmental origins of health and pathology that will hopefully lead to fundamental advances in clinical psychology and psychiatry.

BLAME-LESS STUDY: a two-arm randomized controlled trial evaluating the effects of an online psychoeducation programme for adolescents who have experienced physical/sexual violence or sexual abuse. Rationale, study design, and methods

Background: Victims of physical/sexual violence or sexual abuse commonly experience defense responses that result in feelings of guilt and shame. Although trauma-focused interventions are effective in treating post-traumatic stress disorder symptoms, the presence of trauma-related shame and guilt can potentially hinder the process of disclosure during treatment, thus diminishing their overall effectiveness. It is hypothesized that providing psychoeducation about common defense responses will reduce feelings of shame and guilt, thereby increasing receptivity to trauma-focused treatment.Objective: This paper describes the rationale, study design, and methods of the BLAME-LESS study. The effects of a brief online psychoeducation program will be compared with a waiting-list control group. The intervention aims to reduce feelings of trauma-related shame and guilt that adolescents experience regarding their own defense responses during and after physical/sexual violence or sexual abuse.Methods: Adolescents (12 - 18 years old) with a history of physical/sexual violence or sexual abuse who suffer from trauma-related feelings of shame and guilt can participate in the study. The study follows a two-arm RCT that includes 34 participants. The primary outcomes includes trauma-related feelings of shame and guilt. The secondary outcomes includes PTSD symptoms, anxiety and depression symptoms, traumatic cognitions, readiness to disclose details of memories of the trauma, and motivation to engage in trauma-focused therapy. Assessments take place after screening, at baseline, two weeks after allocation to the intervention or waiting-list, and, only for the waiting-list participants, seven weeks after allocation to the intervention.Conclusions: There is a need for treatment approaches that target trauma-related feelings of shame and guilt. A recently developed brief online psychoeducation program on defense responses during and after trauma offers victims of physical/sexual violence or sexual abuse a free and accessible way to obtain reliable and valid information. The proposed RCT will evaluate the effectiveness of this online psychoeducation program.Trial Registration: Request is pending.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Evaluation of a codesigned group cognitive-behavioural therapy intervention for trans young people (TAG TEAM): protocol for a feasibility trial and a subsequent pilot RCT

INTRODUCTION

Trans young people are at a higher risk of mental health difficulties such as depression, anxiety and suicidality than their cisgender peers, due in part to their experiences of minority stress. This protocol describes a feasibility trial and subsequent pilot randomised controlled trial (RCT) of a codesigned group cognitive-behavioural therapy intervention for trans young people, named Trans Adolescent Group ThErapy for Alleviating Minority stress (TAG TEAM).

METHODS AND ANALYSIS

To evaluate TAG TEAM, we will conduct a feasibility trial followed by a pilot RCT with trans young people aged 14-16 years who have been referred to the Royal Children's Hospital Gender Service in Melbourne, Australia. In the feasibility trial, we aim to enrol 32 participants who will be randomised at a 1:1 ratio to either in-person or online intervention arms. Participants will be assessed at baseline and post-treatment, with a nested qualitative evaluation post-treatment. Primary outcomes are the feasibility and acceptability of the intervention and the study design and associated procedures, including comparison of the in-person and online delivery modes. In the subsequent pilot RCT, we aim to enrol 64 participants who will be randomised at a 1:1 ratio to an intervention or waitlist control arm, with delivery mode determined by the feasibility trial. Participants will complete assessments at baseline, post-treatment and 3-month follow-up. Primary outcomes are the feasibility and acceptability of the RCT study design. In both the feasibility trial and pilot RCT, participants will complete assessments related to mood, anxiety, suicidality, quality of life, minority stress, family support and social transition. Quantitative data will be analysed using descriptive statistics. Qualitative data will be analysed using thematic and interpretive analysis.

ETHICS AND DISSEMINATION

The Royal Children's Hospital Human Research Ethics Committee has approved this study (#91162). Informed consent will be obtained in writing from all participants and a legal guardian. Findings will inform the development of a full-scale RCT to evaluate the efficacy of TAG TEAM and will be disseminated through conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12623000302651, ACTRN12623000318684.

The promise of compassion-based therapy as a novel intervention for adolescent PTSD

In this review, we summarize current evidence for compassion-based approaches for PTSD and the potential for their application to the adolescent PTSD population. Exposure to traumatic events is common in adolescence and PTSD remains a public health crisis. Accessibility, willingness, and engagement are significant barriers to established treatments for PTSD, with attrition rates as high as 50 %. Compassion-based therapies provide potential solutions to treatment obstacles by providing a non-threatening, transdiagnostic option unburdened by aspects of current trauma treatment which may be associated with treatment resistance (e.g., exposure, trauma narrative, induction of fear). Compassion-based approaches are intuitive for trauma treatment, as compassion activates the self-soothing system, thereby disarming the fear system and promoting affect regulation. Compassion-based treatments demonstrate reductions across a substantial range of PTSD symptoms in adults, however, in adolescents extant literature is sparse, with cross-sectional studies suggesting self-compassion is inversely associated with trauma-related psychopathology. Understanding the impact of compassion-based approaches on adolescent PTSD is warranted as the adolescent developmental period may be a particularly opportune time for this approach. Evaluation of the impact of compassion-based treatment on adolescent PTSD in clinical populations via randomized-controlled studies and comparison of its relative efficacy to current evidence-based practices is warranted.

The Effectiveness of Psychological Interventions on the Impact of Trauma Exposure in Foster Care: A Meta-Analysis

Due to prevalent exposure to trauma in the biological family, children in foster care often experience post-traumatic stress symptoms, difficulties in forming secure attachments with the caregivers, and can present a complex range of symptoms and impairments across several areas of development. Therefore, there is an increased necessity for interventions on the effects of trauma exposure in foster care. This is the first meta-analysis to investigate the effectiveness of interventions on the effects of trauma exposure in foster care against control groups. Twelve randomized controlled trials on interventions for children with trauma-related diagnoses or with other mental health problems that are a result of complex trauma were included. A random-effects model was used for pooling the effect sizes, which were calculated for trauma-related outcomes at posttreatment and follow-up. Several potential moderator variables were analyzed. The results showed that participants receiving the intervention on trauma-related problems reported significantly better outcomes than those in the control conditions at posttreatment, after the exclusion of one outlier (g = 0.39; 95% CI [0.18 to 0.62]). The effect size was smaller at follow-up (g = 0.24; 95% CI [0.03 to 0.46]), but significant. Clinical diversity, methodological diversity, as well as other limitations were identified and discussed. Overall, the findings highlight the potential of interventions for trauma-related problems in foster care. These findings bring important contributions to the child welfare system in their efforts to develop and adapt suitable interventions for children with mental health problems due to trauma.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-023-00563-9.

Treatment of multiple traumatized adolescents by enhancing regulation skills and reducing trauma related symptoms: rationale, study design, and methods of randomized controlled trial (the Mars-study)

BACKGROUND

There is ongoing debate regarding the treatment of severe and multiple traumatized children and adolescents with post-traumatic stress disorder (PTSD). Many clinicians favor a phase-based treatment approach (i.e., a stabilization phase prior to trauma-focused therapy) over immediate trauma-focused psychological treatment, despite the lack of scientific evidence. Research on the effects of different treatment approaches is needed for children and adolescents with (symptoms of complex) PTSD resulting from repeated sexual and/or physical abuse during childhood.

OBJECTIVE

This paper describes the rationale, study design, and methods of the MARS-study, a two-arm randomized controlled trial (RCT) that aims to compare the results of phase-based treatment with those of immediate trauma-focused treatment and determine whether immediate trauma-focused treatment is not worse than phase-based treatment in reducing PTSD symptoms.

METHODS

Participants are individuals between 12 and 18 years who meet the diagnostic criteria for PTSD due to repeated sexual abuse, physical abuse, or domestic violence during childhood. Participants will be blindly allocated to either the phase-based or immediate trauma-focused treatment condition. In the phase-based treatment condition, participants receive 12 sessions of the Dutch version of Skill Training in Affective and Interpersonal Regulation (STAIR-A), followed by 12 sessions of EMDR therapy. In the immediate trauma-focused condition, the participants receive 12 sessions of EMDR therapy. The two groups are compared for several outcome variables before treatment, mid-treatment (only in the phase-based treatment condition), after 12 trauma-focused treatment sessions (post-treatment), and six months post-treatment (follow-up). The main parameter is the presence and severity of PTSD symptoms (Clinician-Administered PTSD Scale for Children and Adolescents, CAPS-CA). The secondary outcome variables are the severity of complex PTSD symptoms (Interpersonal Problems as measured by the Experiences in Close Relationship-Revised, ECR-RC; Emotion Regulation as measured by the Difficulties in Emotion Regulation Scale, DERS; Self Esteem as measured by the Rosenberg Self Esteem Scale, RSES), changes in anxiety and mood symptoms (Revised Anxiety and Depression Scale; RCADS), changes in posttraumatic cognitions (Child Posttraumatic Cognitions Inventory, CPTCI), changes in general psychopathology symptoms (Child Behavior Checklist, CBCL), and Quality of Life (Youth Outcome Questionnaire, Y-OQ-30). Furthermore, parental stress (Opvoedingsvragenlijst, OBVL) and patient-therapist relationship (Feedback Informed Treatment, FIT) will be measured, whereas PTSD symptoms will be monitored in each session during both treatment conditions (Children's Revised Impact of Event Scale, CRIES-13).

DISCUSSION

Treating (symptoms of complex) PTSD in children and adolescents with a history of repeated sexual and/or physical abuse during childhood is of great importance. However, there is a lack of consensus among trauma experts regarding the optimal treatment approach. The results of the current study may have important implications for selecting effective treatment options for clinicians working with children and adolescents who experience the effects of exposure to multiple interpersonal traumatic events during childhood.

TRIAL REGISTRATIONS

The study was registered on the "National Trial Register (NTR)" with the number NTR7024. This registry was obtained from the International Clinical Trial Registry Platform (ICTRP) and can be accessed through the ICTRP Search Portal ( https://trialsearch.who.int/ ).

Associations between perfectionism and symptoms of anxiety, obsessive-compulsive disorder and depression in young people: a meta-analysis

Perfectionism is a transdiagnostic process contributing to the onset and maintenance of anxiety, obsessive-compulsive disorder (OCD) and depression. The aim of this systematic review and meta-analysis was to examine the association between perfectionism, and symptoms of anxiety, OCD and depression among young people aged 6-24 years. A systematic literature search retrieved a total of 4,927 articles, with 121 studies included (Mpooled age = ~17.70 years). Perfectionistic concerns demonstrated significant moderate pooled correlations with symptoms of anxiety (r = .37-.41), OCD (r = .42), and depression (r = .40). Perfectionistic strivings demonstrated significant, small correlations with symptoms of anxiety (r = .05) and OCD (r = .19). The findings highlight the substantial link between perfectionistic concerns and psychopathology in young people, and to a smaller extent perfectionistic strivings, anxiety, and OCD. The results indicate the importance of further research on early intervention for perfectionism to improve youth mental health.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

Short-term eye movement desensitization and reprocessing (EMDR) therapy to treat children with posttraumatic stress symptoms after single trauma: A case series

BACKGROUND

Traumatic experiences can lead to posttraumatic stress disorder (PTSD). For young children, even minor, inconspicuous looking events can lead to posttraumatic stress symptoms. Trauma-focused treatment with Eye Movement Desensitization and Reprocessing (EMDR) offers children an age-adapted intervention to help them successfully process traumatic experiences. So far, there has been a lack of well evaluated trauma-focused treatments for young children.

METHODS

These case series examine the effectiveness of a short-term treatment with EMDR therapy for children showing PTSD symptoms after experiencing a single incident induced trauma. Five children between 5 and 10 years of age who developed PTSD after a single incident trauma received a manualized EMDR treatment for 6 weeks (mean number of sessions: seven including a mean number of EMDR sessions: 3.4). Posttraumatic stress symptoms were assessed prior to treatment, following treatment and at a 3-month follow-up with standardized instruments for caregivers and children.

RESULTS

PTSD symptoms decreased for all children after completing the treatment from clinical to non-clinical level. Reductions in vegetative hyperarousal, fears and clinging behaviour were achieved. Furthermore, reductions in the parental stress levels, as well as a recovery of everyday routine and everyday stability were observed.

CONCLUSION

Short-term EMDR treatment appears to be a promising treatment for single incident trauma in young children providing a potentially successful quick and safe psychological treatment for children. Results contribute to the knowledge of feasibility and acceptability of short-term, trauma-focused treatments of children with EMDR. Replication of the results of these case series in larger samples using a randomized controlled design is warranted.

Efficacy of psychological interventions for PTSD in distinct populations - An evidence map of meta-analyses using the umbrella review methodology

We aimed at mapping the meta-analytic evidence base on the efficacy of psychological treatments for posttraumatic stress disorder (PTSD) in specific populations. We conducted a systematic search until January 2022 in MEDLINE, PsycINFO, PTSDpubs, Web of Science, and the Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials. We contrasted all eligible meta-analyses irrespective of overlapping datasets to present a comprehensive overview of the state of research. Reporting quality was assessed using the AMSTAR 2 tool and certainty of evidence was assessed using established umbrella review criteria. Nine meta-analyses with distinct adult populations (51 unique trials) and four with children and adolescents (24 unique trials) were included. Reporting quality of meta-analyses was heterogeneous with risk of bias assessment being rated lowest. The certainty of evidence on the efficacy of psychological interventions for adult populations was thoroughly weak because of small samples and large heterogeneity. In war- and conflict-affected youth, the certainty of evidence was suggestive. Our review highlights the need to improve quality of meta-analyses on treatment efficacy for PTSD. More importantly, however, the findings demonstrate the need for new large-scale trials on the efficacy of treatments for PTSD in distinct populations in order to increase certainty of evidence and to identify potential differences in treatment responses.

A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents

BACKGROUND

Among minors, posttraumatic stress symptoms (PTSS) are a common consequence of traumatic events requiring trauma-focused treatment.

OBJECTIVE

This meta-analysis quantified treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) with PTSS as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes.

PARTICIPANTS AND SETTING

Inclusion criteria for individual settings: (1) patients aged between 3 and 21, (2) at least one traumatic event, (3) minimum 8 sessions of (4) TF-CBT according to Cohen, Mannarino and Deblinger (2006, 2017), (5) a quantitative PTSS measure at pre- and post-treatment, (6) original research only. Inclusion criteria for group settings: had to involve (1) psychoeducation, (2) coping strategies, (3) exposure, (4) cognitive processing/restructuring, (5) contain some reference to the manual and no minimum session number was required.

METHODS

Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey.

RESULTS

4523 participants from 28 RCTs and 33 uncontrolled studies were included. TF-CBT showed large improvements across all outcomes from pre- to post-treatment (PTSS: g = 1.14, CI 0.97-1.30) and favorable results compared to any control condition including wait-list, treatment as usual, and active treatment at post-treatment (PTSS: g = 0.52, CI 0.31-0.73). Effects were more pronounced for group settings. We give pooled estimates adjusted for risk of bias and publication bias, which initially limited the quality of the analyzed data.

CONCLUSIONS

TF-CBT is an effective treatment for pediatric PTSS as well as for depressive, anxiety, and grief symptoms. It is superior to control conditions, supporting international guidelines recommending it as a first-line treatment.

Child Maltreatment and Intimate Partner Violence in Mental Health Settings

Intimate partner violence (IPV) and child maltreatment (physical, emotional, sexual abuse, neglect, and children's exposure to IPV) are two of the most common types of family violence; they are associated with a broad range of health consequences. We summarize evidence addressing the need for safe and culturally-informed clinical responses to child maltreatment and IPV, focusing on mental health settings. This considers clinical features of child maltreatment and IPV; applications of rights-based and trauma- and violence-informed care; how to ask about potential experiences of violence; safe responses to disclosures; assessment and interventions that include referral networks and resources developed in partnership with multidisciplinary and community actors; and the need for policy and practice frameworks, appropriate training and continuing professional development provisions and resources for mental health providers. Principles for a common approach to recognizing and safely responding to child maltreatment and IPV are discussed, recognizing the needs in well-resourced and scarce resource settings, and for marginalized groups in any setting.

Differences in the diagnosis and treatment decisions for children in care compared to their peers: An experimental study on post-traumatic stress disorder

OBJECTIVES

Despite evidence of high rates of diagnosable mental health difficulties in children in care, there remains ongoing debate around the appropriateness of traditional diagnoses and treatments. The aim of this study was to quantitatively explore whether mental health diagnosis and treatment decision-making differed when a young person was identified as being in care, specifically focused on post-traumatic stress disorder (PTSD). PTSD is a trauma-specific mental health disorder with rates substantially higher in children in care versus their peers.

METHODS

Participants were 270 UK mental health professionals who completed an online survey. Participants were randomized to receive one of two vignettes, which were identical in their description of a teenage boy experiencing PTSD symptoms, except in one he was in foster care and in the other he lived with his mother. Participants were asked to select a primary diagnosis, treatment approach, and potential secondary diagnosis.

RESULTS

Professionals were twice as likely to choose a primary diagnosis of PTSD and a National Institute for Clinical Excellence (NICE)-recommended PTSD treatment when randomized to the mother vignette versus the foster carer vignette. Selecting PTSD as the primary diagnosis made clinicians three times more likely to select a NICE-recommended treatment for PTSD. Developmental trauma was the most common 'diagnosis' for both groups, although this led to different treatment decisions.

CONCLUSIONS

In the context of PTSD, we found children in care face diagnosis and treatment decision-making biases. Practice implications are discussed.

Psychotherapeutic interventions for childhood posttraumatic stress disorder: an update

PURPOSE OF THE REVIEW

We review treatment outcome studies and systematic reviews for childhood and adolescent posttraumatic stress disorder (PTSD) between January 2020 and August 2022, including studies involving younger children and different treatment delivery methods and models. We address predictors, moderators, treatment engagement, and attrition.

RECENT FINDINGS

Recent randomised controlled trials corroborate earlier trials documenting trauma-focused cognitive behaviour therapy (TF-CBT) as a highly efficacious treatment for PTSD. Evidence for treatment effects in complex PTSD in youth is still sparse. Research on moderators and predictors of treatment continues to be hampered by multiple factors, including a lack of sufficiently large homogeneous trauma samples.

SUMMARY

TF-CBT is a very effective treatment for children and adolescents with PTSD. Further work is needed to (i) demonstrate that task-shifting models utilising lay community health counsellors and peer counsellors can effectively and cost-effectively close the mental health treatment gap that exists world-wide in children and adolescents diagnosed with PTSD, but particularly within low- and middle income countries, and (ii) better understand moderators and predictors of treatment which remains a priority.

Associations between therapist factors and treatment efficacy in randomized controlled trials of trauma-focused cognitive behavioral therapy for children and youth: A systematic review and meta-analysis

Previous research suggests that the effect of therapist factors on patient outcomes is significant. Yet, to date, no reviews have explored the potential effects of therapist characteristics on treatment outcomes for children and youth with posttraumatic stress disorder (PTSD). This systematic review and meta-analysis aimed to summarize the professional characteristics of trial therapists delivering trauma-focused cognitive behavioral interventions (TF-CBT) for child PTSD in clinical trials and understand the association between treatment efficacy and therapist factors. Systematic searches for randomized controlled trials (RCTs) published through November 3, 2020, were conducted; 40 RCTs were included in the full review. PTSD treatment outcome data were extracted from each publication along with any available data regarding trial therapists. Subgroup analyses were conducted to compare the outcomes of interventions conducted by different types of therapists. All therapist groups yielded significant effects for TF-CBT relative to active and passive control conditions, with the largest effect size, Hedges' g = -1.11, for RCTs that used clinical psychologists and psychiatrists. A significant moderating effect was found when comparing the treatment outcomes of clinical psychologists and psychiatrists versus other professionals, p = .044; however, this effect was no longer apparent when only studies with an active control arm were included. Further moderator analyses demonstrated no significant differences regarding therapists' educational and professional backgrounds and PTSD treatment outcomes. The current RCT evidence for TF-CBT for children and youth with PTSD does not suggest that therapist educational or professional background influences treatment efficacy. Limitations and implications for future research are discussed.

Using Time-out for Child Conduct Problems in the Context of Trauma and Adversity: A Nonrandomized Controlled Trial

Importance

Exposure to adverse childhood experiences substantially increases the risk of chronic health problems. Originally designed to treat child conduct problems, parent management training programs have been shown to be effective in preventing children from being exposed to further adversity and supporting children's recovery from adversity; however, there are increasing concerns that a core component of these programs, the discipline strategy time-out, may be harmful for children with a history of exposure to adversity.

Objective

To investigate the comparative benefits and potential harms to children exposed to adversity that are associated with parenting programs that include time-out.

Design, Setting, and Participants

This nonrandomized waiting list-controlled clinical study was conducted at a specialist clinic for the treatment of conduct problems in Sydney, Australia. The self-referred sample included children with conduct problems and their caregivers. Eligibility was confirmed through clinician-administered interviews. Data were collected between February 14, 2018, and February 1, 2021.

Interventions

Caregivers participated in a 10-session, social learning-based parent management training program. Caregivers were provided with parenting strategies aimed at encouraging desired behaviors through effective reinforcement and managing misbehavior through consistent limit setting, including the use of time-outs.

Main Outcomes and Measures

The primary outcome was the parent-reported Strengths and Difficulties Questionnaire score, and secondary outcomes included subscale scores from the clinician-administered Diagnostic Interview Schedule for Children, Adolescents, and Parents. Multi-informant measures of child adversity were collected using the parent-reported Adverse Life Experiences Scale and the clinician-rated Maltreatment Index.

Results

A total of 205 children were included in analysis (156 in the full intervention and 49 in the control condition; 158 boys [77.1%]; mean [SD] age, 5.6 [1.8] years [range, 2-9 years]). Compared with children with low adversity exposure, children with high adversity exposure showed greater reductions in the Strengths and Difficulties Questionnaire score from baseline (mean difference, 3.46 [95% CI, 1.51-5.41]; P < .001) to after treatment (mean difference, 1.49 [95% CI, -0.46 to 3.44]; P = .13) and in the internalizing symptom subscale score (baseline mean difference, 1.00 [95% CI, -2,00 to 0.00]; P = .50; posttreatment mean difference, 0.06 [95% CI, -0.82 to 0.94]; P = .90). No significant differences in the externalizing symptom subscale score were found.

Conclusions and Relevance

In this nonrandomized clinical study, children with high exposure to adversity experienced equivalent, if not greater, benefits associated with parenting programs that include time-out compared with children with low exposure to adversity. Results suggest that time-out was an effective component of parenting programs for children exposed to adversity.

Trial Registration

anzctr.org.au Identifier: ACTRN12617001472369.

A Biologically Inspired Neural Network Model to Gain Insight Into the Mechanisms of Post-Traumatic Stress Disorder and Eye Movement Desensitization and Reprocessing Therapy

Eye movement desensitization and reprocessing (EMDR) therapy is a well-established therapeutic method to treat post-traumatic stress disorder (PTSD). However, how EMDR exerts its therapeutic action has been studied in many types of research but still needs to be completely understood. This is in part due to limited knowledge of the neurobiological mechanisms underlying EMDR, and in part to our incomplete understanding of PTSD. In order to model PTSD, we used a biologically inspired computational model based on firing rate units, encompassing the cortex, hippocampus, and amygdala. Through the modulation of its parameters, we fitted real data from patients treated with EMDR or classical exposure therapy. This allowed us to gain insights into PTSD mechanisms and to investigate how EMDR achieves trauma remission.

Economic Precarity, Financial Strain, and Job-Related Stress Among Philadelphia's Public Mental Health Clinicians

OBJECTIVE

Efforts to improve mental health treatment delivery come at a time of rising inequality and cuts or insufficient increases to mental health funding. Public mental health clinicians face increased demands, experience economic stress, and treat underresourced patients disproportionately burdened by trauma. The authors sought to understand clinicians' current economic and psychological conditions and the relationship of these conditions to the delivery of an evidence-based intervention (EBI) designed to treat posttraumatic stress disorder among youths.

METHODS

In July 2020, 49 public mental health clinicians from 16 Philadelphia clinics who were trained in an EBI, trauma-focused cognitive-behavioral therapy (TF-CBT), were surveyed by e-mail. Respondents reported on their economic precarity, financial strain, burnout, secondary traumatic stress (i.e., the stress response associated with caring for people exposed to trauma), and TF-CBT use. Associations between clinicians' job-related stressors and their use of TF-CBT were examined with mixed models. Content coding was used to organize clinicians' open-ended responses to questions regarding financial strain related to the COVID-19 pandemic.

RESULTS

Clinicians' economic precarity, financial strain, and job-related stress were high; 37% of clinicians were independent contractors, 44% of whom wanted a salaried position. Of 37 clinicians with education debt, 38% reported owing ≥$100,000. In the past year, 29% of clinicians reported lack of personal mental health care because of cost, and 22% met the cutoff for experiencing secondary traumatic stress symptoms. Education debt was negatively associated with use of TF-CBT (p<0.001).

CONCLUSIONS

The stress of providing care in underresourced clinical settings may interfere with efforts to integrate scientific evidence into mental health care.

Child and parent secondary outcomes in stepped care versus standard care treatment for childhood trauma

INTRODUCTION

Stepped care trauma-focused cognitive behavioral therapy (SC-TF-CBT) is comparable in efficacy to standard TF-CBT for child posttraumatic stress symptoms (PTSS), but less is known about the effectiveness of SC-TF-CBT on child and parent secondary outcomes. The aim of this community-based randomized clinical trial was to compare child- and caregiver-secondary outcomes among SC-TF-CBT versus TF-CBT participants.

METHODS

Children (ages 4 to 12) with PTSS and their caregivers were randomly assigned to either SC-TF-CBT (n = 91) or TF-CBT (n = 92). Secondary child (internalizing and externalizing behavior problems, anger outburst and sleep disturbances) and parent outcomes (PTSS, depression symptoms, and parenting stress) were measured at baseline, post-treatment and 6- and 12-month follow-up.

RESULTS

There were comparable changes at all-time points in child and caregiver secondary outcomes. Non-inferiority tests indicated that for completers and intent-to-treat samples, SC-TF-CBT was non-inferior to TF-CBT for all outcomes except parenting stress at 6-months. The analysis with completers did not support non-inferiority at post-treatment for internalizing and externalizing problems and at 6- and 12-month follow-up assessments for externalizing problems, but the intent-to-treat analysis did support non-inferiority.

LIMITATIONS

Limitations included modest rates of attrition, excluding in vivo component for standard TF-CBT, parent-only assessments, and no control condition.

CONCLUSIONS

SC-TF-CBT is an effective alternative treatment method although parents with high stress may need more support and children with externalizing problems may need more standard TF-CBT sessions.

Respiratory Sinus Arrhythmia Change during Trauma-Focused Cognitive-Behavioral Therapy: Results from a Randomized Controlled Feasibility Trial

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a well-established treatment for pediatric posttraumatic stress disorder (PTSD). Animal-assisted therapy (AAT) has been proposed as an adjunct to TF-CBT that may improve treatment effects through enhanced targeting of affect regulation, as indexed by specific changes in the respiratory sinus arrhythmia (RSA). The current study reports results from a randomized controlled feasibility trial (N = 33; M_age = 11.79 [SD = 3.08]; 64% White; 67% female) that measured RSA during Sessions 1, 4, 8, and 12 of a twelve-session TF-CBT protocol and tested whether: 1) TF-CBT + AAT achieved higher average RSA amplitudes relative to TF-CBT alone, and 2) RSA regulation, defined as less variability around person-specific RSA slopes during treatment, explained variation in post-treatment PTSD symptoms. Multilevel modeling failed to support an effect for TF-CBT + AAT on RSA amplitudes (δ₀₀₁ = 0.08, p = 0.844). However, regardless of treatment condition, greater RSA withdrawal was observed within Sessions 4 (γ₁₁ = -.01, p < .001) and 12 (γ₁₃ = -.01, p = .015) relative to the Session 1 baseline. The average level of RSA amplitude in Session 8 was also significantly lower compared to Session 1 (γ₀₂ = -0.70, p = .046). Intraindividual regression models demonstrated that greater RSA regulation predicted improved PTSD symptoms at post-treatment after adjusting for pre-treatment levels (b₃ = 20.00, p = .012). These preliminary results offer support for future confirmatory trials testing whether affect regulation, as indexed by changes in RSA, is a mechanism of action for TF-CBT in the treatment of pediatric PTSD.

Early Successful Eye Movement Desensitization and Reprocessing (EMDR) Therapy for Verbal Memory Impairment in an Adjustment Disorder: A Case Report in a Newly-Diagnosed Multiple Sclerosis Patient

Multiple sclerosis (MS) is a chronic inflammatory disease of the immune system affecting the central nervous system. Several phenotypes are possible, and cases usually present with a relapsing-remitting (RR) course with disease onset at a young age. MS diagnosis can represent a traumatic event for the patient, possibly evolving into adjustment disorder (AD). AD is defined by the presence of emotional or behavioral symptoms in response to identifiable stress occurring within the prior three months and similarly to post-traumatic stress disorder (PTSD) can significantly affect quality of life. Usually, neuropsychological disorders are not associated with AD. Several treatments are available for AD, and among them, eye movement desensitization and reprocessing (EMDR) is one of the most effective in relieving depression and anxiety. However, little is known about AD and PTSD in the MS population and no data are available on the effectiveness of EMDR for cognitive impairment associated with AD. We describe a 25-year-old patient with RR MS developing an AD with a verbal memory deficit after being diagnosed. Both the psychological and cognitive deficits were diagnosed using an extensive neuropsychological battery. Considering the high impact of the verbal memory deficit, on the patient’s quality of life, an EMDR intervention was planned. After a six-month EMDR intervention performed by two trained neuropsychologists, the patient was retested. There was an improvement in verbal memory tests and depression anxiety scales and the Dissociative Experiences Scale. It is recognized that emotional changes and psychiatric disorders, frequently affect MS patients at diagnosis. It is imperative to recognize this and promptly set a neuropsychological treatment. Moreover, we suggest checking cognition along with depression and anxiety. Finally, to our knowledge, this is the first report of AD with an isolated neuropsychological deficit (verbal memory) developed after the MS diagnosis and treated beneficially with e EMDR. More studies are needed to confirm the efficacy of EMDR in treating cognitive impairment associated with AD in MS patients.

A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents

This multi-level meta-analysis tested if evidence-based trauma treatment was effective in reducing trauma symptoms and externalizing behavior problems in adolescents. Based on eight independent samples and 75 effect sizes, results indicated that Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization Reprocessing (EMDR) had a large and significant overall effect (d = 0.909) on reducing trauma symptoms and externalizing behavior problems. Trauma treatment significantly decreased trauma symptoms (large effect) and externalizing behavior problems (medium effect). Age and type of control group moderated treatment effects. Treatment was more effective in older adolescents. Trauma treatment for adolescents with externalizing behavior problems had a larger effect compared to no treatment, but not compared to treatment as usual. It seems important to provide a broad treatment offer for adolescents with severe externalizing behavior problems, in which, besides trauma treatment, attention is paid to reducing relevant individual risk factors for behavior problems.

Conceptual Application of Trauma-Focused Cognitive Behavioral Therapy to Treat Victims of Bullying

Bullying is a critical pediatric public health problem; estimates across diverse methodologies generally indicate that roughly 36% of youth are bullied. Although policy initiatives aim to address the universal prevention of bullying, and school-level secondary prevention programs aim to reduce the occurrence of bullying, tertiary prevention and intervention programs that mitigate the negative consequences experienced by victims of bullying remain an understudied need. The nature of bullying (that it occurs as events, leaves children feeling unsafe, and engenders emotional distress) and the association of bullying with posttraumatic stress symptoms among youth suggests that trauma treatment for bullying is promising. This manuscript presents the rationale for treating victims of bullying with trauma-focused cognitive behavioral therapy (TF-CBT), describes the components of TF-CBT, and discusses how to use TF-CBT specifically for bullying. Conducting research on treatment outcomes when using TF-CBT for bullying is critical to evaluate its efficacy and effectiveness in this group. Behavioral clinical trials would provide evidence for whether TF-CBT reduces the mental health harm experienced by youth victims of bullying. This evidence is an essential step to address the public health problem of bullying because the scientific literature currently does not have a well-established individual-level treatment for victims of bullying that mental health providers in diverse settings can deliver, despite individuals' beliefs that health care providers are important sources of help for youth who have been bullied.

Common elements of evidence-based trauma therapy for children and adolescents

Background: Numerous evidence-based trauma therapies for children and adolescents have been developed over several decades to minimize the negative outcomes of post-traumatic stress disorder (PTSD). However, PTSD remains a complex construct and is associated with pervasive problems and high comorbidity. To gain more insight, much could be learnt from the similarities in trauma therapies. Objective: The purpose of this study is to derive common elements from evidence-based trauma therapies for children and adolescents. Method: Therapies were selected from a literature search. Five evidence-based trauma therapies were included in this study. A common element list was created through an existing and modified Delphi method, with a diverse group of Dutch trauma therapists. An element was deemed common when it appeared in three or more of the therapies. The final list was presented to international experts on the included trauma therapies. Results: A substantial commonality of techniques and mechanisms was found across the five evidence-based trauma therapies for children and adolescents, showing a strong overlap between therapies. Conclusion: The identified elements create a basis for research and clinical practice, with regard to targeted trauma therapies tailored to each individual child and his or her support system. This promotes therapy modules that are more flexible and accessible for both therapists and clients, in every environment, from specialized psychiatric units to sites with meagre resources. With current integrated knowledge, we can enhance the effectiveness of child psychiatry and refine trauma therapies.

HIGHLIGHTS

Using a modified Delphi method, a substantial commonality of techniques and mechanisms is found in evidence-based trauma therapies for children and adolescents.Understanding the techniques and mechanisms of trauma therapy could be of help in refining upcoming therapies, and creates a basis for future research.Commonalities promote therapy modules that are more flexible and accessible for both therapists and clients, in environments ranging from specialized psychiatric units to sites with meagre resources.

Behavioral and pharmacological interventions for the prevention and treatment of psychiatric disorders with children exposed to maltreatment

There is a well-established relation between exposure to child maltreatment and the onset and course of multiple, comorbid psychiatric disorders. Given the heterogeneous clinical presentations at the time services are initiated, interventions for children exposed to maltreatment need to be highly effective to curtail the lifelong burden and public health costs attributable to psychiatric disorders. The current review describes the most effective, well-researched, and widely-used behavioral and pharmacological interventions for preventing and treating a range of psychiatric disorders common in children exposed to maltreatment. Detailed descriptions of each intervention, including their target population, indicated age range, hypothesized mechanisms of action, and effectiveness demonstrated through randomized controlled trials research, are presented. Current limitations of these interventions are noted to guide specific directions for future research aiming to optimize both treatment effectiveness and efficiency with children and families exposed to maltreatment. Strategic and programmatic future research can continue the substantial progress that has been made in the prevention and treatment of psychiatric disorders for children exposed to maltreatment.

Effectiveness of an intensive treatment programme combining prolonged exposure and EMDR therapy for adolescents suffering from severe post-traumatic stress disorder

Background: Following promising effects of an intensive trauma treatment for adults, the question arises whether adolescents who suffer from severe post-traumatic stress disorder (PTSD) can also profit from a similar treatment programme. Objective: To assess the effectiveness of an intensive trauma-focused treatment programme combining two evidence-based trauma-focused therapies and physical activities for adolescents suffering from severe PTSD. Method: Treatment consisted of daily sessions of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy supplemented with physical activity (13 days on average). All patients (N = 27; 96.3% women, mean age = 16.1 years; SD = 1.3) had been exposed to one or more (interpersonal) traumatic events. Twenty-two of them (81.5%) also fulfilled the diagnostic criteria of a comorbid psychiatric disorder (mean number of comorbid disorders = 2.22). The majority of patients were referred because previous treatment was difficult or complications were expected to occur. Severity of PTSD symptoms and presence of a PTSD diagnostic status were assessed using the Dutch version of the CAPS-CA IV at baseline, post-treatment and at 3-month follow-up. Results: CAPS-CA IV scores decreased significantly from pre- to post-treatment (Cohen's d = 1.39). Of all patients 81.5% (n = 22) showed a clinically meaningful response, of whom 63% (n = 17) no longer fulfilled the diagnostic criteria of PTSD at post-treatment as established with the CAPS-CA IV. The results were maintained at 3-month follow-up. During treatment, neither adverse events nor dropout occurred. Conclusions: The results suggest that an intensive trauma-focused treatment programme combining prolonged exposure, EMDR therapy, and physical activity can be an effective and safe treatment for adolescents suffering from severe PTSD and multiple comorbid psychiatric disorders.

Predictors and moderators of treatment outcome for single incident paediatric PTSD: a multi-centre randomized clinical trial

BACKGROUND

With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments.

OBJECTIVE

To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT).

METHOD

Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8-18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child's baseline sociodemographic and clinical characteristics, and parent's psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups.

RESULTS

At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile.

CONCLUSIONS

The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (<4 hours) of both treatments, the present findings suggest a focus on implementation and dissemination, rather than tailoring, of evidence-based trauma-focused treatments for paediatric PTSD tied to a single event.