Involving Parents in Indicated Early Intervention for Childhood PTSD Following Accidental Injury

Accidental injuries represent the most common type of traumatic event to which a youth is likely to be exposed. While the majority of youth who experience an accidental injury will recover spontaneously, a significant proportion will go on to develop Post-Traumatic Stress Disorder (PTSD). And yet, there is little published treatment outcome research in this area. This review focuses on two key issues within the child PTSD literature—namely the role of parents in treatment and the timing of intervention. The issue of parental involvement in the treatment of child PTSD is a question that is increasingly being recognized as important. In addition, the need to find a balance between providing early intervention to at risk youth while avoiding providing treatment to those youth who will recover spontaneously has yet to be addressed. This paper outlines the rationale for and the development of a trauma-focused CBT protocol with separate parent and child programs, for use with children and adolescents experiencing PTSD following an accidental injury. The protocol is embedded within an indicated intervention framework, allowing for the early identification of youth at risk within a medical setting. Two case studies are presented in order to illustrate key issues raised in the review, implementation of the interventions, and the challenges involved.     

Predicting Response to an Internet-Delivered Parenting Program for Anxiety in Early Childhood

Previous research has identified factors related to outcome in child anxiety treatment and parent training programs for child behavior problems. However, it is unclear what factors predict outcomes in interventions delivered online to parents of young children at risk of anxiety. This study investigated predictors of child anxiety outcomes among 433 families with young children (3–6 years) who participated in a randomized controlled trial of Cool Little Kids Online, an eight-module early intervention program for child anxiety based on cognitive-behavioral therapy (CBT). Potential predictors included baseline demographic factors, child and parent mental health factors, and indicators of program use, including number of online modules completed and frequency of homework practice. Results showed that only access to a printer moderated intervention effectiveness. Printer access predicted lower child anxiety in the Cool Little Kids Online group, but had no effect on outcomes in the wait-list group. In both groups, higher levels of child anxiety symptoms, child-inhibited temperament, and poorer parent mental health at baseline predicted higher levels of child anxiety symptoms at 6-month follow-up. The amount of online program use was not related to improvements in child anxiety symptoms. However, parents who reported practicing the program skills more frequently showed greater reductions in child anxiety, and access to a printer was related to frequency of program skills practice. These findings provide empirical support for the important role of skills practice in online CBT interventions, and suggest that practicing program skills may be more important than completing the online modules.     

Neurophysiological Markers That Predict and Track Treatment Outcomes in Childhood Anxiety

The present study examined the cortical processes that mediate cognitive regulation in response to emotion-eliciting stimuli, before and after anxious children participated in a cognitive behavioral therapy program. Electroencephalographic activity was recorded from anxious children (n?=?24, 8 males) and comparison children (n?=?16, 7 males) at pre-and post-treatment sessions. The change in anxiety T-scores from pre- to post-treatment was used to signify clinical improvement among anxious children (Improvers: n?=?11 vs. Non-improvers: n?=?13). Event-related potential components were recorded while children performed a Go/No-go task using emotional facial expressions. For the P1 component, believed to reflect attention and/or arousal processes, Non-improvers had greater activation levels relative to Improver and comparison groups at both sessions. Greater P1 amplitudes at pre-treatment predicted non-improvement following treatment. For the frontal N2 component, thought to reflect cognitive control processing, Improvers recruited greater activation from pre- to post-treatment, a change in activation that was predictive of treatment outcome. Non-improvers showed increased cortical activation within the time window of the P1, whether at pre- or post-treatment. These data suggest that heightened perceptual vigilance may have led to poorer outcomes. Improvers showed increased prefrontal activation within the time window of the N2 from pre- to post-treatment. These data suggest that increased cognitive control may have led to improved treatment outcomes. In sum, P1 activation may serve as a predictor of treatment outcome, while N2 activation may serve as an indicator of treatment response.     

Assessment and Decision-Making in Early Childhood Education and Intervention

Assessment within the fields of early childhood education and early childhood intervention is guided by the deductive-psychometric model, which is a framework for legitimizing constructs that arise from theories. An alternative approach, termed the inductive-experimental model, places significantly more restrictions on what constitutes a legitimate construct. In this paper, the utility of these two assessment models, one more generative and one more restrictive, are evaluated within the context of a Head Start setting. Given the pragmatic goal of informing instruction, we argue for the superiority of the more restrictive approach. Implications for early childhood intervention are also discussed.     

An Ecological Risk Model for Early Childhood Anxiety: The Importance of Early Child Symptoms and Temperament

Childhood anxiety is impairing and associated with later emotional disorders. Studying risk factors for child anxiety may allow earlier identification of at-risk children for prevention efforts. This study applied an ecological risk model to address how early childhood anxiety symptoms, child temperament, maternal anxiety and depression symptoms, violence exposure, and sociodemographic risk factors predict school-aged anxiety symptoms. This longitudinal, prospective study was conducted in a representative birth cohort (n = 1109). Structural equation modeling was used to examine hypothesized associations between risk factors measured in toddlerhood/preschool (age = 3.0 years) and anxiety symptoms measured in kindergarten (age = 6.0 years) and second grade (age = 8.0 years). Early child risk factors (anxiety symptoms and temperament) emerged as the most robust predictor for both parent-and child-reported anxiety outcomes and mediated the effects of maternal and family risk factors. Implications for early intervention and prevention studies are discussed.     

In-Game Play Behaviours during an Applied Video Game for Anxiety Prevention Predict Successful Intervention Outcomes

Anxiety disorder is the most prevalent and frequently diagnosed disorder in youth, and associated with serious negative health outcomes. Our most effective prevention programs, however, have several limitations. These limitations can be addressed using game-based interventions. Results from two randomized controlled trials on the video game MindLight show improvements in anxiety that are maintained up to 6 months. The game was designed based on evidence-based therapeutic techniques; however, it is unclear if children’s engagement with these techniques actually predict improvements in anxiety symptoms. An important advantage of game-based interventions is that they provide excellent opportunities to isolate therapeutic action mechanisms and test their impact on intervention outcomes. In the current study, on-screen videotaped output while playing MindLight was coded and analysed for forty-three 8 to 12-year old children with elevated levels of anxiety. Results showed that changes in in-game play behaviours representing therapeutic exposure techniques predicted improvements in anxiety symptoms 3 months later (when children had not played the game for 3 months). The current study is a first step towards identifying and validating game mechanics that can be used in new applied games to target anxiety symptoms or other psychopathologies with the same underlying deficits.     

The Early Risers Preventive Intervention: Testing for Six-year Outcomes and Mediational Processes

We examined effects of the Early Risers “Skills for Success” early-age-targeted prevention program on serious conduct problems following 5 years of continuous intervention and one year of follow-up. We also examined if intervention effects on proximally-targeted variables found after 3 years mediated intervention effects on conduct problems found after 6 years. Participants included 151 at-risk children (106 males and 45 females) followed from first through sixth-grade, from 23 semi-rural schools in Minnesota. After 6 years, program children showed fewer oppositional defiant disorder (ODD) symptoms than control children. Program children did not significantly differ from controls on number of conduct disorder (CD) symptoms, DSM-IV diagnoses of ODD and CD, or drug use involvement. Results of the mediation analysis indicated that fewer ODD symptoms among program youth after 6 years were partially mediated by social skills and effective discipline. The study provides support for the early-starter model of conduct problems development that provides the framework for the Early Risers intervention. The study’s implications for prevention and limitations are discussed.     

Treating Childhood Anxiety in Schools: Service Delivery in a Response to Intervention Paradigm

Millions of youth who attend schools in the United States suffer from clinically significant anxiety. Left untreated, these students often experience significant disruptions in their academic, social, and family functioning. Fortunately, promising treatments exist for childhood anxiety that are amenable for delivery in school settings. However, educational law and new service delivery paradigms such as response-to-intervention (RtI) affect the delivery of anxiety interventions. In light of extant laws and practices that govern education, this article discusses the provision of supportive services to address childhood anxiety. Specifically, this article reviews how RtI, the Individuals with Disabilities Education Improvement Act, and Section?504 of the Rehabilitation Act guide service delivery and subsequently impact school-based anxiety treatments. Suggestions are provided to address childhood anxiety within a framework that allows for graduated and fluid service delivery.     

Long‐Term Outcomes of Traumatic Brain Injury in Early Childhood

Mild traumatic brain injury (mTBI) is a leading cause of injury among children, with approximately 15% of children experiencing a TBI prior to 15 years of age. Acutely, mTBI has been associated with a range of cognitive, physical, emotional and behavioural impairments. However, few studies have examined outcomes beyond five years post injury, long before the developmental process is complete and the full extent of any deficits may manifest. Our group had the unique opportunity to use data from a longitudinal birth cohort of 1265 children (Christchurch Health and Development Study) to examine the long term outcomes of early injury (0–5 years). Information about these children, including mTBI events, had been collected at birth, 4 months and at yearly intervals until age 16, and again at ages 18, 21 and 25 years. We found that even after statistical control for a wide range of child and family confounds, children who had been hospitalized for an mTBI had increased inattention/hyperactivity and conduct as rated by mothers and teachers over ages 7–13 years. Increased rates of psychiatric disorders were over 14–16 years for those injured in the preschool, including symptoms consistent with Attention Deficit/Hyperactivity Disorder (ADHD), Odds Ratio = 4.6, Conduct Disorder (CD), Odds Ratio = 5.6 and Substance Abuse (Odds Ratio = 9.1). Over ages 21–25 ongoing behaviour problems were assessed using self‐reported arrests, violent offenses and property offenses. Compared to non‐injured individuals, mTBI groups were more likely to be arrested, involved in property, and violent offences. We controlled for a wide range of factors and there was still clear evidence of ongoing problems for individuals who had experienced a mTBI compared to their non injured counterparts. These findings provide compelling evidence of long term psychosocial and psychiatric outcomes following mTBI.     

Group Intervention for Adolescent Anxiety and Depression: Outcomes of a Randomized Trial with Adolescents in Kenya

Youth mental health interventions in low-resource communities may benefit from including empirically supported elements, using stigma-free content, and using trained lay-providers. We developed and evaluated such an intervention, targeting adolescent depression and anxiety in Kenya, where mental health care is limited by social stigma and a paucity of providers. Kenyan adolescents (N = 51, ages 14–17, 60.78% female) from a school in an urban slum in Nairobi with self-reported moderate-to-severe symptoms of depression or anxiety were randomized to the 4-week “Shamiri” (“thrive”) group intervention or a study skills control intervention of equal duration. The Shamiri intervention included growth mindset, gratitude, and value affirmation exercises. The content was delivered by recent high school graduates (ages 17–21, 60% male) trained as lay-providers. Participants met in school once-a-week in groups of 9–12 youths (average group size 10). Compared to the study-skills control, Shamiri produced greater reductions in adolescent depression symptoms (p = .038; d = .32) and anxiety symptoms (p = .039; d = .54) from baseline to 4-week follow-up, and greater improvements in academic performance (p = .034; d = .32) from the school-term before versus after the intervention. There were no effects on overall social support or perceived control, but the Shamiri group showed larger increases in perceived social support from friends (p = .028, d = .71). This appears to be the first report that a brief, lay-provider delivered, community-based intervention may reduce internalizing symptoms and improve academic outcomes in high-symptom adolescents in Sub-Saharan Africa. Larger replications with extended follow-ups will help gauge the strength and durability of these effects.     

Maternal Over-Control Moderates the Association Between Early Childhood Behavioral Inhibition and Adolescent Social Anxiety Symptoms

Behavioral inhibition (BI) and maternal over-control are early risk factors for later childhood internalizing problems, particularly social anxiety disorder (SAD). Consistently high BI across childhood appears to confer risk for the onset of SAD by adolescence. However, no prior studies have prospectively examined observed maternal over-control as a risk factor for adolescent social anxiety (SA) among children initially selected for BI. The present prospective longitudinal study examines the direct and indirect relations between these early risk factors and adolescent SA symptoms and SAD, using a multi-method approach. The sample consisted of 176 participants initially recruited as infants and assessed for temperamental reactivity to novel stimuli at age 4?months. BI was measured via observations and parent-report across multiple assessments between the ages of 14?months and 7?years. Maternal over-control was assessed observationally during parent–child interaction tasks at 7?years. Adolescents (ages 14–17?years) and parents provided independent reports of adolescent SA symptoms. Results indicated that higher maternal over-control at 7?years predicted higher SA symptoms and lifetime rates of SAD during adolescence. Additionally, there was a significant interaction between consistently high BI and maternal over-control, such that patterns of consistently high BI predicted higher adolescent SA symptoms in the presence of high maternal over-control. High BI across childhood was not significantly associated with adolescent SA symptoms when children experienced low maternal over-control. These findings have the potential to inform prevention and early intervention programs by indentifying particularly at-risk youth and specific targets of treatment.     

认知行为疗法在儿童焦虑症治疗中的应用

焦虑症是一种最常见的儿童疾病.病理焦虑通常被定义为与年龄不适当的焦虑,导致功能障碍和严重痛苦.目前大量调查儿童焦虑的CBT治疗效果的研究显示,针对各种患有不同焦虑障碍的儿童CBT是有效的.典型的认知行为治疗包括四个主要方面:心理教育,应对技能,暴露和应急管理.Coping Cat治疗方案是在随机对照试验中针对儿童焦虑最常被实施的CBT治疗方案.目前认知行为疗法在治疗儿童焦虑症中也存在着局限,今后需要进行更深入的研究.     

Limitations in Verbal Fluency Following Heavy Burdens of Early Childhood Diarrhea in Brazilian Shantytown Children

The effects of heavy burdens of diarrhea in the first 2 years of life on specific executive control function like verbal fluency are not well understood. In previous studies, we have shown associations of early childhood diarrhea (ECD) with nonverbal intelligence and school functioning. Therefore, we postulated that ECD might affect early neuropsychological development leading to long-term deficits in normal cognitive development. Based on our extensive 14-year prospective cohort studies of early childhood diarrheal illnesses in a Brazilian shantytown community, we examined ECD correlations between specific impairments of higher mental function and executive skills in shantytown children 5–10 years later (now at 6–12) years of age. Specifically we examined whether heavy diarrheal illnesses correlate with reduced performance on selected tests of executive function. Our study, for the first time, suggests a disproportional impairment in semantic but not phonetic fluency in a subset of children with heavy burdens of diarrhea in their first 2 years of life even when controlling for maternal education, breastfeeding, and child schooling. Similar semantic decrements have been associated with impaired recovery from brain injury. These exploratory studies suggest the importance of verbal fluency tests to assess executive functioning in children challenged by poor nutrition and diarrhea in early life. In addition, our unique findings show the potential influences of early childhood diarrhea on language development that is so critical to productive adulthood and potentially set a foundation for new neuropsychological approaches, which assess early burdens of enteric illnesses on childhood development.     

A Multivariate Genetic Analysis of Specific Phobia, Separation Anxiety and Social Phobia in Early Childhood

BACKGROUND: Comorbidity amongst anxiety disorders is very common in children as in adults and leads to considerable distress and impairment, yet is poorly understood. Multivariate genetic analyses can shed light on the origins of this comorbidity by revealing whether genetic or environmental risks for one disorder also influence another. We examined the genetic and environmental influences on the comorbidity between three common childhood anxiety disorders: Specific Phobia, Separation Anxiety and Social Phobia. METHODS: Using a two-phase design 4,662 twin-pairs were screened in the first phase and 854 pairs were assessed in the second phase by maternal-informant diagnostic interview using DSM-IV criteria. RESULTS: Multivariate genetic analysis revealed significant shared environmental over-lap between Specific Phobia and Separation Anxiety and significant familial and non-shared environmental over-lap between Specific Phobia and Social Phobia. CONCLUSIONS: Familial influences, especially shared environment, are central to the comorbidity between Specific Phobia and both Separation Anxiety and Social Phobia.     

Parent Training for Childhood Anxiety Disorders: The SPACE Program

Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.