Impact of Caregiver Factors on Youth Service Utilization of Trauma-Focused Cognitive Behavioral Therapy in a Community Setting

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an increasingly available evidence-based therapy that targets the mental health symptoms of youth who have experienced trauma. Limited research has examined how to engage and retain families in TF-CBT services in community settings. Using a mixed-methods approach, the goal of this exploratory study was to identify caregiver factors that impact youth enrollment and completion of community-delivered TF-CBT. The study included 41 caretakers of youth referred to therapy at a local child advocacy center following a forensic assessment substantiating youth trauma exposure. Caregiver factors examined include caregiver demographics, trauma exposure, and mental health symptomology. Results from multivariate logistic regressions indicate that caregivers reporting more children residing in the household were significantly more likely to enroll youth in therapy (OR 2.27; 95 % CI 1.02, 5.03). Qualitative analyses further explicate that parents with personal trauma or therapy experiences expressed positive opinions regarding therapy services for youth, and were more likely to enroll in or complete services. Findings suggest that caregivers with personal traumatic experience and related symptomatology view therapy as important and are more committed to their child receiving therapy. Future research on service utilization is warranted and should explore offering parental psychoeducation or engagement strategies discussing therapy benefits to parents who have not experienced trauma and related mental health symptomatology.     

The Children’s Attention-Deficit Hyperactivity Disorder Telemental Health Treatment Study: Caregiver Outcomes

The Children’s Attention-deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) tested the hypotheses that children and caregivers who received guideline-based treatment delivered through a hybrid telehealth service delivery model would experience greater improvements in outcomes than children and caregivers receiving treatment via a comparison delivery model. Here, we present caregiver outcomes. 88 primary care providers (PCPs) in seven geographically underserved communities referred 223 children (ages 5.5 ? 12.9 years) to the randomized controlled trial. Over 22 weeks, children randomized to the CATTS service delivery model received six sessions of telepsychiatry and six sessions of caregiver behavior management training provided in person by community therapists who were trained and supervised remotely. Children randomized to the comparison Augmented Primary Care (APC) service model received management in primary care augmented by a single telepsychiatry consultation. Caregiver outcomes included changes in distress, as measured by the Patient Health Questionnaire (PHQ-9), Parenting Stress Index (PSI), Caregiver Strain Questionnaire (CSQ) and Family Empowerment Scale (FES). Caregivers completed five assessments. Multilevel mixed effects regression modeling tested for differences between the two service delivery models in caregiver outcomes from baseline to 25 weeks. Compared to caregivers of children in the APC model, caregivers of children in the CATTS service model showed statistically significantly greater improvements on the PHQ-9 (β?=?-1.41, 95 % CI?=?[?2.74, ?0.08], p?<?.05), PSI (β?=??4.59, 95 % CI?=?[?7.87, ? 1.31], p?<?.001), CSQ (β?=??5.41, 95 % CI?=?[? 8.58, ?2.24], p?<?.001) and FES (β?=?6.69, 95 % CI?=?[2.32, 11.06], p?<?.01). Improvement in child ADHD symptoms mediated improved caregiver scores on the PSI and CSQ. Improvement in child ODD behaviors mediated caregiver CSQ scores. The CATTS trial supports the effectiveness of a hybrid telehealth service delivery model for reducing distress in caregivers of children with ADHD and suggests a mechanism through which the service model affected caregiver distress.     

The Value of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in Addressing the Therapeutic Needs of Trafficked Youth: A Case Study

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is currently the leading intervention for childhood trauma as it has accumulated the most empirical support in treating sexual abuse in youth. However, this treatment, widely recognized as the gold-standard for the treatment of childhood trauma, has been applied only in recent years to address the unique needs of children and adolescents with histories of human trafficking and sexual exploitation. This paper strives to expand this limited literature base by examining the clinical value in individualizing TF-CBT to effectively treat an adolescent experiencing posttraumatic stress related to the experience of familial sex trafficking while also maintaining treatment fidelity. This case study emphasizes the value of the TF-CBT components in addressing a variety of factors that impact this population, including psychological coercion, psychological manipulation, the threat of legal action (in this case deportation), lack of community involvement, running away behaviors, and pregnancy by sexual assault. Multisource measures completed at the beginning and end of treatment document a significant decrease in symptoms of posttraumatic stress disorder and a depressive disorder after 20 treatment sessions that comprised individual sessions for the youth, individual sessions for the nonoffending caregiver, and conjoint caregiver-youth sessions.     

Maternal Expressed Emotion in Relation to Child Behavior Problems: Differential and Mediating Effects

Maternal expressed emotion (EE), including maternal criticism and emotional over-involvement, is considered an index of family emotional climate that is critical for children’s psychological well-being. Limited research investigates how each element of EE differentially contributes to child behavior problems, or explores the mechanisms, such as child emotion dysregulation, through which parental EE influences child psychosocial outcomes. This study examined maternal EE, child emotion dysregulation, and child behavior problems among 60 mother–child dyads from a community sample, utilizing multi-method and multi-reporter assessment. Findings indicated that maternal expressed criticism toward the child was positively associated with child externalizing symptoms through its relation to increased child emotion dysregulation, whereas maternal emotional over-involvement was negatively associated with child externalizing symptoms through its negative relation to child emotion dysregulation. These results provided increased support for a model in which maternal criticism remains negatively associated with child psychosocial outcomes, but the construct of emotional over-involvement is not necessarily associated with youth psychosocial problems. This study also illustrated one pathway through which maternal EE influence child psychosocial functioning, thus placing EE research in the broader context of research on family emotion socialization.     

Child and Caregiver Dropout in Child Psychotherapy for Trauma

This study focused on the identification of variables collected at baseline assessments that predict children and caregivers who are at risk for dropout from treatment. A sample of 115 children and their caregivers who received evidence-based treatment for traumatic stress was utilized for this study. Multinomial logistic regression analyses indicated that caregiver and child age, the child's externalizing behaviors, and the child and caregiver's acknowledgment of posttraumatic stress symptoms significantly predicted premature dropout from treatment. Clarification of child and caregiver characteristics that increase the risk of dropout allows for the identification of families in need of additional support to stay in treatment.     

Depression and distress predict time to cardiovascular disease in dementia caregivers.

OBJECTIVE: This study assessed the impact of depressive symptoms and distress from patient problem behaviors on time to developing a diagnosis of cardiovascular disease (CVD) in a sample of 643 dementia family caregivers. DESIGN: A longitudinal, prospective design was used. Over an 18-month period, caregivers free from a CVD diagnosis at baseline were assessed at 6, 12, and 18-month follow-ups for the onset of CVD. MAIN OUTCOME MEASURES: Days to the onset of CVD was the primary outcome. RESULTS: Over the length of the study, 32 participants (5%) reported a diagnosis of CVD. After adjusting for sociodemographic and health factors (e.g., high blood pressure, age, smoking history), greater depressive symptoms (p = .040) and distress from patient problem behaviors (p = .034) were significant predictors of time to CVD diagnosis. CONCLUSION: This study suggests that increased depressive symptoms and reaction to patient problem behaviors (i.e., distress) may increase caregivers' risk for experiencing negative health outcomes, specifically CVD.     

Impact of patient suffering on caregiver well-being: the case of amyotrophic lateral sclerosis patients and their caregivers

The impact of patient suffering on family caregivers is an understudied but important topic. This study of patients with amyotrophic lateral sclerosis (ALS) and their caregivers examined the associations of two components of patient suffering: patient physical symptoms, and mental distress, as well as the patient's support for the caregiver, with caregiver well-being. The sample consisted of 52 patients with ALS and their caregivers. Patients and caregivers each completed a structured survey assessing multiple domains including demographics, health, and well-being. Specifically, patients rated their own physical symptoms and mental distress. Caregivers rated their own daily affect, and the extent to which they perceived the patient as supportive. Caregivers also reported whether or not they had found any benefit in dealing with the patient's illness. Regression analyses yielded significant associations of patient distress with caregiver negative affect; patient support was associated with greater caregiver positive affect, and patient symptoms and support were associated with greater likelihood of caregiver benefit finding. There was a significant two-way interaction of patient symptoms by support, namely, benefit finding was not only more likely with greater physical suffering and patient support, but it was also the case that caregivers who perceived the care recipient as unsupportive could only find benefit when this person experienced intense physical suffering. Support interventions for ALS patients and their caregivers should devote particular attention to how caregivers may be affected by witnessing their loved one's sufferings, as well as identify and address challenges in support exchanges between caregivers and patients.     

Brief Imaginal Exposure for PTSD: Trajectories of Change in Distress

Preliminary evidence shows that brief, condensed imaginal exposure only interventions can be effective in the treatment of PTSD, but we need to understand its mechanisms of action. Consistent with extinction learning and retrieval processes, the present study examined whether a pattern of between-session distress reduction observed during standard prolonged exposure (PE) therapy would be observed and predict outcome. Sixty-three patients with PTSD were enrolled in two clinical trials using our treatment protocol consisting of six daily 50-min sessions focusing on imaginal exposure and processing only. Individual patient trajectories of distress reduction were examined over the course of the five imaginal exposure sessions (Sessions 2-6). Overall, significant linear distress reduction was observed for anticipatory (d = 1.18), peak (d = 1.83), and ending imaginal exposure distress (d = 1.21). Consistent with extinction learning, the steeper slope of peak distress (d = 1.03) and end distress (d = 0.68) across imaginal exposure sessions strongly predicted decreases in PTSD symptoms. Distress reduction across sessions was predicted by higher baseline avoidance and hyperarousal but not reexperiencing symptoms. This condensed format of daily 50-min sessions without in vivo exposure may be operating via similar extinction learning processes as longer protocols. Our clinical observations suggest that the brief daily format may offer the advantage of allowing each session to build on the previous one to promote meaningful shifts in the retrieval of the trauma memory. Brief imaginal exposure and processing may be a viable option for PTSD patients in settings where brief interventions are needed. Understanding potential change processes and baseline predictors of change brings us closer toward precision medicine in treating PTSD.     

Pilot Evaluation of a Tablet-Based Application to Improve Quality of Care in Child Mental Health Treatment

Mental health systems need scalable solutions that can reduce the efficacy–effectiveness gap and improve mental health outcomes in community mental health service settings. Two major challenges to delivery of high-quality care are providers’ fidelity to evidence-based treatment models and children’s and caregivers’ engagement in the treatment process. We developed a novel, tablet-based application designed to enhance via technology the quality of delivery of trauma-focused cognitive-behavioral therapy (TF-CBT). We piloted its use in four community mental health service organizations using a blocked randomized controlled trial to examine the feasibility of implementing tablet-facilitated TF-CBT versus standard TF-CBT with 13 providers and 27 families. Provider fidelity and child engagement in treatment were observationally measured via session audio recording. Parent and child perceptions of the tablet application were assessed using structured interviews and mixed-method analyses. Providers actively and appropriately used tablet TF-CBT to facilitate treatment activities. Providers and families expressed high satisfaction with its use, demonstrating acceptability of this approach. Youth and caregivers in both conditions reported high alliance with their providers. Overall, we found that tablet-facilitated treatment is accepted by providers and families and may be integrated into mental health treatment with minimal training. Further study is needed to examine the extent to which technology-based applications may enhance the reach, quality, and clinical outcomes of mental health treatment delivered to children and families.     

“It's wrong to relax,you have to be on the go,go, go,all the time”: Emotional transformation in a case of emotion-focused therapy for generalised anxiety disorder

Generalised anxiety disorder (GAD) is a highly prevalent, chronic and impairing disorder. The aim of this study was to qualitatively describe the transformation in emotional processing across 16 sessions of a successful emotion-focused therapy (EFT) treatment for GAD. A theoretical framework derived from the EFT model of in-session emotional transformation proposed by Pascual-Leone and Greenberg was used as the basis for qualitative analysis. Additionally, the Classification of Affective Meaning States, the Client-Expressed Arousal Scale-III and the Client Emotional Productivity Scale-Revised were utilised by observer–raters to classify moment-by-moment shifts in client affective-meaning states, emotional arousal and emotional productivity. Results supported the emotion transformation model. The client presented in a state of poorly differentiated but highly aroused distress provoked by identifiable interpersonal and intrapersonal triggers. Emotional and behavioural avoidance provoked by fear of pain was evident. Accessing core pain and responding to attendant needs with compassion and protective anger was shown to facilitate the higher order emotional processing states of grief, relief and agency. Implications are proposed, including that addressing core emotional vulnerability may be a critical intervention in the successful treatment of GAD.     

The Brief Family Distress Scale: A Measure of Crisis in Caregivers of Individuals with Autism Spectrum Disorders

Parents of individuals with autism spectrum disorders (ASD) often experience stressors associated with caring for their child. These stressors can cause considerable distress for families, which at times can develop into full blown crisis, and it is important that professionals be able to quickly identify when families are approaching or are in crisis to respond appropriately. The current study presents an initial attempt at measuring the subjective experience of crisis in 164 caregivers of people with ASD through a single item instrument, the Brief Family Distress Scale. The BFDS was negatively correlated with helpful coping mechanisms (family hardiness, and parent empowerment), and positive adjustment (caregiver quality of life and positive parenting experiences), and positively correlated with known stressors (severity of aggressive behavior, negative life events) and problematic coping and outcomes (caregiver burden, worry, mental health problems). As expected, caregivers at Marked levels of distress (approaching or in crisis) were significantly different from caregivers at lower levels of distress in nearly all of the dependent variables. Having a quick way of measuring where families are in terms of distress and crisis can be helpful for researchers and clinicians alike.     

Stigma,Expressed Emotion,and Quality of Life in Caregivers of Individuals with Dementia

Expressed emotion (EE) is a measure of a caregiver's critical and emotionally overinvolved (EOI; e.g., intrusive, self‐sacrificing) attitudes and behaviors toward a person with a mental illness. Mounting evidence indicates that high levels of these critical and EOI attitudes and behaviors (collectively termed high EE) in family members are associated with a poorer course of illness for people with a range of disorders, including dementia (Nomura et al., 2005). However, less is known about factors that might trigger high EE and how high EE might impact dementia caregivers’ own mental health. In this study we propose that caregivers who perceive stigma from their relative's illness may be more likely to be critical or intrusive (high EOI) toward their relative in an attempt to control symptomatic behaviors. We further hypothesized that high EE would partially mediate the link between stigma and quality of life (QoL) as there is some evidence that high EE is associated with poorer mental health in caregivers themselves (Safavi et al., 2015). In line with study hypotheses and using a sample of 106 dementia caregivers, we found that greater caregiver stigma was associated with both high EE (for criticism and EOI) and with poorer QoL. Mediational analyses further confirmed that high EE accounts for much of the association between stigma and poorer QoL. Study results suggest that addressing caregiver stigma in therapy could reduce levels of high EE and indirectly therefore improve caregiver QoL. Intervening directly to reduce high EE could also improve caregiver QoL.     

Spanish-speaking caregivers’ use of referential labels with toddlers is a better predictor of later vocabulary than their use of referential gestures

Variation in how frequently caregivers engage with their children is associated with variation in children's later language outcomes. One explanation for this link is that caregivers use both verbal behaviors, such as labels, and non-verbal behaviors, such as gestures, to help children establish reference to objects or events in the world. However, few studies have directly explored whether language outcomes are more strongly associated with referential behaviors that are expressed verbally, such as labels, or non-verbally, such as gestures, or whether both are equally predictive. Here, we observed caregivers from 42 Spanish-speaking families in the US engage with their 18-month-old children during 5-min lab-based, play sessions. Children's language processing speed and vocabulary size were assessed when children were 25 months. Bayesian model comparisons assessed the extent to which the frequencies of caregivers’ referential labels, referential gestures, or labels and gestures together, were more strongly associated with children's language outcomes than a model with caregiver total words, or overall talkativeness. The best-fitting models showed that children who heard more referential labels at 18 months were faster in language processing and had larger vocabularies at 25 months. Models including gestures, or labels and gestures together, showed weaker fits to the data. Caregivers’ total words predicted children's language processing speed, but predicted vocabulary size less well. These results suggest that the frequency with which caregivers of 18-month-old children use referential labels, more so than referential gestures, is a critical feature of caregiver verbal engagement that contributes to language processing development and vocabulary growth.

Research Highlights

• We examined the frequency of referential communicative behaviors, via labels and/or gestures, produced by caregivers during a 5-min play interaction with their 18-month-old children.
• We assessed predictive relations between labels, gestures, their combination, as well as total words spoken, and children's processing speed and vocabulary growth at 25 months.
• Bayesian model comparisons showed that caregivers’ referential labels at 18 months best predicted both 25-month vocabulary measures, although total words also predicted later processing speed.
• Frequent use of referential labels by caregivers, more so than referential gestures, is a critical feature of communicative behavior that supports children's later vocabulary learning.

     

Grief and trauma intervention for children after disaster: exploring coping skills versus trauma narration

This study evaluated the differential effects of the Grief and Trauma Intervention (GTI) with coping skills and trauma narrative processing (CN) and coping skills only (C). Seventy African American children (6-12 years old) were randomly assigned to GTI-CN or GTI-C. Both treatments consisted of a manualized 11-session intervention and a parent meeting. Measures of trauma exposure, posttraumatic stress symptoms, depression, traumatic grief, global distress, social support, and parent reported behavioral problems were administered at pre, post, 3 and 12 months post intervention. In general, children in both treatment groups demonstrated significant improvements in distress related symptoms and social support, which, with the exception of externalizing symptoms for GTI-C, were maintained up to 12 months post intervention. Results suggest that building coping skills without the structured trauma narrative may be a viable intervention to achieve symptom relief in children experiencing trauma-related distress. However, it may be that highly distressed children experience more symptom relief with coping skills plus narrative processing than with coping skills alone. More research on the differential effects of coping skills and trauma narration on child distress and adaptive functioning outcomes is needed.     

Parental Experiences of Having a Child with Obsessive-Compulsive Disorder: Associations with Clinical Characteristics and Caregiver Adjustment

We examined parental experience of having a child with obsessive-compulsive disorder (OCD) in 62 parent–child dyads. Youth with a primary diagnosis of OCD and their parent(s) were administered the CY-BOCS jointly by a trained clinician. Parents completed several measures about their child’s OCD-related impairment and accommodation, emotional and behavioral functioning, parental distress, caregiver stress, and parental experiences of having a child with OCD. Results indicated that parents of children with OCD are considerably distressed about their child’s condition. As expected, negative parental experiences (e.g., anxiety about child’s condition, uncertainty about their future) were directly related to OCD symptom severity and impairment, as well as child internalizing and externalizing problems, family accommodation of symptoms, and caregiver strain. The presence of emotional resources was negatively related to most outcomes, although some of these relationships did not achieve statistical significance. The presence of internalizing symptoms mediated the relationship between parental experiences and parental distress. Given these findings, addressing parental experiences as part of a family based cognitive-behavioral treatment program for pediatric OCD may help reduce parental distress and improve patient prognosis.     

Understanding Strengths in Relation to Complex Trauma and Mental Health Symptoms within Child Welfare

Strengths can have a potent effect in mitigating the impact of trauma on mental health needs and functioning. Yet, evidence is limited on the role that strengths may have in ameliorating trauma-related or mental health symptoms over time. Providing a comprehensive assessment that includes strengths, as well as needs, is an important step in making appropriate service recommendations for youth in child welfare. This study assessed 7,483 children and adolescents entering an intensive stabilization program through the Illinois child welfare system. The interaction of individual, child strengths in relation to complex trauma exposure, traumatic stress symptoms, risk behaviors, and other mental health needs were examined. Results indicated strengths are relatively stable over time and inversely associated with several negative outcomes, including risk behaviors (?.32, p?<?.001), emotional/ behavioral needs (?.33, p?<?.001) and overall functioning (?.47, p?<?.001). Traumatic stress symptoms were also related to increases in these negative outcomes. Overall, strengths had a buffering effect on traumatic stress symptoms and outcomes over time. The role of strengths in relation to traumatic stress symptoms, however, was less consistent. Youth with histories of complex trauma exposure had significantly fewer useable strengths than youth without this exposure. However, strengths improved for both youth with and without complex trauma exposure over the course of stabilization services. These findings suggest that early identification and development of child strengths can mitigate risk-taking behaviors, mental health, and functional difficulties among youth in the child welfare system. Implications for more targeted trauma-informed and strengths-based assessment, and treatment/service planning are discussed.     

Influences of parent and child negative emotionality on young children's everyday behaviors

Negative emotionality is linked to unfavorable life outcomes, but studies have yet to examine negative emotionality of parents and children as predictors of children's problem behaviors and negative emotion word use in everyday life. This study used a novel naturalistic recording device called the Electronically Activated Recorder to investigate the separate and interactive influences of parent and child negative emotionality on daily child behaviors in a sample of 35 preschool-aged children over two time points separated by 1 year. Fathers' negative emotionality predicted children's whining at Time 1; mothers' negative emotionality predicted children's negative emotion word use at Time 1 and increases in children's arguing/fighting from Time 1 to Time 2. Parents' ratings of child negative emotionality also were associated with increases in children's arguing/fighting from Time 1 to Time 2, and child negative emotionality moderated the association between mothers' negative emotionality and children's arguing/fighting. Further, children with mothers high in negative emotionality displayed higher levels of problem behaviors when their mothers self-reported low levels of positive emotional expressiveness and/or high levels of negative emotional expressiveness. These findings offer preliminary evidence linking parent and child negative emotionality to everyday child behaviors and suggest that emotional expressiveness may play a key role in moderating the links between maternal negative emotionality and child behavioral problems. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Improved Perceptions of Emotion Regulation and Reflective Functioning in Parents: Two Additional Positive Outcomes of Parent-Child Interaction Therapy

The purpose of this study was to test whether Parent-Child Interaction Therapy (PCIT), a widely used effective therapy for children’s externalizing behaviors and parenting problems, was associated with improvements in parents’ emotion regulation and reflective functioning. We also investigated whether these improvements had unique associations with children’s improvements in externalizing and internalizing symptoms. Participants were 139 Australian children aged 29 to 83 months and their caregivers; all were referred for child externalizing behavior problems coupled with parenting skill deficits or high parent stress. All data were gathered via a questionnaire completed prior to and after completion of PCIT. Significant improvements were found in parents’ self-reported emotion dysregulation and capacity to use cognitive reappraisal for emotion regulation. There was also improvement in parents’ self-report of children’s symptoms, parenting practices, and reflective functioning in the form of prementalizing, which measured a low capacity to understand the emotional world of the child. Multiple regression showed that improvements in cognitive reappraisal, prementalizing, and negative parenting practices were associated with improvement in children’s symptoms. The findings extend the existing evidence for PCIT as an effective parenting intervention, adding parents’ perceived emotion regulation and reflective functioning to the list of positive outcomes from PCIT. Improved emotion regulation and reflective functioning, unique from changes in parenting practices, could be mechanisms that help explain why PCIT has been associated with improvements in children’s externalizing behaviors.     

A Pilot Randomized Clinical Trial of a Novel,Culturally Adapted,Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.