A multi-method and multi-informant approach to assessing post-traumatic stress disorder (PTSD) in children.

Trauma exposure is highly prevalent among children globally, and is associated with elevated rates of PTSD. The goal of this study was to systematically evaluate the effects of multiple informants and multiple screening measures on the identification of specific PTSD symptoms and rates of PTSD diagnoses. Participants in this study included 350 maltreated children from two cohorts, one recruited from Connecticut (n = 130), and the other from Vermont (n = 220). Both cohorts completed the Screen for Child Anxiety-Related Emotional Disorders (SCARED) before a PTSD self-report measure. The KSADS psychiatric interview was also completed with the Connecticut cohort, with best-estimate ratings generated using parent and child interview, child self-report, and teacher questionnaire data. In addition to the SCARED and PTSD self-report scale, parents of the Vermont cohort completed the Child Behavioural Checklist. Significant differences emerged between parent and child report of sleep, nightmares, concentration, and irritability problems, suggesting the need for multiple informants in PTSD screening. Children also under-reported nightmares when asked in the context of a trauma-specific screening tool. As child trauma is associated with a broad range of psychiatric sequelae, comprehensive assessment using both general symptomatology and trauma-specific measures is recommended, since children often shut down when completing trauma measures.

Randomized Clinical Trial of Dialectical Behavior Therapy for Preadolescent Children With Disruptive Mood Dysregulation Disorder: Feasibility and Outcomes.

OBJECTIVE: Persistent irritability and behavior outbursts in disruptive mood dysregulation disorder (DMDD) are associated with severe impairment in childhood and with negative adolescent and adult outcomes. There are no empirically established treatments for DMDD. This study examined the feasibility and preliminary efficacy of dialectical behavior therapy adapted for preadolescent children (DBT-C) with DMDD. METHOD: Children 7 to 12 years old with DMDD (N = 43) were randomly assigned 1:1 to DBT-C or treatment as usual (TAU). The 6 domains of feasibility included recruitment, randomization, retention, attendance, participants' satisfaction, and therapist adherence. Blinded raters assessed participants at baseline, after 8, 16, 24, and 32 weeks, and at 3-month follow-up. The primary efficacy outcome was the positive response rate on the Clinical Global Impression-Improvement scale. Improvements in behavior outbursts and angry/irritable mood were assessed by the Clinical Global Impression-Severity scale. RESULTS: Mean number of participants randomized per month was 2.53 ± 2.72. Participants in DBT-C (n = 21) attended 89% of sessions compared with 48.6% in TAU (n = 22). Eight TAU participants (36.4%) dropped out compared with none in DBT-C. Parents and children in DBT-C expressed significantly higher treatment satisfaction than those in TAU. The rate of positive response was 90.4% in DBT-C compared with 45.5% in TAU, despite 3 times as many participants in TAU receiving psychiatric medications. Remission rates were 52.4% for DBT-C and 27.3% for TAU. Improvements were maintained at 3-month follow-up. Therapists showed adherence to DBT-C. CONCLUSION: DBT-C demonstrated feasibility in all prespecified domains. Outcomes also indicated preliminary efficacy of DBT-C. Clinical trial registration information-Adapting DBT for Children With DMDD: Pilot RCT; http://clinicaltrials.gov/; NCT01862549.

Child abuse, depression, and methylation in genes involved with stress, neural plasticity, and brain circuitry.

OBJECTIVES: To determine whether epigenetic markers predict dimensional ratings of depression in maltreated children. METHOD: A genome-wide methylation study was completed using the Illumina 450K BeadChip array in 94 maltreated and 96 healthy nontraumatized children with saliva-derived DNA. The 450K BeadChip does not include any methylation sites in the exact location as sites in candidate genes previously examined in the literature, so a test for replication of prior research findings was not feasible. RESULTS: Methylation in 3 genes emerged as genome-wide-significant predictors of depression: DNA-Binding Protein Inhibitor ID-3 (ID3); Glutamate Receptor, Ionotropic N-methyl-D-aspartate (NMDA) 1 (GRIN1); and Tubulin Polymerization Promoting Protein (TPPP) (p < 5.0 × 10(-7), all analyses). These genes are all biologically relevant with ID3 involved in the stress response, GRIN1 involved in neural plasticity, and TPPP involved in neural circuitry development. Methylation in CpG sites in candidate genes were not predictors of depression at significance levels corrected for whole genome testing, but maltreated and control children did have significantly different ß values after Bonferroni correction at multiple methylation sites in these candidate genes (e.g., BDNF, NR3C1, FKBP5). CONCLUSIONS: This study suggests that epigenetic changes in ID3, GRIN1, and TPPP genes, in combination with experiences of maltreatment, may confer risk for depression in children. The study adds to a growing body of literature supporting a role for epigenetic mechanisms in the pathophysiology of stress-related psychiatric disorders. Although epigenetic changes are frequently long lasting, they are not necessarily permanent. Consequently, interventions to reverse the negative biological and behavioral sequelae associated with child maltreatment are briefly discussed.

Child abuse and epigenetic mechanisms of disease risk.

BACKGROUND: Child abuse is highly prevalent and associated with increased risk for a range of health problems, including cancer, cardiovascular disease, diabetes, psychiatric disorders, and other health problems. Little is currently known about the mechanism by which early adversity confers risk for health problems later in life. PURPOSE: To determine if there are epigenetic differences associated with child maltreatment that may help explain association between adverse childhood experiences and later health problems. METHODS: As part of a study examining genetic and environmental factors associated with depression, saliva DNA specimens were collected on 96 maltreated children removed from their parents due to abuse or neglect and 96 demographically matched control children between 2003 and 2010. In 2011, the Illumina 450K BeadChip was used on stored DNA specimens and analyzed to examine whole-genome methylation differences between maltreated and control children. RESULTS: After controlling for multiple comparisons, maltreated and control children had significantly different methylation values at 2868 CpG sites (p<5.0 × 10(-7), all sites; average methylation difference per site=17%; range=1%-62%). The gene set contained numerous markers of diseases and biological processes related to the health problems associated with early childhood adversity. CONCLUSIONS: Although replication is required, this study suggests that epigenetic mechanisms may be associated with risk for health problems later in life in maltreated children. This study lays the groundwork for future studies examining health and methylation measures to further characterize the role of epigenetic mechanisms in conferring risk for medical problems in individuals with histories of early adversity.

Borderline personality disorder features and history of childhood maltreatment in mothers involved with child protective services.

This study examines the history of childhood maltreatment and Borderline Personality Disorder (BPD) symptoms in mothers whose children were removed from the home by Child Protective Services (CPS) to identify potential targets for future intervention efforts. Forty-one mothers of children removed from the home due to abuse and/or neglect and 58 community-control mothers without CPS involvement were assessed for history of childhood maltreatment, alcohol and drug use, and BPD features. CPS-involved mothers scored significantly higher on measures of childhood maltreatment history and BPD features than did control mothers. The highest BPD scores were associated with the most severe histories of mothers' childhood maltreatment. In total, 50% of CPS-involved mothers reported elevated BPD features, compared with 15% of control mothers. Further, 19% of CPS-involved mothers had self-reported scores consistent with a BPD diagnosis, compared with 4% of control mothers. BPD features rather than maltreatment history per se predicted maternal involvement with CPS, controlling for alcohol and drug use predictors. The present data suggest that evidence-based treatments to address BPD symptoms may be indicated for some CPS-involved parents.

On the Topic of Treatment Integrity.

Treatment integrity, also known as treatment fidelity, is integral for empirical testing of intervention efficacy as it allows for unambiguous interpretations of the obtained results. Assuring treatment integrity is also important for dissemination of evidence-based practices and quality improvement of services. However, in the examination of the relationship between treatment integrity and treatment outcome it is important to consider that treatment integrity may be a proxy variable for other variables impacting therapeutic change (e.g., characteristics of intervention, clients, setting, and therapist). Considerations on examining the association between integrity and outcome are discussed. Further, recommendations on the level to which treatment integrity needs to be addressed in psychotherapy research and clinical practice are provided.

Adapting Dialectical Behaviour Therapy for Children: Towards a New Research Agenda for Paediatric Suicidal and Non-Suicidal Self-Injurious Behaviours.

BACKGROUND: Dialectical Behaviour Therapy (DBT) has been used to treat adults and adolescents with suicidal and non-suicidal self-injury. This article describes initial progress in modifying DBT for affected pre-adolescent children. METHOD: Eleven children from regular education classes participated in a 6-week pilot DBT skills training program for children. Self-report measures of children's emotional and behavioural difficulties, social skills and coping strategies were administered at pre- and post-intervention, and indicated that the children had mild to moderate symptoms of depression, anxiety and suicidal ideation at baseline. RESULTS: Subjects were able to understand and utilise DBT skills for children and believed that the skills were important and engaging. Parents also regarded skills as important, child friendly, comprehensible and beneficial. At post-treatment, children reported a significant increase in adaptive coping skills and significant decreases in depressive symptoms, suicidal ideation and problematic internalising behaviours. CONCLUSIONS: These promising preliminary results suggest that continued development of DBT for children with more severe clinical impairment is warranted. Progress on adapting child individual DBT and developing a caregiver training component in behavioural modification and validation techniques is discussed.

Emotion regulation and substance use frequency in women with substance dependence and borderline personality disorder receiving dialectical behavior therapy.

BACKGROUND: Dialectical behavior therapy (DBT) identifies emotion dysregulation as central to the dangerous impulsivity of borderline personality disorder (BPD) including substance use disorders, and DBT targets improved emotion regulation as a primary mechanism of change. However, improved emotion regulation with DBT and associations between such improvement and behavioral outcomes such as substance use has not been previously reported. OBJECTIVE: Thus, the goal of this study was to assess for improvement in emotion regulation and to examine the relationship between improvements in the emotion regulation and substance use problems following DBT treatment. METHOD: Emotion regulation as assessed by the Difficulties in Emotion Regulation Scale, depressed mood as assessed by the Beck Depression Inventory, and their associations with substance use frequency were investigated in 27 women with substance dependence and BPD receiving 20 weeks of DBT in an academic community outpatient substance abuse treatment program. RESULTS: Results indicated improved emotion regulation, improved mood, and decreased substance use frequency. Further, emotion regulation improvement, but not improved mood, explained the variance of decreased substance use frequency. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This is the first study to demonstrate improved emotion regulation in BPD patients treated with DBT and to show that improved emotion regulation can account for increased behavioral control in BPD patients. SIGNIFICANCE AND FUTURE RESEARCH: Emotion regulation assessment is recommended for future studies to further clarify the etiology and maintenance of disorders associated with emotional dysregulation such as BPD and substance dependence and to further explore emotion regulation as a potential mechanism of change for clinical interventions.

Emotional and behavioral sequelae of childhood maltreatment.

PURPOSE OF REVIEW: To summarize research on the emotional and behavioral consequences of childhood maltreatment published between January 2009 and April 2010. RECENT FINDINGS: Many studies published during this time frame replicated prior research studies that have shown that childhood maltreatment is a nonspecific risk factor for a range of different emotional and behavioral problems. Two research groups highlighted the high revictimization rate among abused girls, with more than one in five abused girls found to have subsequent experiences of rape by young adulthood. The association between physical and sexual abuse and subsequent perpetration of violence toward self and other was also demonstrated, with one study noting the particular vulnerability of sexually abused boys to these negative outcomes. In this study, sexually abused boys had a 15-fold increased risk of making a suicide attempt, and a 45-fold increased risk of perpetrating domestic violence. A three-generation longitudinal study of the intergenerational transmission of abuse is also highlighted in the review, together with emerging findings on genetic and environmental risk and protective factors associated with variability in child outcomes. SUMMARY: Maltreated children are at-risk for a host of negative outcomes. Although marked gains have been made in treating trauma-related psychopathology, these recent studies highlight the need to examine long-term outcomes of youths who have received state-of-the-art evidence-based interventions, and determine if there is a need for more comprehensive and sustained intervention approaches.

Barriers to implementing treatment integrity procedures: survey of treatment outcome researchers.

Treatment integrity refers to implementing interventions as intended. Treatment integrity is critically important for experimental validity and for drawing valid inferences regarding the relationship between treatment and outcome. Yet, it is rarely adequately addressed in psychotherapy research. The authors examined barriers to treatment integrity implementation by surveying psychotherapy researchers. Results indicate that lack of theory and guidelines on treatment integrity procedures, as well as time, cost, and labor constraints, were regarded as strong barriers. The lack of general knowledge about treatment integrity and the lack of editorial requirement for reporting integrity procedures were also perceived as barriers to its implementation. However, psychotherapy researchers indicated awareness of the importance of treatment integrity for the experimental validity of a study and did not regard lack of its appreciation as a barrier for implementing integrity procedures. Further, a higher number of endorsed barriers predicted lower adequacy of treatment integrity procedures in the authors' own research. Recommendations for improving how integrity is addressed include journal and editorial enforcement of treatment integrity implementation, funding for integrity procedures, and provision of specific guidelines.

Practitioner review: adolescent alcohol use disorders: assessment and treatment issues.

BACKGROUND: Alcohol use disorders in adolescents are associated with significant morbidity and mortality. Over the past decade, there has been a burgeoning of research on adolescent alcohol use disorders. METHODS: A summary of the alcohol assessment tools is provided, and randomized studies reviewed and synthesized to provide an overview of state of the art knowledge of treatment of adolescent alcohol use disorders. Animal models of addiction are also briefly reviewed, and the value of translational research approaches, using findings from basic studies to guide the design of clinical investigations, is also highlighted. RESULTS: Comorbidity is the rule, not the exception in adolescent alcohol use disorders. Comprehensive assessment of psychiatric and other substance use disorders, trauma experiences, and suicidality is indicated in this population to optimize selection of appropriate clinical interventions. In terms of available investigated treatments for adolescents with alcohol use disorders, Multidimensional Family Therapy and group administered Cognitive Behavioral Therapies have received the most empirical support to date. There is a paucity of research on pharmacological interventions in this patient population, and no firm treatment recommendations can be made in this area. CONCLUSIONS: Given the high rate of relapse after treatment, evaluation of combined psychosocial and pharmacological interventions, and the development of novel intervention strategies are indicated.

Treatment integrity in psychotherapy research: analysis of the studies and examination of the associated factors.

Treatment integrity refers to the degree to which an intervention is delivered as intended. Two studies evaluated the adequacy of treatment integrity procedures (including establishing, assessing, evaluating, and reporting integrity; therapist treatment adherence; and therapist competence) implemented in psychotherapy research, as well as predictors of their implementation. Randomized controlled trials of psychosocial interventions published in 6 influential psychological and psychiatric journals were reviewed and coded for treatment integrity implementation. Results indicate that investigations that systematically addressed treatment integrity procedures are virtually absent in the literature. Treatment integrity was adequately addressed for only 3.50% of the evaluated psychosocial interventions. Journal of publication and treatment approach predicted integrity implementation. Skill-building treatments (e.g., cognitive-behavioral) as compared with non-skill-building interventions (e.g., psychodynamic, nondirective counseling) were implemented with higher attention to integrity procedures. Guidelines for implementation of treatment integrity procedures need to be reevaluated.