A parallel investigation of trauma exposure, maladaptive appraisals and posttraumatic stress reactions in two groups of trauma-exposed adolescents.

Background: Maladaptive appraisals, such as thoughts about experiencing a permanent and disturbing change and about being a fragile person in a scary world, are associated with posttraumatic stress reactions (PTSR) for trauma-exposed children and adolescents. Less is known about what puts young people at risk for developing such appraisals, and the differential relationship between the types of appraisals and PTSR.Objective: The primary aim was to examine the role of age, gender and exposure to potentially traumatizing events (PTEs) for the levels of maladaptive appraisals. The secondary aim was to investigate the association between the levels of maladaptive appraisals (appraisals of a permanent change and appraisals about a scary world) and PTSR.Methods: We investigated these aims in two samples: survivors after the terror attack at Utøya island in Norway in 2011 (N = 165, mean age 17.65, SD = 1.19) and adolescents referred to treatment after mainly interpersonal trauma (N = 152, mean age 15.08, SD = 2.18). The aims were investigated using linear regression and partial correlation.Results: In the terror-exposed sample, female gender was significantly associated with higher levels of scary-world appraisals, witnessing or learning that someone close were exposed to physical violence was significantly associated with more permanent-change appraisals, and a higher number of PTEs was significantly associated with higher levels of both types of appraisals. For the clinical sample, we found no significant associations between exposure to PTEs, gender, age, and the level of maladaptive appraisals. Both types of maladaptive appraisals were highly associated with PTSR in both samples, and there was no significant difference in the strength of the associations between the types of appraisals and PTSR.Conclusions: The results have implications for identifying adolescents at risk for developing harmful maladaptive appraisals. Both scary-world appraisals and permanent-change appraisals were strongly associated with PTSR in both groups of trauma-exposed adolescents.

Factors associated with elevated levels of maladaptive appraisals, and associations between maladaptive appraisals and posttraumatic stress reactions were investigated in two samples of trauma-exposed adolescents.Both appraisals about experiencing a permanent and disturbing change and appraisals about being a fragile person in a scary world were significantly associated with posttraumatic stress reactions.Exposure to a higher number of potentially traumatizing events (PTEs), being female, and witnessing or learning that someone close was exposed to physical violence were significantly associated with a higher level of maladaptive appraisals among terror-exposed adolescents.

The dissemination and implementation of trauma-focused cognitive behavioural therapy for children and adolescents in seven European countries.

BACKGROUND: There is broad scientific evidence for the effectiveness of individual trauma-focused evidence-based treatments (EBTs) such as "trauma-focused cognitive behavioural therapy" (TF-CBT) for children and adolescents with posttraumatic stress symptoms. However, there is a significant research-to-practice gap resulting in traumatized children in high-income countries in Europe having only very limited access to these treatments. The aim of this study was, therefore, to identify common barriers and successful dissemination and implementation (D&I) strategies of evidence-based trauma-focused treatments (in particular TF-CBT) in seven European countries. METHODS: For this study, we chose a mixed-method approach: an online survey among certified European TF-CBT trainers (N = 22) and the collection of country-based narratives from TF-CBT experts in different European countries (Finland, Germany, Italy, Netherlands, Norway, Sweden). RESULTS: Common modifiable barriers to the implementation of TF-CBT were identified on different levels (e.g. government or treatment level), and successful D&I strategies were highlighted across all countries, such as translations of materials. Additionally, the experts from the country narratives put together a broad overview of TF-CBT research in Europe. CONCLUSIONS: The results of this study revealed that especially learning collaborations and the development of joint European efforts in funding and researching D&I strategies are crucial for future implementation of trauma-focused EBTs in Europe.

Do psychological treatments for PTSD in children and young people reduce trauma-related appraisals? A systematic review and meta-analysis.

Research is increasingly highlighting the role of negative trauma-related appraisals in child and adolescent post-traumatic stress disorder (PTSD). The cognitive model of PTSD claims that an essential mechanism of treatment is a reduction in these appraisals. The current systematic review with meta-analysis investigated the extent to which psychological treatments for PTSD reduce negative trauma-related appraisals in children and adolescents. Four databases (PsycINFO, Medline Complete, CINAHL Complete and PTSDpubs) were searched on the 11-12th December 2022. The Risk of Bias 2 (ROB-2) tool was used to assess for risk of bias. Thirteen studies were included in this review, comprising 937 child and adolescent participants. Using a random effects model to perform the meta-analysis, a medium pooled effect size for the effect of current treatments on trauma-related appraisals was found (g = -.67, 95% CI [-.86, -.48]). There was only a moderate level of heterogeneity between studies (I2 = 44.4%), increasing the confidence with which these findings can be interpreted. These results indicate that psychological treatments for child and adolescent PTSD significantly reduce negative trauma-related appraisals. However, it is important to note that no trial included in the review was categorised as having low risk of bias.

Predictors of burnout, secondary traumatic stress, and compassion satisfaction among practitioners in Norwegian child advocacy centers.

BACKGROUND: Practitioners at Child Advocacy Centers (CACs) are frequently exposed to indirect trauma through their job, yet there is a lack of knowledge on how this affects them emotionally. OBJECTIVE: This study aimed to investigate the levels of burnout, secondary traumatic stress (STS), and compassion satisfaction among practitioners at Norwegian CACs, and possible individual or work-related predictors. PARTICIPANTS AND SETTING: An electronic cross-sectional survey was sent to practitioners at Norwegian CACs. A total of 77 practitioners completed the survey (response rate 86.5 %). METHODS: Variables were measured with the Professional Quality of Life Scale, the Multifactor Leadership Questionnaire, and questions on personal traumatic experiences, support, and supervision. Bivariate and multivariate mixed effects modeling analyses and logistic regression analyses were employed. RESULTS: The results showed relatively low levels of burnout and STS, and high levels of compassion satisfaction, compared to other studies of child protective and child welfare professionals. Work-related factors, but not individual factors, were found to predict all three outcome variables: Burnout was predicted by transformational leadership (p = .002) and laissez-faire leadership (p = .012), secondary traumatic stress by case supervision (p = .001), and compassion satisfaction by transformational leadership (p < .000), laissez-faire leadership (p = .028), and personal supervision (p = .023). CONCLUSIONS: The results indicate that transformational leadership and supervision may protect against burnout and STS and promote compassion satisfaction in practitioners working at CACs. The type of supervision may be relevant, as case-focused supervision predicted STS, while personal supervision predicted compassion satisfaction.

Stepping Together for Children After Trauma (ST-CT): Feasibility and Predictors of Outcome of a Parent-led, Therapist Assisted Treatment.

Stepping Together for Children after Trauma (ST-CT) is the first step of the promising intervention Stepped Care CBT for Children after Trauma. In ST-CT, the task of leading treatment is partially shifted to the parents, and the child and parent work together to complete therapeutic tasks from a workbook with therapist supervision. We aimed to investigate the feasibility of ST-CT in Norwegian first line services and explore child factors predicting outcome. Eighty-two children (mean age 9.9 years, 56% girls) participated. Feasibility was defined by treatment completion, reductions of child posttraumatic stress symptoms (PTSS) mid- and post-treatment, and client treatment satisfaction. Predictors included child baseline PTSS, depressive symptoms, posttraumatic cognitions, externalizing symptoms, number of different traumatic events, and type of trauma. Results showed that rates of completion (78.0%) and response (81% of completers/59.8% intention-to-treat) were comparable to previous studies by the ST-CT developer. Overall treatment effect was d = 2.46 and client treatment satisfaction was high (mean score child: 8.3, parent: 9.0, on a scale from 0 - 10). Higher baseline PTSS and depressive symptoms predicted poorer outcome at both mid- and post-treatment, while more posttraumatic cognitions, and exposure to interpersonal trauma predicted poorer outcome at mid-treatment only. These associations were no longer significant in the fully adjusted models. In conclusion, ST-CT shows promise as an effective first line treatment in this new context, with two of three children responding to the treatment. Baseline PTSS, depression, post-traumatic cognitions and type of trauma may be related to outcomes and should be explored further. (Trial registration:  ClinicalTrials.gov Identifier: NCT04073862. Retrospectively registered June 3rd 2019, first patient recruited May 19th 2019).

Scoping Review: Digital Mental Health Interventions for Children and Adolescents Affected by War.

OBJECTIVE: More than 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, to examine the strength of the evidence base, and to inform the development of future interventions. METHOD: Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to September 30, 2022, identifying k = 6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network. RESULTS: The systematic search identified 6 relevant studies: 1 study evaluating digital mental health interventions for children and adolescents affected by war, and 5 studies for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents or carers/caregivers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear. CONCLUSION: There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions. DIVERSITY & INCLUSION STATEMENT: We actively worked to promote sex and gender balance in our author group. STUDY PREREGISTRATION INFORMATION: Digital mental health interventions for children and young people affected by war: a scoping review; https://osf.io/; hrny9.

'My child could have died': counterfactual thoughts and psychological distress in parents of trauma survivors.

Background: After exposure to a potentially traumatic event, survivors may experience thoughts about 'what could have happened', referred to as counterfactual thoughts (CFTs). CFTs have been found to have a negative impact on survivors' mental health. This is the first study to investigate whether parents of trauma survivors experience CFTs and the association with psychological distress in this group.Objective: The main aim of the present study is to investigate CFTs in parents of trauma survivors and the relationship between the frequency and vividness of CFTs and psychological distress.Method: The participants (N = 310, 191 females) were parents of the youths targeted in the terror attack on Utøya island, Norway, in 2011. Frequency and vividness of CFTs, posttraumatic stress reactions (PTSR), and symptoms of anxiety and depression were measured 8.5-9 years post-terror.Results: The majority of the parents (74%) reported having experienced CFTs at some time point since the attack. For almost one-third of the parents, CFTs were still present more than eight years after the attack. Higher frequency and vividness of CFTs were uniquely associated with higher levels of PTSR, anxiety, and depression.Conclusion: The present findings suggest that frequent and vivid CFTs may contribute to mental health problems in parents of trauma survivors and should be addressed in therapy.

A quantitative study investigating the relationship between counterfactual thoughts and psychological distress, in parents of trauma survivors.The majority of the parents reported having experienced counterfactual thoughts at some time point since the attack. For almost one-third of the parents, counterfactual thouhgts were still present more than eight years after the attack. Higher frequency and vividness of counterfactual thoughts were uniquely associated with higher levels of psychological distress.The present findings suggest that frequent and vivid counterfactual thouhgts may contribute to mental health problems in parents of trauma survivors and should be addressed in therapy.

Exploring key job demands and resources in Norwegian child mental health services: a cross-sectional study of associations with and relationship between compassion satisfaction, burnout, secondary traumatic stress and turnover intention.

Background: Burnout, secondary traumatic stress, and high turnover rates among child mental health clinicians are a challenge, not only for the individual therapist and the organization but also for the successful implementation of evidence-based practices. However, little is known about which and how job-and implementation-related factors are associated with burnout, secondary traumatic stress, and turnover intention as well as compassion satisfaction among child therapists. In the present study, we aimed to explore these factors and related mechanisms by integrating the "professional quality of life" and the "job demands-resources" models of occupational health. Methods: We measured the perceived professional quality of life and turnover intention among a national sample of 256 therapists working in Norwegian Child and Adolescence Mental Health Clinics (n = 44) that implemented Trauma-Focused Cognitive Behavior Therapy (TF-CBT). Seventeen Job-and implementation-related resources and demands were also measured using the General Nordic Questionnaire for Psychological and Social Factors at Work and the Implementation Component Questionnaire. Path analysis was used to test whether burnout and compassion satisfaction mediate the relationship between job demands and resources on one hand, and secondary traumatic stress and turnover intention on the other hand. Results and discussion: Results revealed that two job resources, i.e., positive challenges at work and mastery of work, were significant predictors of all professional outcomes. The proposed model was only partly supported. That is, while burnout did mediate the relationship between some job demands (i.e., work-family interference and role conflict) and job resources (i.e., human resource primacy, positive challenges, and mastery of work) with secondary traumatic stress and turnover intention, compassion satisfaction did not mediate the relationship between job resources and turnover intention. Moreover, in addition to their indirect effects via burnout, role conflict and organizational climate (human resource primacy) also directly affected turnover intention. These findings propose that interventions that reduce burnout should be prioritized to improve the professional quality of life and turnover intention among child therapists. Theoretically, it seems that compassion satisfaction and work engagement act differently.

The bidirectional associations between caregiver and child symptoms in the parent-led treatment stepping together for children after trauma.

BACKGROUND: An innovative approach to child trauma treatment in which caregivers are allocated treatment tasks has shown promising results, but less is known about the bidirectional associations between caregiver and child symptoms during treatment. METHODS: Eighty-two child-caregiver dyads who participated in the parent-led therapist-assisted Stepping Together for Children after Trauma (ST-CT) were included (child age: 7-12 years, mean = 9.9 years). Caregivers' emotional reactions and anxiety/depression and children's posttraumatic stress (PTS) and depression were assessed pretreatment, mid-treatment, and posttreatment. We investigated the possible directional associations between caregivers' emotional reactions and anxiety/depression and children's PTS and depression using random intercept cross-lagged panel models. RESULTS: Symptoms improved in both caregivers and children. Lower levels of caregiver emotional reactions at pretreatment predicted improved child PTS at mid-treatment; lower levels of caregiver emotional reactions at mid-treatment predicted improved child depression at posttreatment; and lower levels of child PTS at mid-treatment predicted improved caregiver emotional reactions at posttreatment. CONCLUSIONS: These findings suggest that caregivers and children can impact each other's responses to a parent-led child trauma-focused treatment. Notably, children with caregivers who were less affected by their own emotional reactions exhibited greater improvement in both PTS and depression. Supporting the caregivers may benefit both children and caregivers. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials.

BACKGROUND: Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators. METHODS: This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954. FINDINGS: We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms. INTERPRETATION: This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress. FUNDING: Swiss National Science Foundation.

The differential impact of the DSM-5 post-traumatic stress symptoms on functional impairment in traumatized children and adolescents.

BACKGROUND: This study aims to provide a better understanding of the individual impact of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) post-traumatic stress symptoms (PTSS) on functional impairment in trauma-exposed children and adolescents. Identifying PTSS that have the most impact on functional impairment can broaden our understanding of post-trauma reactions and guide the selection of treatment components and techniques required to help patients to restore functioning following trauma exposure. METHOD: Utilizing relative importance analyses, unique shared variance of each DSM-5 PTSS with functional impairment were estimated in clinical samples of 3400 Norwegian (Mage = 14.18, SDage = 2.49, rangeage = 7-17) and 747 US (Mage = 10.76, SDage = 3.10, rangeage = 7-17) children and adolescents from naturalistic settings. RESULTS: Negative beliefs, detachment from others, inability to experience positive emotions, and diminished interest in activities within the symptom cluster negative alterations in cognitions and mood, and the hyperarousal symptom concentration problems accounted for the largest proportions of unique variance explained in functional impairment in both samples. Further, the hyperarousal symptom irritability showed a unique high association with functional impairment in the US sample. CONCLUSION: As negative beliefs, emotional numbing symptoms, concentration problems and irritability may be especially related to functional impairment in traumatized children and adolescents, monitoring and targeting these symptoms throughout therapy might be of particular importance to restore functioning as early as possible and to facilitate overall recovery.

Parent-Led Stepped Care Trauma Treatment: Parents' Experiences With Helping Their Child Recover.

Purpose: There is a need for interventions for traumatized children that are easily accessible and effective, and that involve parents directly in the recovery process. To meet this challenge, stepped care trauma-focused cognitive behavioral treatment (SC TF-CBT), which consists of a parent-led therapist-assisted intervention as the first step, was developed. Parent-led trauma-treatment is a promising, but novel approach. The aim of this study was therefore to gain knowledge on how parents experience the model. Methods: Parents who participated in a SC TF-CBT feasibility study were consecutively recruited and interviewed with semi-structured interviews, which were then analysed using interpretative phenomenological analysis. Results: The parents described that the intervention gave them insights that led to a sense of parental agency. Through the analysis we identified and labelled four themes: (i) understanding my child: how the trauma has affected my child and our relationship; (ii) understanding myself: how my reactions have stood in the way of helping my child; (iii) gaining competence: how to learn specific tasks that were not part of my normal parenting skills; and (iv) receiving support: how guidance, warmth and encouragement was necessary. Conclusions: The results from this study show how the shifting of therapeutic tasks to parents may facilitate parental empowerment and improve the parent-child relationship. This knowledge may guide clinicians on how to provide support to parents so they can take a leading role in their child's recovery process after trauma. Trial registration: ClinicalTrials.gov, NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019), https://clinicaltrials.gov/ct2/show/NCT04073862.

Parent-led stepped care for traumatised children: parental factors that predict treatment completion and response.

Background: Stepped care cognitive behavioural therapy for children after trauma (SC-CBT-CT; aged 7-12 years) can help to increase access to evidence-based trauma treatments for children. SC-CBT-CT consists of a parent-led therapist-assisted component (Step One) with an option to step up to standard therapist-led treatment (Step Two). Studies have shown that SC-CBT-CT is effective; however, less is known about what parent variables are associated with outcome of Step One.Objective: To examine parent factors and their relationship with completion and response among children receiving Step One.Method: Children (n = 82) aged 7-12 (M = 9.91) received Step One delivered by their parents (n = 82) under the guidance of SC-CBT-CT therapists. Logistic regression analyses were used to investigate whether the following factors were associated with non-completion or non-response: the parents' sociodemographic variables, anxiety and depression, stressful life experiences and post-traumatic symptoms, negative emotional reactions to their children's trauma, parenting stress, lower perceived social support, and practical barriers to treatment at baseline.Results: Lower level of educational achievement among parents was related to non-completion. Higher levels of emotional reactions to their child's trauma and greater perceived social support were related to non-response.Conclusions: The children seemed to profit from the parent-led Step One despite their parents` mental health challenges, stress, and practical barriers. The association between greater perceived social support and non-response was unexpected and warrants further investigation. To further increase treatment completion and response rates among children, parents with lower education may need more assistance on how to perform the interventions, while parents who are very upset about their child's trauma may need more emotional support and assurance from the therapist.Trial registration: ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019).

The children seemed to profit from Step One despite parents' mental health challenges and practical barriers.Response may improve if parents' emotional reactions to a child's trauma is addressed.Parents with lower education may need more assistance in performing Step One.

Efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents exposed to single versus multiple traumas: meta-analysis of randomised controlled trials.

BACKGROUND: Previous meta-analyses of psychotherapies for children and adolescents with post-traumatic stress disorder (PTSD) did not investigate whether treatment efficacy is diminished when patients report multiple (versus single) traumas. AIMS: To examine whether efficacy of psychological interventions for paediatric PTSD is diminished when patients report multiple (versus single) traumas. METHOD: We systematically searched PsycInfo, MEDLINE, Web of Science and PTSDpubs on 21 April 2022 and included randomised controlled trials (RCTs) meeting the following criteria: (a) random allocation; (b) all participants presented with partial or full PTSD; (c) PTSD is the primary treatment focus; (d) sample mean age <19 years; (e) sample size n ≥ 20. Trauma frequency was analysed as a dichotomous (single versus ≥2 traumas) and continuous (mean number of exposures) potential moderator of efficacy. RESULTS: Of the 57 eligible RCTs (n = 4295), 51 RCTs were included in quantitative analyses. Relative to passive control conditions, interventions were found effective for single-trauma-related PTSD (Hedges' g = 1.09; 95% CI 0.70-1.48; k = 8 trials) and multiple-trauma-related PTSD (g = 1.11; 95% CI 0.74-1.47; k = 12). Psychotherapies were also more effective than active control conditions in reducing multiple-trauma-related PTSD. Comparison with active control conditions regarding single-event PTSD was not possible owing to scarcity (k = 1) of available trials. Efficacy did not differ with trauma exposure frequency irrespective of its operationalisation and subgroup analyses (e.g. trauma-focused cognitive-behavioural therapy only). CONCLUSIONS: The current evidence base suggests that psychological interventions for paediatric PTSD can effectively treat PTSD in populations reporting single and multiple traumas. Future trials for PTSD following single-event trauma need to involve active control conditions.

The relationship between youth involvement, alliance and outcome in trauma-focused cognitive behavioral therapy.

OBJECTIVE: Research suggests that combining the trauma-specific elements with a strong alliance helps optimize treatment outcomes in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth. Building on this, we investigate whether more positive and less negative involvement behaviors during trauma narration are associated with a stronger alliance and predict fewer posttraumatic stress symptoms (PTSS). METHOD: Participants were 65 youth (M age = 15.5, SD = 2.2; 77% girls) receiving TF-CBT. Both youth self-report (Child PTSD Symptom Scale and Therapeutic Alliance Scale for Children) and observer ratings (Client Involvement Rating Scale) were used, and relationships were investigated with correlations and regression analyses. RESULTS: The positive involvement behaviors demonstration of treatment understanding and self-disclosure predicted fewer PTSS but were not associated with the alliance - while initiation of discussions and showing enthusiasm predicted more PTSS but were associated with a stronger alliance. The negative involvement behaviors passivity and avoidance did not predict PTSS but were negatively associated with the alliance. CONCLUSION: The relationships between traumatized youths' positive and negative involvement behaviors, alliance and PTSS outcomes appear mixed. The combination of a clear understanding of why processing the trauma can be helpful, more trauma-related self-disclosure and a stronger alliance seem favorable for alleviating PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Professional wellbeing and turnover intention among child therapists: a comparison between therapists trained and untrained in Trauma-Focused Cognitive Behavioral Therapy.

BACKGROUND: Poor professional wellbeing and job turnover is challenging for child mental health clinics and despite an increasing interest in implementing evidence-based practices (EBPs) in mental health services, little is known about if and how using EBPs may influence therapists' professional wellbeing and turnover intention. To investigate this, we compare the average level of compassion satisfaction, burnout, secondary traumatic stress, and turnover intention between therapists trained in an EBP (Trauma-Focused Cognitive Behavioral Therapy - TF-CBT) and untrained therapists. We also explore the prevalence of and the associations between these personal and organizational outcomes. METHOD: In this cross-sectional study, the data is collected from a national sample of 373 therapists 5 years after an implementation program began (i.e., in the sustainment phase). The variables were measured by the Professional Quality of Life and the Turnover Intention Scales. The Evidence-Based Practice Attitude Scale was also used to measure therapists' attitudes toward EBPs. RESULTS: Over 70% of the respondents reported medium to high levels of burnout, secondary traumatic stress symptoms, and compassion satisfaction, whereas one-third of the respondents reported a high level of intention to leave their job in the current or near future. Higher ratings on burnout and secondary traumatic stress were significantly associated with lower compassion satisfaction and higher turnover intention. Finally, we found significantly lower degree of burnout and turnover intention along with higher compassion satisfaction among TF-CBT therapists (n = 96), compared to other therapists who were not trained in TF-CBT (n = 231). These differences could not be explained by between-group differences in age, job tenure, educational background, or therapists' attitudes towards EBPs. However, mean differences in ratings on secondary traumatic stress symptoms were not statistically significant. CONCLUSION: Although the prevalence findings are in general alarming, the present study provides the first empirical evidence for a potential positive effect of being trained in TF-CBT on therapists' wellbeing and turnover intention. We discuss these findings in the light of self-efficacy theory and the job demands-resources model.

Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study.

Background: Complex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD. Objectives: This study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth. Methods: Youth (n = 73, 89.0% girls, M age = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT. Results: Among the 73 youth, 61.6% (n = 45) fulfilled criteria for CPTSD and 38.4% (n = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions. Conclusions: This is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.

Antecedentes: El trastorno de estrés postraumático complejo (TEPT-C) ha sido agregado recientemente al sistema de diagnóstico para la clasificación de enfermedades CIE-11. El nuevo trastorno agrega tres grupos de síntomas al trastorno de estrés postraumático (TEPT), relacionados con alteraciones en la autoorganización (desregulación afectiva, autoconcepto negativo y alteraciones en las relaciones). Poco se sabe acerca de si los tratamientos basados en evidencia recomendados para el TEPT en jóvenes son útiles para los jóvenes con TEPT-C.Objetivos: Este estudio examinó si la Terapia Cognitiva Conductual Centrada en el Trauma (TF-CBT en sus siglas en inglés) es útil para reducir el TEPT y el TEPT-C en jóvenes traumatizados.Método: Se incluyó en el estudio a jóvenes derivados a una de las 23 clínicas noruegas de salud mental para niños y adolescentes, que cumplían con los criterios para TEPT o TEPT-C según el CIE-11 y recibieron TF-CBT (n = 73, 89% niñas, M edad = 15,4, DE = 1,8). Se realizaron evaluaciones antes del tratamiento y cada cinco sesiones. Se ejecutaron modelos de efectos mixtos lineales para investigar si los jóvenes con TEPT-C y TEPT respondían de manera diferente a la TF-CBT.Resultados: Entre los 73 jóvenes, el 61,6% (n = 45) cumplió con los criterios de TEPT-C y el 38,4% (n = 28) cumplió con los criterios de TEPT. No hubo diferencias en sexo, edad, país de nacimiento, tipo de trauma, número de tipos de trauma o duración del tratamiento entre los grupos. Los jóvenes con TEPT-C tuvieron una disminución más pronunciada en TEPT y TEPT-C en comparación con los jóvenes con TEPT. Los grupos reportaron niveles similares de TEPT y TEPT-C después del tratamiento. El porcentaje de jóvenes que abandonaron el tratamiento no difirió entre los grupos. Además, los grupos no difirieron significativamente en el número de sesiones de tratamiento recibidas.Conclusiones: Éste es el primer estudio que examina si la TF-CBT es útil para los jóvenes que tienen TEPT-C mediante un instrumento validado para medir el TEPT. Los resultados sugieren que la TF-CBT puede ser útil para tratar el TEPT-C en jóvenes. Estos son hallazgos prometedores que deberían replicarse en estudios con tamaños muestrales más grandes.

Predictors of nonresponse and drop-out among children and adolescents receiving TF-CBT: investigation of client-, therapist-, and implementation factors.

BACKGROUND: There is a paucity of evidence about effective implementation strategies to increase treatment response and prevent drop-out among children receiving evidence-based treatment. This study examines patient, therapist, and implementation factors and their association to nonresponse and drop-out among youth receiving Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). METHODS: Youth (n = 1240) aged 6-18 (M = 14.6) received TF-CBT delivered by 382 TF-CBT therapists at 66 clinics. Odds ratio analyses were used to investigate whether pretreatment child (age, gender, number of trauma experiences, post-traumatic stress symptoms (PTSS), therapist (education), and implementation strategy factors (high-low, low-low, low-high intensity therapist and leadership training respectively) or tele-mental health training during the Covid-19 pandemic are associated with nonresponse (above clinical PTSS level post-treatment) and drop-out (therapist-defined early termination). Fidelity checks were conducted to ensure that TF-CBT was used consistently. RESULTS: One fourth of the children (24.4%) were nonresponders and 13.3 percent dropped out. Exposure to three or more traumatic experiences were related to nonresponse and drop-out. Higher baseline PTSS was related to a higher probability of nonresponse. There was no effect of therapist education or child gender on nonresponse and drop-out, whereas children over 15 years had a higher likelihood of both. After controlling for baseline PTSS, the effect of age on nonresponse was no longer significant. Drop-out was related to fewer sessions, and most dropped out during the first two phases of TF-CBT. Fidelity was high throughout the different implementation phases. High-intensity therapist training was related to a lower probability of both nonresponse and drop-out, whereas low therapist and leadership training were related to a higher likelihood of both. Multivariate analysis revealed higher child age and higher PTSS baseline scores as significant predictors of nonresponse, and number of trauma experiences (> = 3) at baseline as the only predictor of drop-out. CONCLUSIONS: High-intensity therapist training seem key to prevent patient nonresponse and drop-out. Leadership training might positively affect both, although not enough to compensate for less intensive therapist training. More complex cases (higher PTSS and exposure to more traumas) predict nonresponse and drop-out respectively, which underscores the importance of symptom assessment to tailor the treatment. The lack of predictive effect of therapist education increases the utilization of TF-CBT. TRIAL REGISTRATION: Retrospectively registered in ClinicalTrials, ref. nr. NCT05248971.

The child and Adolescent Trauma Screen 2 (CATS-2) - validation of an instrument to measure DSM-5 and ICD-11 PTSD and complex PTSD in children and adolescents.

Background: The study examined the psychometric properties of the Child and Adolescent Trauma Screen 2 (CATS-2) as a measure of posttraumatic stress disorder (PTSD) according to DSM-5 and (Complex) PTSD following the ICD-11 criteria in children and adolescents (7-17 years). Methods: Psychometric properties were investigated in an international sample of traumatized children and adolescents (N = 283) and their caregivers (N = 255). We examined the internal consistency (α), convergent and discriminant validity, the factor structure of the CATS-2 total scores, latent classes of PTSD/Complex PTSD (CPTSD) discrimination, as well as the diagnostic utility using ROC-curves. Results: The DSM-5 total score (self: α = .89; caregiver: α = .91), the ICD-11 PTSD total score (self: α = .67; caregiver: α = .79) and the ICD-11 CPTSD total score (self: α = .83; caregiver: α = .87) have proven acceptable to excellent reliability. The latent structure of the 12-item ICD-11 PTSD/CPTSD construct was consistent with prior findings. Latent profile analyses revealed that ICD-11 CPTSD was empirically distinguishable from ICD-11 PTSD using the CATS-2. ROC-analysis using the CAPS-CA-5 as outcome revealed that CATS-2 DSM-5 PTSD scores of ≥21 (screening) to ≥25 (diagnostic) were optimally efficient for detecting probable DSM-5 PTSD diagnosis. For the ICD-11 PTSD scale scores of ≥7 (screening) to ≥9 (diagnostic) were optimally efficient for detecting probable DSM-5 PTSD diagnosis. Conclusions: The CATS-2 is a brief, reliable and valid measure of DSM-5 PTSD, ICD-11 PTSD and CPTSD symptomatology in traumatized children and adolescents, allowing crosswalk between diagnostic systems using one measure. HIGHLIGHTS: The CATS-2 screens for potentially traumatic events (PTEs) and PTSD symptoms.The CATS-2 captures DSM-5 and ICD-11 criteria for PTSD and CPTSD and enables clinicians and researchers to crosswalk between both diagnostic systems.International validation has proven good psychometric properties and presents cut-off scoresThe CATS-2 is a license-free instrument and is freely accessible.