The therapist role in parent-led cognitive behavioral therapy for children after trauma: treating trauma from a distance.

This article examines the therapist experience of their role in providing Stepped Care Cognitive-Behavioral-Therapy for Children after Trauma (SC-CBT-CT), a semi-homebased, parent-led trauma-treatment for children (7-12). Previous research has documented that parent-led, therapist-assisted psychological interventions are an acceptable and effective type of service delivery. Yet, the therapist perspective on their role when providing parent-led treatments has received limited research attention. Attention is therefore directed to the therapist experience of engaging parents, establishing relationships, and working with children's trauma narratives from a distance-through the engagement of parents. The data material consists of semi-structured interviews with SC-CBT-CT therapists. To identify patterns of experience, thought, and viewpoints in the overall data, a stepwise thematic analysis approach was applied. Two core themes emerged: 1) Perceptions of therapeutic control and therapeutic presence when engaging parents to lead their own children through an exposure-based program; 2) Establishment and maintenance of therapeutic alliances with and between parents and children. Although parents are inherently well-positioned to engage with their own children about trauma, the article highlights that treatment adherence, progression, and perseverance is contingent upon systematic therapist guidance, monitoring, and availability for support and problem-solving.

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).

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.

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.

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..

Four perspectives on traumatized youths' therapeutic alliance: Correspondence and outcome predictions.

OBJECTIVE: Does the rater-perspective of youths' therapeutic alliance matter? To answer this, we evaluated the relationships between four perspectives of youths' alliance, then, we examined whether each perspective and potential discordance between the perspectives predicted outcomes. METHOD: Participants were 65 youth (M age = 15.11, SD = 2.14; 76.9% girls) undergoing trauma-focused cognitive behavioral therapy (TF-CBT) and their therapists (n = 24). Youths' alliance was rated by youth, therapists and parents using the Therapeutic Alliance Scale for Children-revised and by observers using the Therapy Process Observational Coding System-Alliance scale. Posttraumatic stress symptoms (PTSS) were assessed with the Child PTSD Symptom Scale (CPSS) and the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA). RESULTS: The alliance ratings by youth-parent, parent-therapist, and therapist-observer significantly correlated. Only a higher youth-rated alliance significantly predicted fewer PTSS. Furthermore, a higher therapist-rated than youth-rated alliance significantly predicted higher scores on CPSS and CAPS-CA, and a higher parent-rated than youth-rated alliance predicted significantly higher CPSS score. CONCLUSION: Therapists should explicitly check in with youth clients about the alliance; because only youths' evaluation of their alliance predicted the outcome and an overestimation of their alliance by therapists and parents predicted more PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Perceived social support and posttraumatic stress symptoms in children and youth in therapy: A parallel process latent growth curve model.

Many studies show that perceived social support protects against the development of posttraumatic stress symptoms (PTSS) in the aftermath of trauma, but less is known about support in relation to PTSS in trauma therapy. This study examined associations between perceived social support and PTSS in children and adolescents during trauma therapy. Parallel process latent growth curve modeling was used to examine trajectories of perceived social support and PTSS over five measurement waves in a sample of 156 patients, aged between 10 and 18 years (M age = 15.1, SD = 2.2, 79.5% girls), randomized to receive trauma-focused cognitive behavior therapy (TF-CBT) or therapy-as-usual (TAU). Across all participants there was an average decline in PTSS and increase of perceived social support from pre-therapy to 18 months after therapy. Most of the change occurred during therapy and was maintained after therapy. Higher levels of PTSS prior to therapy were associated with lower levels of perceived social support prior to therapy, and a decrease in PTSS was associated with increase in perceived social support. This co-development may have been directed by a third underlying factor or short-term temporal effects. Studies investigating within-person associations over shorter time intervals will benefit our understanding of possible temporal effects.

Therapists' behaviors and youths' therapeutic alliance during trauma-focused cognitive behavioral therapy.

OBJECTIVE: Trauma-focused cognitive-behavioral therapy (TF-CBT) is a recommended treatment for posttraumatic stress (PTS) in youth, and a strong therapeutic alliance predicts reductions of PTS in TF-CBT. However, little is known of how therapists can build a strong alliance. This study seeks to understand which therapist behaviors are associated with the strength of alliance in TF-CBT. METHOD: Participants were 65 youth (M age = 15.1, SD = 2.19; 77% girls) engaged in TF-CBT and their therapists (n = 24). The alliance was assessed midtreatment using the Therapeutic Alliance Scale for Children-revised. Therapists' behaviors were coded using the Adolescent Alliance-Building Scale-revised, and youth engagement behavior was coded using the Behavioral Index of Disengagement Scale. Linear mixed-effects models were used to evaluate clients' and therapists' in-session behaviors as predictors of the alliance, in addition to assessing the potential moderating effects of youth behaviors. RESULTS: Rapport-building behaviors were significantly predictive of higher alliance scores (Est. = 1.81, 95% CI [0.11, 3.52], p = .038), whereas there was no predictive effect of treatment socialization or trauma-focusing behavior on alliance scores. Initial youth behavior significantly moderated the effect of trauma-focusing on the alliance (p = .007); greater focus on trauma was associated with higher alliance scores among passively disengaged youth (Est. = 4.92, 95% CI [1.80, 8.05], p = .003). CONCLUSIONS: Rapport-building behaviors are associated with a stronger alliance in TF-CBT. Gradual exposure through initial trauma-eliciting does not appear to undermine alliance formation but is rather associated with higher alliance-scores among passively disengaged youth. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Cost-Effectiveness Analysis of Trauma-Focused Cognitive Behavioral Therapy: A Randomized Control Trial among Norwegian Youth.

Traumatic events by young people can adversely affect their psychological and social well-being when left untreated. This can result in high costs for society. In this study, we aimed to evaluate whether trauma-focused cognitive behavioral therapy (TF-CBT) is a cost-effective alternative to therapy as usual (TAU). Individual-level data were collected from 2008 to 2013, as part of a randomized control trial in Norwegian youth, 10-18 years of age, presenting with symptoms of posttraumatic stress (N = 156). Health outcomes, costs, and patient and family characteristics were recorded. Health-related quality of life (HRQoL) was measured with the 16D instrument, and quality-adjusted life-years (QALYs) were derived; total costs included the costs of therapy, and last we calculated the incremental cost-effectiveness ratio (ratio of differences in costs and QALYs gained). We performed nonparametric bootstrapping and used the results to draw a cost-effectiveness acceptability curve depicting the probability that TF-CBT is cost-effective. HRQoL increased in both treatment groups, whereas no significant differences in QALYs were observed. Resource use measured in minutes per session was significantly higher in the TF-CBT group; however, total minutes of therapy and costs were not significantly different between the two groups. In addition, use of resources, such as psychological counseling services, welfare services, and medication, was lower in the TF-CBT group posttreatment. The likelihood of TF-CBT being cost-effective varied from 91% to 96%. TF-CBT is likely to be a cost-effective alternative to standard treatment and should be recommended as the guideline treatment for youth with posttraumatic stress disorder.

Investigating treatment characteristics and first-session relationship variables as predictors of dropout in the treatment of traumatized youth.

OBJECTIVE: Attrition is a common problem in youth trauma treatment, but there is currently little knowledge of why so many youths drop out. In this study, treatment variables (caregiver attendance in the first session and exposure vs. non-exposure-based treatment) and first-session process variables (the therapeutic alliance and youths' perceptions of parental treatment approval) were investigated as predictors of dropout. METHOD: Participants (N = 156, mean age = 15.1) were randomly assigned to trauma-focused cognitive behavioral therapy or therapy as usual in a community trial. RESULTS: Dropout (n = 39, 25.0%) was predicted by a lack of caregiver attendance, lower rates of youth-perceived parental treatment approval, and weaker therapist-rated youth alliance. Neither type of treatment, youth-rated alliance or caregiver alliance, predicted dropout. CONCLUSIONS: The findings indicate that in addition to caregivers' actual participation in the first session, youths' perception of their parents' approval of treatment seems to influence treatment attendance. This finding implies that therapists should engage caregivers in therapy and address possible discordance in treatment goals and tasks. Furthermore, consistent with adult studies, exposure-based treatments do not appear to increase dropout rates.

A Follow-Up Study from a Multisite, Randomized Controlled Trial for Traumatized Children Receiving TF-CBT.

Trauma-focused cognitive behavioral therapy (TF-CBT) is the treatment of choice for traumatized youth, however, follow-up studies are scarce, and treatment effects for co-occurring depression show mixed findings. The aims of this study were to examine whether treatment effects of TF-CBT are maintained at 18 month follow-up and whether degree of co-occurring depression influences treatment effects. As rapid improvement in psychological functioning is warranted for youth, we also investigated whether the symptom trajectory was different for TF-CBT compared to therapy as usual (TAU). The sample consisted of 156 youth (M age = 15.05, 79.50% girls) randomly assigned to TF-CBT or TAU. The youth were assessed for posttraumatic stress symptoms (PTSS), depression, anxiety and general mental health symptoms. Mixed effects analyses followed the symptom courses over 5 time points. Youth receiving TF-CBT maintained their symptom improvement at 18 months follow-up with scores below clinical cut-of on all symptom measures. The most depressed youth had also a significant decline in symptoms that were maintained at follow-up. Symptom trajectories differed as the TF-CBT group reported a more rapid symptom reduction compared to the TAU condition. In the TAU condition, participants received 1.5 times the number of treatment sessions compared to the TF-CBT participants. After 18 months the groups were significantly different on general mental health symptoms only. In conclusion, youth receiving TF-CBT experienced more efficient improvement in trauma related symptoms than youth receiving TAU and these improvements were maintained after 18 months. Also youth experiencing serious co-occurring depression benefitted from TF-CBT.

Therapist and client perspectives on the alliance in the treatment of traumatized adolescents.

OBJECTIVE: Client ratings of the therapeutic alliance are an important predictor of outcome in the treatment of traumatized adolescents and adults, but less is known about the therapists' perspective. The aim of this study was to investigate how therapists' ratings relate to the adolescents' perspective, how individual therapist and adolescent ratings relate to change in symptoms and treatment satisfaction, and whether discrepant alliance perspectives impact treatment outcome. METHOD: The sample consisted of 156 youth (mean age 15.1, range 10-18), randomized to trauma-focused cognitive behavioral therapy or treatment as usual, and alliance ratings from 62 therapists. Alliance was measured midtreatment with the Therapeutic Alliance Scale for Children, and the factor structure of the two scales was analyzed with exploratory factor analyses. A change in posttraumatic symptoms was assessed with the Child PTSD Symptom Scale (CPSS) and the Clinicial-Administered PTSD Scale for Children and Adolescents (CAPS-CA). RESULTS: Therapist and client perspectives on the alliance were significantly, but moderately, associated (intraclass correlations [ICC]=0.54, p<0.001). Both scales predicted adolescent treatment satisfaction but only the client scale was significantly related to change in symptoms. Factor analyses revealed differences in factor structure with therapist ratings organized around bond and task dimensions and adolescent ratings organized by item valence. Higher therapist ratings compared to adolescent ratings predicted higher residual PTS symptoms. DISCUSSION: Although adolescent and therapist alliance ratings are moderately associated, results suggest that the ratings are differentially associated with outcomes. These findings, along with results indicating important differences in factor structure, imply that adolescent and therapist ratings are not interchangeable. Future studies should investigate how therapists can improve their judgments of adolescents' perceptions of the alliance as an overestimation of the quality of the relationship seems to be negatively related to outcome.

A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual for youth.

The efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) has been shown in several randomized controlled trials. However, few trials have been conducted in community clinics, few have used therapy as usual (TAU) as a comparison group, and none have been conducted outside of the United States. The objective of this study was to evaluate the effectiveness of TF-CBT in regular community settings compared with TAU. One hundred fifty-six traumatized youth (M age = 15.1 years, range = 10-18; 79.5% girls) were randomly assigned to TF-CBT or TAU. Intent-to-treat analysis using mixed effects models showed that youth receiving TF-CBT reported significantly lower levels of posttraumatic stress symptoms (est. = 5.78, d = 0.51), 95% CI [2.32, 9.23]; depression (est. = 7.00, d = 0.54), 95% CI [2.04, 11.96]; and general mental health symptoms (est. = 2.54, d = 0.45), 95% CI [0.50, 4.58], compared with youth in the TAU group. Youth assigned to TF-CBT showed significantly greater improvements in functional impairment (est. = -1.05, d = -0.55), 95% CI [-1.67, -0.42]. Although the same trend was found for anxiety reduction, this difference was not statistically significant (est. = 4.34, d = 0.30), 95% CI [-1.50, 10.19]. Significantly fewer youths in the TF-CBT condition were diagnosed with posttraumatic stress disorder compared to youths in the TAU condition, χ(2)(1, N = 116) = 4.61, p = .031, Phi = .20). Findings indicate that TF-CBT is effective in treating traumatized youth in community mental health clinics and that the program may also be successfully implemented in countries outside the United States.

The therapeutic alliance in treatment of traumatized youths: relation to outcome in a randomized clinical trial.

OBJECTIVE: We examined the contribution of alliance to the outcome of therapy with traumatized youths across two different treatment conditions (trauma-focused cognitive behavioral therapy [TF-CBT] and therapy as usual [TAU]). METHOD: Participants were 156 youths (M age = 15.1 years, range = 10-18; 79.5% girls), randomly assigned to TF-CBT or TAU. Symptoms were assessed pretreatment, midtreatment (Session 6), and posttreatment (Session 15). Alliance was assessed after Sessions 1 and 6, using the Therapeutic Alliance Scale for Children-Revised (TASC-R). RESULTS: Alliance scores were comparable across treatment conditions, but TF-CBT participants had significantly lower posttraumatic stress symptoms (PTSS) posttreatment (d = 0.51). Hierarchical regression analyses showed that there were no significant alliance effects in models without an Alliance × Treatment Group interaction: Alliance ratings were significant predictors of reduction in PTSS (Est. = -0.53, p = .003, 95% confidence interval [CI] = -0.87 to -0.18) and additional outcomes measured in TF-CBT but not in TAU (PTSS posttreatment: Est. = 0.01, p = .647, 95% CI = -0.29 to 0.47). CONCLUSION: This study was the first to investigate the contribution of alliance to outcome among adolescents with posttraumatic symptoms, treated with TF-CBT or TAU. Our findings indicated that there was an important interaction between alliance and therapeutic approach, as alliance predicted outcome in TF-CBT, but not in the nonspecific treatment condition. A positive working relationship appeared to be especially important in the context of this evidence-based treatment, which requires youth involvement in specific therapy tasks. Further, findings showed that use of a manual did not compromise alliance formation.

Diagnostic utility of CPSS vs. CAPS-CA for assessing posttraumatic stress symptoms in children and adolescents.

OBJECTIVES: This study compared the diagnostic utility of the symptom part of the child PTSD symptom scale (CPSS) screening instrument with the clinician-administered PTSD scale for children and adolescents (CAPS-CA). METHODS: The study included a clinical sample of traumatized children and adolescents (mean age 15.1, range 10-18) living in Norway, who were assessed for posttraumatic stress symptoms using the CPSS and the CAPS-CA. Diagnostic utility was investigated using receiver operating characteristic analyses. RESULTS: The results showed that CPSS reached medium effect sizes (AUC from .63 to .76). The sensitivity was good (.80), but the specificity was relatively low (.56). Kappa between CPSS and CAPS-CA was low (κ=.27). CONCLUSIONS: Findings suggests that CPSS is a good tool for screening purposes, but not as a diagnostic instrument in an early phase of assessment. Implications and limitations of the findings are discussed.