Research roundup: Working with traumatized youth

In this installment of “Research Roundup,” we look at three new studies that explore different facets of childhood trauma: childhood adversities and co-occurring trauma, the implementation of evidenced-based psychotherapies (EBPs) with traumatized youth, and the experiences of parents whose children receive psychological treatment for post-traumatic stressⁱ.

Hodgdon, H.B., Suvak, M., Zinoviev, D.Y., Liebman, R.E., Briggs, E.C., & Spinazzola, J. (2019). Network analysis of exposure to trauma and childhood adversities in a clinical sample of youth. Psychological Assessment, 31(11), 1294–1306. https://doi.org/10.1037/pas0000748

The authors of this study applied a novel statistical approach—network analysis—to understand how different types of trauma and childhood adversities co-occur in a treatment-seeking group of youth.

The authors studied 618 participants ages 4 to 18 attending treatment for a variety of issues including post-traumatic stress symptoms (PSS), co-morbid diagnoses (i.e., PTSD and depression, anxiety or behavioral disorders), and general behavioral and family functioning. At the beginning of treatment, the participants, their parents/caregivers and clinicians completed measures on trauma history, internalizing and externalizing behaviors, and PTSD symptoms.

The data was analyzed using the generalized similarity model (Kovacs, 2010) and resulted in a network of trauma/childhood adversities types with four distinct clusters:

• Cluster 1 represented overt forms of trauma at the individual level including psychological maltreatment, physical abuse/assault and sexual abuse/assault.
• Cluster 2 was labeled environmental family trauma and comprised of neglect, impaired caregiving and forced displacement.
• Cluster 3 was labeled environmental community and represented trauma/childhood adversities occurring at the broader community level: exposure to domestic, school, community and extreme interpersonal violence.
• Cluster 4 represented acute trauma, and was comprised of medical trauma, traumatic loss and injury/ accident.

The authors identified interesting patterns in the network based on statistical importance, age of onset, and timing of the trauma and childhood adversities types. For example, children who experienced psychological maltreatment and neglect were most likely to experience later occurrences of trauma and childhood adversities. Along with physical abuse, psychological maltreatment and neglect appear to represent “gateway stressors” that increase the risk for future trauma and childhood adversities exposure.

Further analyses showed that each of the clusters were differentially related to symptoms of PSS and internalizing and externalizing problems. Cluster 1 significantly predicted PSS and internalizing problems, while Cluster 3 significantly predicted externalizing problems. Cluster 4, acute trauma, was predictive only of internalizing problems. Cluster 2 by itself was not predictive of psychological adjustment issues, possibly due to neglect’s high overlap with trauma and CA in other clusters.

Clinical implications

Early screening of and interventions for psychological maltreatment and neglect may reduce the overall burden of trauma and childhood adversities exposure by decreasing the likelihood that children will experience other trauma and childhood adversities that directly affect psychological functioning (i.e., Clusters 1, 2 and 3). Psychologists working with youth who have been exposed to traumatic events and other childhood adversities may wish to use the four distinct clusters to provide guidance for additional screening priorities.

Barnett, E.R., Jankowski, M.K., & Trepman, A.Z. (2019). State-wide implementation and clinical outcomes associated with evidence-based psychotherapies for traumatized youth. Psychological Trauma: Theory, Research, Practice, and Policy, 11(7), 775–783. https://doi.org/10.1037/tra0000444

This study examined the implementation and clinical outcomes of two evidence-based psychotherapies (EBPs), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Child Parent Psychotherapy (CPP), in community agencies across the state of New Hampshire (NH).

The authors invited agencies and clinicians with master’s degrees or higher through-out NH to participate. Participants registered to complete two-days of clinician training; weekly consultation groups for nine or 12 months; web-based reading/training; and agreed to deliver the specified model with at least two youth/families within the first two-months of the program. The clinician participants as well as the consultant group leaders used tracking forms to measure implementation adherence. Treatment dropout rates and changes in post-traumatic stress (PTS) symptoms were assessed to determine patient outcomes.

Of the 292 clinicians who registered for the trainings and consultations, 243 (83%) attended the trainings and 168 (58%) began consultation groups. Only 70 participants (24%) completed the implementation requirements. A higher proportion of clinicians participating in TF-CBT stuck with the implementation requirements than those participating in CPP.

A total of 363 children and adolescents were tracked as patients of the clinicians who fulfilled the implementation expectations. Youth/family dropout rates and clinical outcomes were similar across both EBP models. At the end of the tracking period, 47% had dropped out of treatment, 44% were ongoing, and 9% had successfully completed treatment. Given that families entered treatment on a rolling basis during the tracking period, those entering later could still be ongoing and not yet counted as completed. Using pre-post PTS scores, 59% of the tracked youth who completed the EBPs demonstrated significant improvement.

The clinical outcomes for youth who completed treatment in this study were similar to those of highly controlled trials. However, the implementation outcomes were mixed compared with those of more resource-intensive implementation models.

Clinical implications

This study offers further evidence for clinicians and families that those who do receive evidence-based treatment are likely to get better. However, despite the provision of free training and consultation on two EBP models for treating traumatized youth to clinicians state-wide, implementation in real world settings proved challenging. Administrators and other decision-makers will need to prepare for the upfront costs of implementing EBP models and put forth sizable effort toward clinician adherence.

Williamson, V., Creswell, C., Butler, I., Christie, H., & Halligan, S.L. (2019). Parental experiences of supporting children with clinically significant post-traumatic distress: A qualitative study of families accessing psychological services. Journal of Child & Adolescent Trauma, 12(1), 61–72. https://doi.org/10.1007/s40653-017-0158-8

For children who have been exposed to trauma, a parent’s response can ease or intensify their vulnerability to posttraumatic stress symptoms (Scheering & Zeanah, 2001). This qualitative study examined the experiences of parents in England following their child’s participation in psychological treatment for clinically significant levels of post-traumatic stress.

Six parents of children ages 8 to 15 completed in-depth telephone interviews that prompted them to answer questions about their thoughts, feelings and behaviors after the trauma; their concerns about their child; their experiences of providing support for their child; and their perceptions of their child’s psychological treatment.

Analysis of these interviews revealed that parents use three main strategies to try to support their children: promoting avoidant coping, scaffolding trauma-related discussions and providing warmth. All of the parents reported that they felt anxious and helpless about their ability to care for their child following a trauma. That anxiety led several parents to use avoidant coping strategies because they were uncertain if discussing the trauma would worsen their child’s posttrauma difficulties. Other parents, however, encouraged their child to discuss the event believing that it was important to address potentially maladaptive beliefs around blame or other misinformation about the trauma. All of the parents reported that they reassured their children, encouraging them to feel safe, and seeking to normalize the children’s responses to the trauma.

Parents reported having to overcome several barriers to access psychological treatment. They included a lack of awareness of services, not being automatically referred to services by their child’s physician after voicing concerns about their child’s adjustment difficulties, and long wait times for assessments or infrequent therapy sessions. Once a child received services, most parents perceived the treatment as helpful in addressing the adjustment difficulties and as an opportunity for their children to discuss the trauma or to obtain coping advice.

Parents also described expecting to receive more guidance from the therapist for how to best support their child, especially when symptoms became severe, and expressed feelings of disappointment and increased distress when that didn’t happen.

Clinical implications

The qualitative interviews with parents of children who receive psychological treatment for posttraumatic stress symptoms suggest a need for more accessible care. Clinicians who work with this population may wish to consider providing targeted information and advice directly to parents on promoting child adjustment and how to positively manage their child’s symptoms, particularly during acute crisis episodes, to help address parental concerns and potentially improve outcomes for the entire family.