David J. Kolko

Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events.

The article reviews the current status (1993–2007) of psychosocial treatments for children and adolescents who have been exposed to traumatic events. Twenty-one treatment studies are evaluated using criteria from Nathan and Gorman (2002) along a continuum of methodological rigor ranging from Type 1 to Type 6. All studies were, at a minimum, robust or fairly rigorous. The treatments in each of these 21 studies also are classified using criteria from Chambless et al. (1996), and Chambless and Hollon (1998). Trauma-Focused Cognitive-Behavioral Therapy met the well-established criteria; School-Based Group Cognitive-Behavioral Treatment met the criteria for probably efficacious. All the other treatments were classified as either possibly efficacious or experimental. Meta-analytic results for four outcomes (i.e., posttraumatic stress, depressive symptoms, anxiety symptoms, and externalizing behavior problems) across all treatments compared to waitlist control and active control conditions combined reveal that, on average, treatments had positive, though modest, effects for all four outcomes. We also cover investigative work on predictors, moderators, and mediators of treatment outcome, as well as the clinical representativeness and generalizability of the studies. The article concludes with a discussion of practice guidelines and future research directions.

The Role of Therapist Training in the Implementation of Psychosocial Treatments: A Review and Critique with Recommendations

Evidence-based treatments (EBT) are underutilized in community settings, where consumers are often seen for treatment. Underutilization of EBTs may be related to a lack of empirically informed and supported training strategies. The goals of this review are to understand the state of the literature for training therapists in psychotherapy skills and to offer recommendations to improve research in this area. Results of this review of 55 studies evaluating six training methods indicate that multi-component trainings have been studied most often and have most consistently demonstrated positive training outcomes relative to other training methods. Studies evaluating utility of reading, self-directed trainings, and workshops have documented that these methods do not routinely produce positive outcomes. Workshop follow-ups help to sustain outcomes. Little is known about the impact of train-the-trainer methods. Methodological flaws and factors that may influence training outcome and future directions are also reviewed.

Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression.

OBJECTIVE To assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response. METHOD One hundred seven adolescent outpatients, aged 13 to 18 years, with DSM-III-R major depression were randomly assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Those with good and poor outcomes were compared. RESULTS Continued depression was predicted by clinical referral (versus via advertisement) and was in part mediated by hopelessness. Other predictors of depression were comorbid anxiety disorder and higher levels of cognitive distortion and hopelessness at intake. Achievement of clinical remission was predicted by a higher level of self-reported depression. Poorer functional status was predicted by a higher level of initial interviewer-rated depression. Comorbid anxiety and maternal depressive symptoms predicted differential treatment efficacy. CBTs performance continued to be robust with respect to nondirective supportive therapy, even in the presence of the above-noted adverse predictors. CONCLUSION Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.

Individual Cognitive Behavioral Treatment and Family Therapy for Physically Abused Children and their Offending Parents: A Comparison of Clinical Outcomes

Few studies have evaluated short-term psychosocial treatments with physically abused school-aged children and their offending parents or families. This study compares the treatment outcomes of 55 cases that were randomly assigned to individual child and parent cognitive behavioral therapy (CBT) or family therapy (FT) with those who received routine community services (RCS). Measures of child, parent, and family dysfunction and adjustment were collected from both participants and supplemented with official social service records to evaluate the efficacy of treatment through 1-year follow-up. Compared with RCS, CBT and FT were associated with improvements in child-to-parent violence and child externalizing behavior, parental distress and abuse risk, and family conflict and cohesion. All three conditions reported several improvements across time. One parent participant each in CBT and FT and three in RCS were found to have engaged in another incident of physical maltreatment after treatment had begun. No differences between CBT and FT were observed on consumer satisfaction or maltreatment risk ratings at termination. The findings of this evaluation provide additional support for the continued development and evaluation of individual and family treatments involving child victims of physical abuse.

Salivary Testosterone and Cortisol in Disruptive Children: Relationship to Aggressive, Hyperactive, and Internalizing Behaviors

OBJECTIVE To test predictions that basal salivary testosterone and cortisol are related to antisocial and internalizing behaviors, respectively, and that cortisol moderates the testosterone-aggression relationship. METHOD Saliva samples were assayed to determine testosterone and cortisol levels in 40 clinic-referred disruptive children (aged 7 through 14 years) who were rated on aggression, inattention/overactivity, and internalizing behavior by parents, teachers, and clinic staff members. RESULTS Results indicated significant positive relationships between testosterone and staff-rated aggression and between cortisol and parent-rated internalizing behavior. A significant negative relationship was found between cortisol and staff-rated inattention/overactivity. No interactions between testosterone and cortisol were found. These results were maintained regardless of age, racial background, height, weight, diagnosis, or medication status. CONCLUSIONS Results suggest moderate relationships between testosterone and observed aggression, and between cortisol and emotional behaviors, in a group of disruptive children. Cortisol did not moderate the testosterone-aggression relationship in this population.

Child abuse potential in parents with histories of substance use disorder.

OBJECTIVE To examine the relationship between parental history of substances use disorders (SUDs) and abuse potential. METHOD Milners (1986) Child Abuse Potential Inventory (CAPI) was administered to fathers and mothers (with and without histories of SUDs) of 10- to 12-year-old boys. RESULTS Fathers and mothers with lifetime histories of SUDs had higher Abuse Scale scores and were more likely to score in the Elevated range (as determined by clinically significant cutoff scores) than parents without such histories. No differences were found between parents with current diagnoses of SUD and those with past (but not current) histories of SUD. Fathers and mothers with a partner who had a history of SUD were more likely to score in the Elevated range, regardless of their own SUD histories. Separate regression models revealed that, for both fathers and mothers, emotional dysregulation (positive and negative affectivity) predicted Abuse Scale scores. Additional contributors to Abuse Scale scores were SUD status in fathers, and lack of involvement with the child in mothers. CONCLUSIONS History of SUDs in both fathers and mothers increases abuse potential. Contributors to abuse potential differed in fathers and mothers, underscoring the importance of examining parents separately in child maltreatment research.

Cognitive and family therapies for adolescent depression: treatment specificity, mediation, and moderation.

The specificity of cognitive and family therapies, and potential treatment mediators and moderators, was examined in a randomized clinical trial for adolescent depression. After acute treatment, cognitive-behavioral therapy (CBT) exerted specific effects on cognitive distortions relative to either systemic-behavioral family therapy (SBFT) or nondirective supportive therapy (NST). At 2-year follow-up, SBFT was found to impact family conflict and parent-child relationship problems more than CBT; NST and CBT tended to show a greater reduction in anxiety symptoms than SBFT. Nonspecific therapist variables qualified few outcome analyses. No measures of cognitive distortion or family dysfunction mediated or moderated treatment outcome. As in adult studies, relatively few areas of treatment specificity or mediation were identified. The implications of these findings for clinical treatment and research in adolescent depression are discussed.

The Psychological Autopsy: Methodological Considerations for the Study of Adolescent Suicide

The psychological autopsy has been employed to study risk factors for completed suicide for more than three decades. Despite a wide range in methods of approach to families and interview techniques, the studies show high compliance and remarkable consistency of results across a wide age range and diverse geographic samples. The convergent evidence is that the diagnostic information obtained is both reliable and valid, although it is likely that such an approach will be more specific than sensitive. Integration of data obtained through psychological autopsies with data obtained through biochemical, toxicological, and epidemiological approaches is likely to deepen our understanding of suicide. Successful completion of careful psychological autopsy studies should enable investigators to examine intensively patients who resemble suicide completers, thereby transcending the inherent limitations of this important first step in the investigation of suicide.

Characteristics of Child Victims of Physical Violence Research Findings and Clinical Implications

This article reviews recent empirical studies that examine the short- and long-term sequelae of physical child maltreatment (PCM). The current status of research examining the impact of PCM on childrens development (e.g., medical, cognitive) and psychosocial functioning (e.g., psychiatric disorders, behavioral, interpersonal, academic, affective) is reviewed. Major findings are discussed in the context of pertinent qualifications of existing evidence. To encourage clinical-research advances in this area, recent developments and future directions pertaining to the areas of conceptualization, assessment/methodology, and intervention are described.

Clinical monitoring of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons

Weekly reports of high-risk indicators designed to monitor the course of treatment were obtained from physically abused, school-aged children and their parents/guardians who were randomly assigned to Individual Child and Parent Cognitive-Behavioral Treatment (CBT) or Family Therapy (FT). Measures of parental anger and physical discipline/force, and family problems were obtained each session. The measures showed moderate stability and parent-child correspondence. Between 20% and 23% of the two informants reports acknowledged high levels of physical discipline/force during the early and late phases of treatment, respectively, and an even higher percentage of cases reported heightened parental anger and family problems. Early treatment reports from both informants predicted late period reports, but only parent reports were related to validity measures. The overall levels of parental anger and physical discipline/force were lower in CBT than FT families, though each group showed a reduction on these items from the early to late treatment sessions. The importance of routine monitoring of clinical course during intervention, especially in the identification of cases at-risk of reabuse, is discussed.